The down titration makes this trial less of a clinical trial and more of a physiology experiment in my opinion. The results are achieved in an unethical manner but aren’t invalidated. I don’t think it changes clinical practice massively but I think having this trial is a nice reference point. Lower BP is associated with better outcomes.
Down titration must be prohibited even despite of desire to separate two group more clear.Down titration in SPRINT and ACCORD possibly impacted result.I have one paper on this issue where at least more sudden deaths in standard group vs intensive group in SPRINT associated with down titration.
Blood pressure is one of the most overtreated numbers in clinical medicine but blood glucose and A1C are coming up fast on the outside. Cholesterol isn't even in the race because there is no scientifically credible evidence that lowering it will do any good at all. I was in medical school followed by Internal Medicine Residency and then Cardiology Fellowship throughout the 1970s----not exactly the dark ages. The consensus at that time was that long term studies had shown a modest reduction in subsequent stroke in patients with sustained diastolic pressures greater than 105 mmHg. Systolic pressures were felt to have little effect on subsequent health. I am not aware of any studies since then that show otherwise. So I am immediately skeptical of any study that proposes to find differences of 10-20 mmHg in systolic pressure to have a significant effect. Accurate measurement of blood pressure can be problematic since it is affected by multiple physical and emotional factors. Now that we have electronic BP measurement devices we tend to accept the numbers displayed as absolute. But is it really more reliable and consistent than those determined by the old fashioned BP cuffs? We would need some sort of "gold standard" for comparison such as an intra-arterial catheter. With all these caveats and a number of others too long to list here, I am surprised that anyone would undertake an effort to determine benefits from what are really small reductions in systolic pressure.
Focusing on numbers creates a lot of "patients" out of the healthy population. One can see why the pharmaceutical companies would promote this nonsense but why would doctors go along with it? One explanation may be that most all of these new patients require only a BP check, blood tests, and/or prescriptions. They are basically healthy people who have few complaints and require less of the doctor's time. In fact, much of this can be carried out by the office staff. I am not saying that the doctor would deliberately promote this but when experts recommend these measures and it also redounds to the doctor's benefit he may be less motivated to look at the recommendations with a critical eye. Of course these experts are usually professional researchers who may have connections with the pharmaceutical industry.
This is a useful reminder that the control arm should be representative of “usual care”, in order for any positive trial result to truly compel a change in practice.
Sprint never really impacted my pattern of practice, since a patient with an average age of 68, without recent MI, symptomatic HF, or low EF, does not resemble the majority of my general cardiology practice. Also, down titration of meds is not a common strategy; if anything, I’m usually trying to uptitrate in order to treat comorbid CV conditions. Sprint merely provided reassurance that, in the course of up titration, if I happened to lower BP to <120 without causing side effects, I was providing a corollary add-on benefit for free.
There is no standard blood pressure or blood pressure reading. You cannot tell anything from one reading three or four times a week. My wife's pressure is mostly below 100/70 with taking pills. My top number is often 30-40 points higher. I do not care for the one-size-fits-all approach to health care and standards. It's insane.
I don't agree that SPRINT was a flawed study. The study was designed to challenge the conventional standard level of SBP <140 mmHg. So to me the design of the trial was correct and for the sake of comparison between 2 arms SBP numbers were maintained. Where is confusion? Prior to the study I reduced the doses of antihypertensives in many patients in my clinical practice, it was not uncommon. However, following SPRINT, I don't reduce the doses of antihypertensives if the patient is tolerating.
I’m not in healthcare, but my main interest is health. I am smart, logical, patient, and most importantly, curious. Given what I’ve learned since 2020, I don’t trust any study anymore. And I haven’t trusted the standard of care or lab ranges since 2012 when I started my deep dive into healthcare based on my own health issues. The standard of care is a betrayal to doctors and patients. It’s big business. I see it as a problem from the top down. Insurance has too much influence. Pharma has too much influence. Politics has too much influence.
