Why do doctors get so obsessed with BP

[Leo_Bloom]

@LSLGuy

Leo old buddy, when somebody uses a phrase in a way that makes you think that they think it’s a common phrase, not some arcane term of art, you really oughta try wiki or Google or even both…

Well, Mr. LMGTFY, the whole point, as I wrote, was I thought it wasn’t a common phrase or term, but a bit of sarcasm whipped out for the occasion.

So WTF is “burbling?”

[yorick73]

@Wesley_Clark

That is very interesting about atenolol. The question then becomes if lowering blood pressure doesn’t cause benefits with atenolol patients, why is that?

Does this finding apply to all beta blockers, or just atenolol? Does propranolol prevent heart attacks? I found a study that says yes.

Propranolol therapy in patients with acute myocardial infarction: the Beta-Blocker Heart Attack Trial - PubMed

So I wonder, is there something in atenolol that is toxic/dangerous that negates the benefits of lowering blood pressure, so whatever benefits it gives are negated by the damage the drug does? Who knows. Bodies are complicated. It just seems weird because I was always under the impression it didn’t matter how you lowered your blood pressure, just that you lowered it. Different drugs have different side benefits (beta blockers help anxiety. Calcium channel blockers help migraines. ACE inhibitors help kidney function, etc) but the lowering of blood pressure was universally beneficial no matter how you did it.

According to the abstract for the 1997 article linked it appears angiotensin II may be important as well. Atenolol doesn’t block the effects of angiotensin II. I’m not in medicine so I don’t know if this idea panned out.

[Really_Not_All_That_Bright]

@yorick73

From the same article:
Looks like that modification is taking a little longer than expected.

Older patients have older doctors, I guess.

Sent from my LG-H872 using Tapatalk

[DSeid]

@Wesley_Clark

That is very interesting about atenolol. The question then becomes if lowering blood pressure doesn’t cause benefits with atenolol patients, why is that?

Does this finding apply to all beta blockers, or just atenolol? …

FWIW what seems to be the most recent Cochrane review on the subject:

@20 January 2017: Cochrane Hypertension Group

… Beta-blockers were not as good at preventing the number of deaths, strokes, and heart attacks as other classes of medicines such as diuretics, calcium-channel blockers, and renin-angiotensin system inhibitors. Most of these findings come from one type of beta-blocker called atenolol. However, beta-blockers are a diverse group of medicines with different properties, and we need more well-conducted research in this area. …

… Beta-blockers probably make little or no difference in the number of deaths among people on treatment for high blood pressure. This effect appears to be similar to that of diuretics and renin-angiotensin system inhibitors, but beta-blockers are probably not as good at preventing deaths from high blood pressure as calcium-channel blockers.

Beta-blockers may reduce the number of strokes, an effect which appears to be similar to that of diuretics. However, beta-blockers may not be as good at preventing strokes as renin-angiotensin system inhibitors or calcium-channel blockers.

Beta-blockers may make little or no difference to the number of heart attacks among people with high blood pressure. The evidence suggests that this effect may not be different from that of diuretics, renin-angiotensin system inhibitors, or calcium-channel blockers. However, among people aged 65 years and older, the evidence suggests that beta-blockers may not be as good at reducing heart attacks as diuretics. …

Please not: I have no expertise in adult hypertension and am only sharing what I can find that might be of interest.

[DSeid]

@psychobunny

The problem is that doctors don’t always know what is the optimal blood pressure. Studies are still ongoing. Some of the earlier trials that compared decreasing systolic blood pressure (the upper number) from 160 or 150 to 140 in older people were inconclusive, which led to many doctors being more “lenient” with blood pressure control. However, the majority of recent studies have shown a definite benefit to lowering blood pressure across all age groups. The recent SPRINT trial which compared getting blood pressure to below 140 (standard) to getting it below 120 (intensive treatment) was actually stopped early because of the significant benefits seen (NNT to prevent coronary events, stroke or death was 60). So, if there is no difference between 160 and 140, but a significant difference between 140 and 120, does that mean that 160 is OK or that everybody should be less than 120? All this is complicated by the fact that blood pressure is very labile and can change minute to minute, especially with anxiety. State of the art treatment is continuous home blood pressure monitoring, to get an accurate value over time.

FWIW, nonvasodilating beta-blockers (such as atenolol) have fallen out of favor recently for blood pressure control. Most specialists would put them third line at best and there are many arguing for them being fourth line treatment, although many patients can benefit from their use for other reasons.
It’s a complicated subject since you have to balance risks or medication versus benefits and to patients who have no symptoms, the risks of medications are magnified since the blood pressure does not affect them.

So psychobunny can you educate me please? Because it sure does get complicated fast.

The 2010 ACCORD trial specifically looked at a lower cardiovascular event risk T2 diabetics (those with dyslipidemia had been enrolled in a lipid trial instead) and found no advantage to aiming for 120 or below in that specific population. Of note at study entry 87% of the population was already being treated for hypertension.
The SPRINT trial excluded diabetics from their study, selected for those at high risk for cardiovascular events, and as part of the multi-drug intensive approach ended up with 41% on a beta-blocker, and found significant benefits to more intensive management.

Right off it seems that intensive goal setting results in fairly common beta-blocker use.

The SPRINT trials’s discussion goes into the ACCORD trial’s results and notes:

… A secondary analysis of the ACCORD results showed that, as compared with the combined standard glycemia and blood-pressure treatments, intensive blood-pressure treatment alone reduced major cardiovascular outcomes by 26% without additional benefit from combining the two intensive treatments.38 Thus, the difference in results between the trials could be due to differences in study design, treatment interactions, or the play of chance. An inherent difference in the cardiovascular benefits of systolic blood-pressure lowering between the population with diabetes and the population without diabetes seems unlikely but cannot be ruled out. …

ISTM that it is hard to extrapolate even from SPRINT to “everybody” since SPRINT specifically selected for those with an increased risk of cardiovascular events.

Right now how decent is the evidence of benefit for treatment to what level of aggressiveness for those who are not at an increased risk of cardiovascular events? (And do you include those whose only risk factor is dyslipidemia adequately managed with a statin plus diet/exercise as a low risk group?)

[qfo_jb2013]

Another reason to monitor blood pressure is, even with low blood pressure per se, high pulse pressure [ a large difference between the two measurments] can mean a higher risk for stroke from UNSEEN plaque bursts that are not detectable from ordinary stress tests.