Martin's blog

Benefit Assessment

Martin — Fri, 05 Oct 2012 18:14:27 +0000

I have been thinking a lot lately about the concept of risk and benefit. Over the last 20 to 25 years or so we have become quite adept at calculating risk for individual patients. Certainly from a cardiovascular point of view we are very good at defining high risk individuals, i.e. those at a high likelihood of having a first or subsequent adverse CV event. To date our strategy has been to treat high risk individuals aggressively, attempting to reduce CV events. In many cases this is completely appropriate. My concern is that sometimes high risk individuals may not benefit from CV risk reduction (ie BP lowering) and may in fact be harmed. These are often individuals with significant completing health concerns or co-morbidities. It is in these clients where the health care individual needs to move beyond risk assessment and ask questions to help identify potential benefit. Clients who have major competing co-morbidities may not benefit from LDL lowering or BP reduction and may be harmed physically or even financially by over aggressive treatment.

Taking medications regularly...

Martin — Sun, 17 Jun 2012 11:03:06 +0000

Taking medications regularly and potentially for the rest of your life can be difficult. Sometimes it is a difficulty in remembering to take pills, especially when your medication schedule is complex. In other cases it has more to do with the psychological barriers associated with needing to take “drugs”. I think it is worth understanding the balance between potential benefits and potential downsides to taking medication. Once the decision is made to embark on therapy it is crucial to take your medications regularly so you can achieve the maximum benefit from the medications. By taking medications irregularly your BP control can suffer. In this case you are exposed to the potential risks of the medication but are not achieving the maximal benefit. If you have trouble with continuing to take prescribed medications communicating with your healthcare team is crucial.

Category:

Client

Thoughts on therapeutic choices

Martin — Sun, 17 Jun 2012 10:57:39 +0000

When treating with anti-hypertensive agents several principles can help guide therapeutic choices;

In any individual with hypertension, consideration should be given to using two or more antihypertensive agents, in half to standard doses, to achieve additive blood pressure lowering while minimizing the adverse effect profile.

Consideration of single pill, fixed dose combos as initial therapy as this has been shown to be more likely to achieve BP control in the briefiest time

Cover the entire 24hour period with long acting meds, preferably with once a day dosing to promote adherence to therapy

Dose once a day anti-hypertensives (particularly ACEis and/or ARBs) at night to help restore circadian BP patterns

Category:

Professional

Out of Office BP Monitoring

Martin — Sun, 17 Jun 2012 10:54:50 +0000

The most important component to the evaluation and treatment of hypertension is the accurate measurement of BP. Evaluation of BP in the office is limited by; small number of measurements, poor technique, the white coat effect (increase in BP in the medical environment) and the masked effect (a decrease in BP that happened in the medical environment). For these reasons there is considerable increased focus on out of office BP measurements. This includes the utilization of either home self-BP measurement or ambulatory blood pressure measurement (ABPM). Both techniques can accurately determine the presence of both white coat hypertension and masked hypertension. Increasing data suggests that out of office BP measurements by both measures give a better assessment of future cardiovascular risk than office BP. Finally the use of out of office BP monitoring has been associated with lower costs, and lower numbers of antihypertensive agents.

Category:

Professional

Which anti-hypertensive agent?

Martin — Sun, 17 Jun 2012 10:51:35 +0000

Patents at low cardiovascular risk and stage 1 hypertension can be initially treated with lifestyle modification solely. Those with manifestations of target organ damage and sustained BP >140/90 should have initiation of pharmacologic therapy after diagnosis of hypertension is confirmed. All classes of blood pressure lowering drugs have similar effects in reducing coronary heart disease and stroke for a given level of BP reduction. The Canadian Hypertension Education Program outlines specific clinical scenarios when specific anti-hypertensive classes are preferred (at least as initial therapy). These compelling indications include such clinical entities as; previous stroke (preferred use of ACEi/ARB and thiazide diuretics), left ventricular systolic dysfunction (ACEi, ARB, B-blocker and spironolactone), and CKD with proteinuria (RAS blockade – ACEi or ARBs).

Category:

Professional