Even a layperson can watch several YouTube videos on the proper way to take BP. I learned a few years ago that the wrist cuff reading, in particular, is worthless. Knowing this saved me a trip to the emergency room:
My 87-year-old mother had a fall, & experienced a brain bleed. At the two week follow up with the neurosurgeon to see if the bleed resolved itself, or if my mother would need brain surgery, the staff took her blood pressure with a wrist cuff. The reading was extremely high, like we’re going to send her to the emergency room right now. I said she’s on blood pressure medicine that has historically controlled it. I realize it can change at anytime, but let’s make sure the wrist cuff is accurate. Can we get a regular, old school arm cuff? They took her blood pressure three more times with the wrist cuff. All sky high, but different readings. I asked again can we get the other cuff? They scrambled around, but there were no other cuffs in the office. I said I don’t want to go to the emergency room without another reading. (It had already been a hell of a week for my mom and an extra, unnecessary ER visit would have been too much for her.) After another 15 minutes, the staff finally found a third person with an arm cuff to come in and take her BP. It was totally normal. I had him take it again. Totally normal.
I wasn’t even mad. I’ve accepted that this is how it goes in medicine today, and truly for the last decade or more . You need to do homework prior to every doctor visit. Learn about your condition. Learn the basics. List questions. Go to the appointment & observe and listen closely. Be kind yet assertive…”that BP is concerning, I’d like to confirm the results. I’ve found it valuable to check and double check. I’m sure you understand.” What you don’t know you can’t look for. We are all human, and I don’t mind errors, but if we could catch some of these things, upstream and correct the protocols, it would be nice. I certainly don’t fault the staff. They have to work with the tools are given and training they are given.
This was a neurosurgeons office. So, if you can’t get the basics, right, like taking accurate blood pressure, that bit of data is going to skew all other decisions. Anyways, her brain bleed had resolved and we didn’t need surgery.
And since I’m on a roll…if you are still reading… that same week some other medical errors I noticed & addressed: 5 days after my mom’s fall and head injury, she was having a very bad night. I had moved in with her to care for her after her fall, so I was observing her closely 24/7. She was in a lot of pain with a bad headache, and actually asked to be taken to the hospital. That never happens. I got her to the ER, they did multiple tests, gave her fluids and IV Tylenol. All her tests were fine except she had a sinus infection. Got script for antibiotics. We were waiting to be discharged, and an ER staff member came in lugging an oxygen tank. She said your mom has Covid, but we’re going to send her home with oxygen instead of admitting her. I said her Covid test came back negative. She said well sometimes the doctors diagnose through symptoms. I said I’d like you to double check, this is patient Jane Doe, date of birth XX. She left the room and came back 10 minutes later, grabbing the oxygen tank, saying you were right, they sent me to the wrong room. Observe and assist. My mom was too sick to advocate for herself. If she had been alone, she would’ve been sent home with an oxygen tank.
Take care of your people.
Then … 10 days, post concussion and brain bleed, per ER doctors orders we went to my mom’s primary care physician to follow up. She had been going to this PCP for 30 years and I knew him well. My mom was describing to him that she still doesn’t feel well. He asked her if she had left the house and resumed her activities as my mom had been extremely active, working part time, etc. at 87. My mom said no she had not left the house she doesn’t feel good. I said she is still acting extremely concussed , foggy, no short term memory and I mean within 30 seconds she doesn’t know what she did 30 seconds ago. She has ear pain. I saw her holding her right ear, in pain. She is using a walker to be steady. The PCP said your mom is depressed. I’m going to give you a script for XYZ antidepressant I said no, she is not depressed. I know what depression is. She’s not resumed her normal activities because she feels unwell. She is sick, not depressed. She had a brain injury 10 days ago. Bleeding in both ears. He said we’re watching that. He was insistent about the script, and I still said no, thinking to myself the last thing we need is another new medication that can make her dizzy or foggy, and then we have another fall. I thought he was shockingly off-base, missing the elephant in the room/brain bleed concussion. Anyway, he wrote down the name of the drug on a piece of paper, handed it to me and said please please look into this. This is not who your mom is, she has always been so active.
I don’t really know that that’s a medical error per se, it was his opinion. Maybe that antidepressant has been shown to be useful off label for concussions ?? He did not explain it that way. But I was certainly not in agreement that she was depressed. The good news is, after about eight weeks. My mother returned to mostly normal. But she stopped driving, and thus her activities were greatly reduced, but she really just couldn’t manage a bigger environment now anyways. I moved her to my town and moved her into a nice senior, living community where I could see her frequently, assist her, and she became very active with in the community which doesn’t require any driving to participate . She is happy and relatively healthy.
