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High Blood Pressure an Added Risk in Some Groups of Patients

Public awareness of the importance of treating high blood pressure has actually gone down in the past decade, and so has the percentage of people with this condition who are treating it successfully, according to a nationally recognized expert in this area. The potential consequences of this lack of awareness and appropriate treatment: increased rates of cardiovascular disease and death.

Jerome D. Cohen, M.D. of the St. Louis University Health Sciences Center in Missouri, talked to a group of physicians about treating hypertension this week during the annual meeting of the American College of Physicians/American Society for Internal Medicine, in Philadelphia.

According to Cohen, there are three groups of patients that need special attention during doctors’ efforts to reduce cardiovascular disease and heart-related death: people with multiple cardiovascular risk factors, people with diabetes and the elderly.

The National Institutes of Health has called for a multi-pronged attack on heart disease that attempts to prevent it by controlling cholesterol, regulating glucose metabolism, and getting patients to quit smoking. (These factors increase the risk of heart disease dramatically.) But the problem, Cohen said, is that patients with normal blood pressure who have more than one of these risk factors are often not identified.

“These are the most common patients [doctors] see, and are also the most undertreated. They have multiple risk factors, and we must recognize that,” Cohen stated. He noted that patients with high cholesterol, poor glucose regulation, and a history of smoking have 10 times the risk of developing and dying from heart disease compared to those without these risk factors, even if they don’t have high blood pressure.

One recommendation for addressing this is to begin treating patients who have blood pressure in the high normal range, if they also have certain conditions that add to their risk of heart disease. This would include patients with diabetes, kidney failure, and heart failure. Cohen reported that putting these patients on blood pressure medications has been shown to reduce their risk.

“We have compelling data that shows that we can change the natural progress of [heart] disease and prevent morbidity and mortality,” stated Cohen.

Diabetics are a particularly important group, said Cohen, because high blood pressure in this group is a serious risk factor for heart disease and death. For example, hypertensive patients with diabetes are just as likely to die as those who have already had heart attacks. On the other hand, research shows that when blood pressure is tightly controlled in diabetics, their chances of developing diabetic complications, having a heart attack, and having a stroke are significantly reduced.

The class of blood pressure drugs called ACE inhibitors “are clearly the drug of choice in diabetics with hypertension,” Cohen stated, citing the results of a number of large clinical trials.
In fact, in one recent study of patients with high blood pressure, those who took these drugs were significantly less likely to develop diabetes than those who took a placebo. The group receiving ACE inhibitors also had a large reduction in stroke, heart attack, and other cardiovascular events.

In the same study, hypertensive patients who already had diabetes and who received ACE inhibitors had about one-third the rate of cardiovascular disease, stroke, and death compared to those who took placebo. So, Cohen explained, these drugs are appropriate for treating patients who have high blood pressure with or without diabetes.

Another group that tends to be undertreated for their high blood pressure, Cohen stated, is the elderly. “Heart disease is by far the leading cause of death among older folks,” he noted, but many doctors are reluctant to treat hypertension in this age group. One reason for this is that elderly patients often have an elevated systolic blood pressure — the first and higher number of the two measured when blood pressure is taken—while their diastolic pressure remains normal.

In the past, physicians have focused on this lower diastolic number when diagnosing hypertension. More recent research, Cohen explained, clearly shows that high systolic pressure needs to be treated regardless of whether the diastolic pressure is high or not. Appropriate treatment, he said, can reduce heart failure by 55 percent, stroke by 33 percent and overall cardiovascular disease by 32 percent.

“There is no reason not to treat an otherwise healthy person in their 80s for high blood pressure,” Cohen concluded, noting that without treatment, “they are at increased risk for stroke and sudden death.”

By looking at the whole patient and considering each person’s overall risk factors, Cohen explained, doctors can do a lot toward reducing cardiovascular disease and its fatalities in these often overlooked groups of patients.

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