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Ask
the Doctor - February 2000 - Hypertension
Q: What is the
initial treatment of high blood pressure, i.e., blood pressure above
140 mm Hg systolic or over 90 mm Hg diastolic.
Doctor: Initial
lifestyle changes and medications, such as atenolol, a beta blocker,
or low dose hydrochlorothiazide (HCTZ), a diuretic, for high blood
pressure is usually prescribed by family practitioners and internists. This includes sodium reduction, weight loss, and alcohol restriction
to less than 1 or 2 glasses per day.
Q: Who needs
to see a specialist for hypertension treatment?
Doctor: If
blood pressure is not reduced to goal of less than 140 systolic and
less than 90 diastolic, then a second medication is usually added. If
4 weeks later blood pressure is still not at target, or if patients
have side effects from medications, then they may be referred to me or
another specialist for evaluation and treatment of difficult to
control hypertension.
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Q:
How soon do you see patients back for blood pressure check?
Doctor: If
pressure is 160-170 (systolic)/100-110 or higher (diastolic), or if
patients have diabetes, high cholesterol, if they smoke, or if they
are severely overweight, then they may be referred for more intensive
hypertension therapy. But in these cases, I like to bring the blood
pressure down over a 1-, 2-, or 4-week period, depending on how high the
blood pressure was initially.
Q: How quickly
do you have to correct high blood pressure?
Doctor: One of
the major problems I see is that some patient's blood pressure is
reduced too quickly, which may cause people to become fatigued, tired,
or less alert. Occasionally, patients may even become impotent. Good
blood pressure control may require eventually titrating up to two or
more medications. It is the responsibility of the physician to add,
subtract, or combine medications or treatments to get patients blood
pressure down to goal level. Unfortunately, recent studies demonstrate
that many physicians do not change or add medications in over 50% of
patients who are not controlled.
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Q: How useful
are home blood pressure monitors?
Doctor: I like
to encourage patients to use home blood pressure monitors. It
sometimes help to record blood pressures in the morning,
afternoon, and the evening, and look for patterns over a few days. In
addition to finding time periods when patients may have worse
hypertension, often times related to stress or medication schedule,
checking home blood pressures eliminates over treatment from white
coat hypertension in those 30% patients with reactive blood pressure
in the doctor's office.
Ask
the Doctor - April 2000 - Congestive Heart
Failure
Congestive Heart Failure (CHF) is a
common problem in patients with heart disease. It is the most common
DRG diagnosis for Medicare cardiology patients. Symptoms include:
Shortness of breath and fatigue. Leg swelling (edema) is a common
sign. Causes include: heart attacks, hypertension, and valve disease.
Prognosis for CHF is improving with
additional medications. Our present treatment consists of several
drugs: beta blockers to improve survival, diuretics for relief of
congestion, ACE-inhibitors (angiotensin converting enzyme inhibitors)
to improve survival, digoxin (lanoxin) to decrease hospitalizations
and improve well being, and sometimes spironolactone (aldactone) to
further improve survival in the very sickest patients (Class IV CHF).
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Heart failure treatment centers focus
on patient education often with extended visits with a nurse
practitioner regarding use of scales to recognize early fluid
accumulation, diet management regarding salt and fluids, and
adjustment of medications. Our best results are achieved by adding on
therapy, such as decreasing diuretics prior to adding blockers and
then carefully titrating up doses of metoprolol or Calvedilol with
visits every 2 to 8 weeks. Beta blockers require careful titration to
avoid fatigue, slow heart rate, and low blood pressure. Metoprolol and
Calvedilol have been tested and shown to improve survival.
Careful monitoring and heart imaging
helps to guide therapy. echocardiography is a good non-invasive way to
follow heart function in patients with CHF. Many patients with
congestive heart failure will require cardiac catheterization to
determine if coronary artery disease is the cause of their heart
failure. It may improve the effectiveness of ACE- Inhibitors if
aspirin can be discontinued in patients that do not have coronary
artery disease.
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Citrus Valley Cardiology Medical
Group, Inc., directed by Dr. Neil Doherty, is pleased to include
these treatments of CHF and potential access to heart failure research
trials. Its office is located at 412 West Carroll Avenue, Suite 210,
Glendora, California 91741. Phone (626) 857-7344 for appointments.
The ATLAS trial showed at that higher
doses of ace-inhibitors may be accompanied by less morbidity but
survival was not necessarily better.
New therapies being studied include
Omnipipralat (Vanlev by Bristol Myers-Squibb) angiotensin receptor
blockers TNF receptor binding, and bi-ventricular pacing.