My comment may be reaching the wrong audience here, but I very much appreciate the Substack and I always learn a lot. My experience boils down to 80% of the time I will catch an error or inconsistency when I must visit a doctor. Unfortunately, most people are too busy to do homework prior to going to the doctors office and they fully rely on the doctor to get everything 100% right. That is a mistake in any industry.
Just one patient’s perspective. I hope no one is offended. I have so much respect for physicians and what it took to become one. Truly. I just feel bad that doctors are caught up in this mess. They need you in order to keep the wheels turning. Band together and resist. Easier said than done, but this stack & commenters give me hope. Strength in numbers.
I am shocked that a medical professional would use a wrist cuff. Even many non-professionals know that wrist devices are unreliable. To use a wrist cuff to make medical decisions is malpractice. Good on you for standing your ground. I would have done the same
My dentist uses a wrist cuff too. I am friendly with my hygienist, and I tease her “ you know that wrist cuff is going to give an inaccurate reading”. She smiles and agrees. Every 6 months. 🙂
Amen to everything you said above! Your mom is truly blessed to have you as her advocate and you speak so much truth - I am also not a doctor, and I have witnessed firsthand everything you witnessed with your mom in the doctor's offices with my twins and myself at our doctors appointments. And you are so right - health care has lost the "care" and has become a business that is run by insurance companies and pharmaceutical companies. I always wondered why doctors don't band together and sue the insurance companies for trying to dictate how they practice...
Maybe this is subtle, or maybe I'm not fully awake yet (coffee not kicked in). It's clear that the control group received potentially non-standard care and was exposed to harm. There are so many potential confounders in studying BP. How WOULD you design a solid and ethical RCT aiming to identify optimal BP?
Wow. I am shocked. I have never picked up on that issue with the control arm. Disappointing. Those of us in primary care have got to be able to "trust the science". When a landmark study comes out and every body that gives guidance is in agreement and gives you specific advice for these targets, you generally accept that the science is good! It is a very unsettling situation that we've really got to question everything told to us and go back to the study design to parse it out for ourselves. The bigger take home point I've gotten from Sprint is that the method by which we are even measuring BP is extremely important! I can attest to the high variability in blood pressures obtained in daily clinical practice. Health systems that continue to use auscultatory methods are not using what was done in Sprint. The entire procedure used to measure BP has so many areas where things can be done "wrong" - taking BP over shirts/sweaters/jackets, while talking to the patient, patient legs crossed, patient sitting on exam table with arm not at correct level, not waiting 5 minutes, etc etc. This is how BP is monitored in the vast majority of places. I'll consistently get a certain BP range on a patient and the very next day in the cardiology office, a drastically different result is obtained. Not terribly helpful. Before we can hit targets, it would make most sense to get the data point in correct fashion! It would also be useful to do a "real world" study to see how big health system "quality metrics" affect BP data collection, overall BP control, and patient outcomes. When your health care system takes "the last BP measurement for the year" as the data point on which your "quality bonus" will be determined, it drives various providers to do different things to make sure their patients hit that target. Again, if you focus on blood pressure for a living, you realize how labile this particular data point can be and the myriad factors that affect the measurement and the treatment of such. In all honesty, I don't think this realization of Sprint design will change my practice. Several years ago I decided to focus on the actual measurement of blood pressure in my office and to make sure we were doing it correctly. Having patients able to do home BP monitoring and instructing them on the ideal method is also helpful. The first step is making sure the quality of your "data" is as accurate as it can be and then make the adjustments from there.
Please describe the do’s and don’ts or give link. My BP tends to be high in doctors offices in part because I’m so ticked at how it’s being done. Just a patient here. Thanks for what you’ve already said!
I would recommend you get a basic home BP cuff (automatic)(omron makes good ones - don't need anything fancy - should be < $50). You can take personal control of this and monitor your own blood pressure periodically at home (don't need to get anxiously checking daily, but do it twice daily for 5-7 days just before your doctors' appointment. (first thing in the morning and sometime in the evening). Bring results to your doctor - will give 10-14 more "data points" to help make decisions about blood pressure, medications, etc. Looking around on American Heart Association website will also give info; Heart.org as linked here, etc. Good luck!
When my blood pressure is taken at doctor offices, it usually hurts. I believe I recall being told it’s because my BP is high. I think the wrap is too tight. Is there leeway there?
I would say it is rarely taken properly. I am on medication. My pressure ranges between 125 to 140. No recollection of the diastolic.
5 minute wait is to let you be more relaxed - they did this in the Sprint trial. Rushing into an appointment or running up the stairs and checking BP immediately is not the data point we are looking for. The more consistent you can make this method of checking blood pressure, the more accurate your results will be. Better data, better decisions.
It’s embarrassing to me that as a nurse, I wasn’t trained on taking a proper BP in nursing school. It was reading a doctor’s blog many years ago where I learned about waiting 5 mins, feet flat on floor, back supported, arm at heart level, and no talking. It amazes me that I’ve NEVER had it taken properly when going to a doctor appointment. Now I don’t shut up about it when I see another nurse or CNA do it incorrectly, and I don’t care who it pisses off. This is important stuff!
In our large health care system, they trained the LPNs or CMAs to do an extensive "check in" process that involved at least 27 steps! Asking all kinds of questions, measuring height and weight at every appointment, then reviewing complicated medication lists. I cannot blame these hard working people for not recalling this specific (and somewhat cumbersome) routine as the months/years go by. It is just not reasonable to do it this way. (so I don't get irritated at these people). The "system" should come up with a better method. Having a "blood pressure station" for patient to go into when they arrive and follow this procedure on their own w/ an automatic cuff makes much more sense. And you can control the method with your own home BP checks and get good data points that way.
After the last several years those of us actually looking for truth in the science need to return to the old standard, multiple independent RCTs not funded by pharmaceutical companies before we change policy.
And let’s not forget what we know from the Million Hearts Model. Pharmacologically keeping blood pressure low might be better for the heart, but comes at a cost of more ER visits, kidney injuries, electrolyte abnormalities, falls, medication side effects. Sure am glad grandma’s Cardiologist kept her blood pressure low so she could die in a nursing home 3 months after breaking her hip!
Remember that ACCORD was unable to replicate SPRINT’s results. Causes of death during SPRINT are in the link below. Of the 365 deaths, 200 of them were cancer, accidents, unknown, unclassified, dialysis, suicide/homicide. The trial only lasted 3 years. The NNT for cardiovascular death was 175. That’s an awful lot of extra medication.
Interesting comment. Can you confirm my understanding of it? Are you saying that we would have to pharmaceutically treat 175 patients, getting their systolic below 120/80 in order to prevent 1 cardiovascular death? If yes, in how many years would that NNT apply to?
That is correct. Treat 175 people to prevent one of them from dying of a heart attack. Better buy your lottery tickets while you’re at it.
175 isn’t astoundingly bad in the scheme of medical interventions. Similar to statins for primary prevention, depending on the data set you look at. Nearly an order of magnitude better than a pneumonia vaccine.
The trial lasted 3 years, so we can draw conclusions for that period. But, you know, pull the timeline long enough and all your trial enrollees will be dead anyway.
Fascinating - I did not know this. A very important detail and example of how RCTs can be gamed to favor the study hypothesis. Would like to know your take on the pivotal trial for Entresto, which used a run in period for the study drug, selecting out those destined to have an adverse reaction. Does this negate the findings?
Completely agree!
The down titration makes this trial less of a clinical trial and more of a physiology experiment in my opinion. The results are achieved in an unethical manner but aren’t invalidated. I don’t think it changes clinical practice massively but I think having this trial is a nice reference point. Lower BP is associated with better outcomes.
Down titration must be prohibited even despite of desire to separate two group more clear.Down titration in SPRINT and ACCORD possibly impacted result.I have one paper on this issue where at least more sudden deaths in standard group vs intensive group in SPRINT associated with down titration.