Heart
to Heart - February 2000 -ALLHAT -Cholesterol
& Hypertension
An interesting result of the ALLHAT
investigation, of which I am regional San Gabriel Valley director, is
the early termination of the doxazosin (Cardura) arm. The patient
safety monitoring board decided there was a very low probability of
finding a favorable outcome for the group assigned to doxazosin (Cardura)
compared to those assigned to the diuretic (Chlorthalidone) arms, but
there was a significant two-fold higher rate of congestive heart
failure with Cardura compared with the diuretic arm.
This shows us the importance of the
patient safety monitoring boards in research studies. While Pfizer has
promoted the use of Cardura for many good theoretical Reasons, this is
the first study that looked at a large group of patients to determine
if it actually resulted in improved survival. No one anticipated that
an inexpensive diuretic might have an advantage in patients with high
risk for coronary artery disease, which are the types of patients
recruited into the ALLHAT study, but this study showed that the
diuretic had a lower rate of congestive heart failure than at least
one of the drugs that was being studied. This probably reflects the
value of diuretics for preventing congestive heart failure more than
it reflects any deleterious effects of doxazosin but will certainly
alter the practice of doctors caring for patients with high blood
pressure.
Undoubtedly, there will be a flood of
calls to change patients off Cardura in the next few months, which
would be imprudent. Rather, it would be better to keep patients on
Cardura, check their blood pressure and evaluate whether they develop congestive heart failure. Meanwhile, new patients with
hypertension are best started on diuretics or beta blockers until
results of the ALLHAT study let us know if alternative first line drug
are really any better.
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Heart
to Heart - April 2000
"The Cost of
Cardiology" - Foothill Foundation
I just returned from the American
College of Cardiology annual meeting in Anaheim, which attracted over
32,000 visitors. There were four buildings of new or improved
cardiovascular machines, instruments, medicines, and books that
merchants wanted doctors to buy as agents of our hospitals. The new
tissue harmonic echocardiography machines, and digital workstations
that go with them looked very appealing and I will share this
information with the administrators at Foothill Presbyterian Hospital,
who have previously indicated to me that an echo machine will be on
the budget for next year.
Hospitals in southern California are
generally running at a 2.5% loss the last two years, and most have put
tight clamps on the pharmaceutical and purchase budgets, so the
physicians are confronting the prospect that we are not going to get
everything we want for our patients. Community philanthropy will need
to play a growing role in major equipment purchases if we want to keep
withholding from patients and still reach hospital financial
targets.
The heart of the American College of
Cardiology meetings are the scientific presentations. Dr. Jimmy Tseng,
from Duke, presented the result of the ESPRIT trial, which showed
Integrelin was associated with fewer complications, such as heart
attacks, within 48 hours of STENTS. Its manufacturer, Cor
Pharmaceuticals, is hoping that cardiologists will use their drug
instead of Reopro, made by Johnson & Johnson, which cost $14000
per dose, resulting in a savings of $1000 per patient. Since only 25%
of patients getting STENTS currently receive Reopro nationally, they
are also hoping that more patients will be receiving Integrelin than
used to receive Reopro. One of the economics lectures described how
the savings could translate into hospital services. By way of analogy
with Inter-Community campus, where 200 STENTS are placed annually, if
that hospital used integrelin at $400 instead of Reopro at $14000,
then the $200,000 savings could be used to pay salaries for 5 nurses
or to help buy a new cath lab. This would pay for 1/5 of a new cath
lab! I don't know where the generate the other $800,000 but I'm
hopeful that major benefactor will step forward to meet this community
need, because I cannot imagine that the administrators will find that
much treasure in the operating budget.
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As data continues to show that acute
PTCA has superior results to TPA, we may wish to look for ways to
quickly transport patients from Foothill Presbyterian Hospital to
Inter-Community campus for urgent cardiac catheterization. There also
may be a role for small doses of Reopro or Integrelin, TPA and Lovenox
(more costs) in these patients.
We can't lose sight of what we are
trying to accomplish in cardiology because of the cost of the mission.
I met a lot of old friends and learned a great deal in several areas
of cardiology at this 4-day meeting, but can't fit it all into one
column. As our group grows and our importance in the East San Gabriel
Valley develops, I think we need to understand the impact of economics
on the services that we can offer, and seek to have more community
members understand the choices we have to make.
Dr. Doherty is a member of the
Foothill Foundation, which seeks charitable donations to enhance
hospital services to the community. Questions regarding the Foundation
can be directed through Jill Donuhue at 857-3349.
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