Blood pressure is one of the most overtreated numbers in clinical medicine but blood glucose and A1C are coming up fast on the outside. Cholesterol isn't even in the race because there is no scientifically credible evidence that lowering it will do any good at all. I was in medical school followed by Internal Medicine Residency and then Cardiology Fellowship throughout the 1970s----not exactly the dark ages. The consensus at that time was that long term studies had shown a modest reduction in subsequent stroke in patients with sustained diastolic pressures greater than 105 mmHg. Systolic pressures were felt to have little effect on subsequent health. I am not aware of any studies since then that show otherwise. So I am immediately skeptical of any study that proposes to find differences of 10-20 mmHg in systolic pressure to have a significant effect. Accurate measurement of blood pressure can be problematic since it is affected by multiple physical and emotional factors. Now that we have electronic BP measurement devices we tend to accept the numbers displayed as absolute. But is it really more reliable and consistent than those determined by the old fashioned BP cuffs? We would need some sort of "gold standard" for comparison such as an intra-arterial catheter. With all these caveats and a number of others too long to list here, I am surprised that anyone would undertake an effort to determine benefits from what are really small reductions in systolic pressure.
I'm finding it's rare to find an internist, let alone a cardiologist, that isn't hyper focused on treating BP and LDL to a target number.
Focusing on numbers creates a lot of "patients" out of the healthy population. One can see why the pharmaceutical companies would promote this nonsense but why would doctors go along with it? One explanation may be that most all of these new patients require only a BP check, blood tests, and/or prescriptions. They are basically healthy people who have few complaints and require less of the doctor's time. In fact, much of this can be carried out by the office staff. I am not saying that the doctor would deliberately promote this but when experts recommend these measures and it also redounds to the doctor's benefit he may be less motivated to look at the recommendations with a critical eye. Of course these experts are usually professional researchers who may have connections with the pharmaceutical industry.
This is a useful reminder that the control arm should be representative of “usual care”, in order for any positive trial result to truly compel a change in practice.
Sprint never really impacted my pattern of practice, since a patient with an average age of 68, without recent MI, symptomatic HF, or low EF, does not resemble the majority of my general cardiology practice. Also, down titration of meds is not a common strategy; if anything, I’m usually trying to uptitrate in order to treat comorbid CV conditions. Sprint merely provided reassurance that, in the course of up titration, if I happened to lower BP to <120 without causing side effects, I was providing a corollary add-on benefit for free.
Down titration in SPRINT and ACCORD meant deconnection,discontinuation of anti-hypertensive drugs.
There is no standard blood pressure or blood pressure reading. You cannot tell anything from one reading three or four times a week. My wife's pressure is mostly below 100/70 with taking pills. My top number is often 30-40 points higher. I do not care for the one-size-fits-all approach to health care and standards. It's insane.
I don't agree that SPRINT was a flawed study. The study was designed to challenge the conventional standard level of SBP <140 mmHg. So to me the design of the trial was correct and for the sake of comparison between 2 arms SBP numbers were maintained. Where is confusion? Prior to the study I reduced the doses of antihypertensives in many patients in my clinical practice, it was not uncommon. However, following SPRINT, I don't reduce the doses of antihypertensives if the patient is tolerating.
Prior to the study, how did you make the decision to reduce dose of anti hypertensives in a patient tolerating the current regimen?
I’ve often wondered if the BP measurement at which a diagnosis of high blood pressure is made was changed in order to prescribe more medication…
Another big problem in translation, is that they measured blood pressure very differ than we typically do in primary care.
Also, how many of the interventions arm participants actually achieved the target? Few!
I’m not in healthcare, but my main interest is health. I am smart, logical, patient, and most importantly, curious. Given what I’ve learned since 2020, I don’t trust any study anymore. And I haven’t trusted the standard of care or lab ranges since 2012 when I started my deep dive into healthcare based on my own health issues. The standard of care is a betrayal to doctors and patients. It’s big business. I see it as a problem from the top down. Insurance has too much influence. Pharma has too much influence. Politics has too much influence.
Even a layperson can watch several YouTube videos on the proper way to take BP. I learned a few years ago that the wrist cuff reading, in particular, is worthless. Knowing this saved me a trip to the emergency room:
My 87-year-old mother had a fall, & experienced a brain bleed. At the two week follow up with the neurosurgeon to see if the bleed resolved itself, or if my mother would need brain surgery, the staff took her blood pressure with a wrist cuff. The reading was extremely high, like we’re going to send her to the emergency room right now. I said she’s on blood pressure medicine that has historically controlled it. I realize it can change at anytime, but let’s make sure the wrist cuff is accurate. Can we get a regular, old school arm cuff? They took her blood pressure three more times with the wrist cuff. All sky high, but different readings. I asked again can we get the other cuff? They scrambled around, but there were no other cuffs in the office. I said I don’t want to go to the emergency room without another reading. (It had already been a hell of a week for my mom and an extra, unnecessary ER visit would have been too much for her.) After another 15 minutes, the staff finally found a third person with an arm cuff to come in and take her BP. It was totally normal. I had him take it again. Totally normal.
I wasn’t even mad. I’ve accepted that this is how it goes in medicine today, and truly for the last decade or more . You need to do homework prior to every doctor visit. Learn about your condition. Learn the basics. List questions. Go to the appointment & observe and listen closely. Be kind yet assertive…”that BP is concerning, I’d like to confirm the results. I’ve found it valuable to check and double check. I’m sure you understand.” What you don’t know you can’t look for. We are all human, and I don’t mind errors, but if we could catch some of these things, upstream and correct the protocols, it would be nice. I certainly don’t fault the staff. They have to work with the tools are given and training they are given.
This was a neurosurgeons office. So, if you can’t get the basics, right, like taking accurate blood pressure, that bit of data is going to skew all other decisions. Anyways, her brain bleed had resolved and we didn’t need surgery.
And since I’m on a roll…if you are still reading… that same week some other medical errors I noticed & addressed: 5 days after my mom’s fall and head injury, she was having a very bad night. I had moved in with her to care for her after her fall, so I was observing her closely 24/7. She was in a lot of pain with a bad headache, and actually asked to be taken to the hospital. That never happens. I got her to the ER, they did multiple tests, gave her fluids and IV Tylenol. All her tests were fine except she had a sinus infection. Got script for antibiotics. We were waiting to be discharged, and an ER staff member came in lugging an oxygen tank. She said your mom has Covid, but we’re going to send her home with oxygen instead of admitting her. I said her Covid test came back negative. She said well sometimes the doctors diagnose through symptoms. I said I’d like you to double check, this is patient Jane Doe, date of birth XX. She left the room and came back 10 minutes later, grabbing the oxygen tank, saying you were right, they sent me to the wrong room. Observe and assist. My mom was too sick to advocate for herself. If she had been alone, she would’ve been sent home with an oxygen tank.
Take care of your people.
Then … 10 days, post concussion and brain bleed, per ER doctors orders we went to my mom’s primary care physician to follow up. She had been going to this PCP for 30 years and I knew him well. My mom was describing to him that she still doesn’t feel well. He asked her if she had left the house and resumed her activities as my mom had been extremely active, working part time, etc. at 87. My mom said no she had not left the house she doesn’t feel good. I said she is still acting extremely concussed , foggy, no short term memory and I mean within 30 seconds she doesn’t know what she did 30 seconds ago. She has ear pain. I saw her holding her right ear, in pain. She is using a walker to be steady. The PCP said your mom is depressed. I’m going to give you a script for XYZ antidepressant I said no, she is not depressed. I know what depression is. She’s not resumed her normal activities because she feels unwell. She is sick, not depressed. She had a brain injury 10 days ago. Bleeding in both ears. He said we’re watching that. He was insistent about the script, and I still said no, thinking to myself the last thing we need is another new medication that can make her dizzy or foggy, and then we have another fall. I thought he was shockingly off-base, missing the elephant in the room/brain bleed concussion. Anyway, he wrote down the name of the drug on a piece of paper, handed it to me and said please please look into this. This is not who your mom is, she has always been so active.
I don’t really know that that’s a medical error per se, it was his opinion. Maybe that antidepressant has been shown to be useful off label for concussions ?? He did not explain it that way. But I was certainly not in agreement that she was depressed. The good news is, after about eight weeks. My mother returned to mostly normal. But she stopped driving, and thus her activities were greatly reduced, but she really just couldn’t manage a bigger environment now anyways. I moved her to my town and moved her into a nice senior, living community where I could see her frequently, assist her, and she became very active with in the community which doesn’t require any driving to participate . She is happy and relatively healthy.
My comment may be reaching the wrong audience here, but I very much appreciate the Substack and I always learn a lot. My experience boils down to 80% of the time I will catch an error or inconsistency when I must visit a doctor. Unfortunately, most people are too busy to do homework prior to going to the doctors office and they fully rely on the doctor to get everything 100% right. That is a mistake in any industry.
Just one patient’s perspective. I hope no one is offended. I have so much respect for physicians and what it took to become one. Truly. I just feel bad that doctors are caught up in this mess. They need you in order to keep the wheels turning. Band together and resist. Easier said than done, but this stack & commenters give me hope. Strength in numbers.
I am shocked that a medical professional would use a wrist cuff. Even many non-professionals know that wrist devices are unreliable. To use a wrist cuff to make medical decisions is malpractice. Good on you for standing your ground. I would have done the same
My dentist uses a wrist cuff too. I am friendly with my hygienist, and I tease her “ you know that wrist cuff is going to give an inaccurate reading”. She smiles and agrees. Every 6 months. 🙂
Amen to everything you said above! Your mom is truly blessed to have you as her advocate and you speak so much truth - I am also not a doctor, and I have witnessed firsthand everything you witnessed with your mom in the doctor's offices with my twins and myself at our doctors appointments. And you are so right - health care has lost the "care" and has become a business that is run by insurance companies and pharmaceutical companies. I always wondered why doctors don't band together and sue the insurance companies for trying to dictate how they practice...
I’m not offended at all. In a complex world things go wrong with the best of intentions. You never
Suggested the people involved didn’t want to care for your mom. She is lucky to have you. As a retired surgeon I have similar experiences.
Maybe this is subtle, or maybe I'm not fully awake yet (coffee not kicked in). It's clear that the control group received potentially non-standard care and was exposed to harm. There are so many potential confounders in studying BP. How WOULD you design a solid and ethical RCT aiming to identify optimal BP?
Wow. I am shocked. I have never picked up on that issue with the control arm. Disappointing. Those of us in primary care have got to be able to "trust the science". When a landmark study comes out and every body that gives guidance is in agreement and gives you specific advice for these targets, you generally accept that the science is good! It is a very unsettling situation that we've really got to question everything told to us and go back to the study design to parse it out for ourselves. The bigger take home point I've gotten from Sprint is that the method by which we are even measuring BP is extremely important! I can attest to the high variability in blood pressures obtained in daily clinical practice. Health systems that continue to use auscultatory methods are not using what was done in Sprint. The entire procedure used to measure BP has so many areas where things can be done "wrong" - taking BP over shirts/sweaters/jackets, while talking to the patient, patient legs crossed, patient sitting on exam table with arm not at correct level, not waiting 5 minutes, etc etc. This is how BP is monitored in the vast majority of places. I'll consistently get a certain BP range on a patient and the very next day in the cardiology office, a drastically different result is obtained. Not terribly helpful. Before we can hit targets, it would make most sense to get the data point in correct fashion! It would also be useful to do a "real world" study to see how big health system "quality metrics" affect BP data collection, overall BP control, and patient outcomes. When your health care system takes "the last BP measurement for the year" as the data point on which your "quality bonus" will be determined, it drives various providers to do different things to make sure their patients hit that target. Again, if you focus on blood pressure for a living, you realize how labile this particular data point can be and the myriad factors that affect the measurement and the treatment of such. In all honesty, I don't think this realization of Sprint design will change my practice. Several years ago I decided to focus on the actual measurement of blood pressure in my office and to make sure we were doing it correctly. Having patients able to do home BP monitoring and instructing them on the ideal method is also helpful. The first step is making sure the quality of your "data" is as accurate as it can be and then make the adjustments from there.
Please describe the do’s and don’ts or give link. My BP tends to be high in doctors offices in part because I’m so ticked at how it’s being done. Just a patient here. Thanks for what you’ve already said!
I would recommend you get a basic home BP cuff (automatic)(omron makes good ones - don't need anything fancy - should be < $50). You can take personal control of this and monitor your own blood pressure periodically at home (don't need to get anxiously checking daily, but do it twice daily for 5-7 days just before your doctors' appointment. (first thing in the morning and sometime in the evening). Bring results to your doctor - will give 10-14 more "data points" to help make decisions about blood pressure, medications, etc. Looking around on American Heart Association website will also give info; Heart.org as linked here, etc. Good luck!
When my blood pressure is taken at doctor offices, it usually hurts. I believe I recall being told it’s because my BP is high. I think the wrap is too tight. Is there leeway there?
I would say it is rarely taken properly. I am on medication. My pressure ranges between 125 to 140. No recollection of the diastolic.
I really appreciate this commentary.
another view of same info:
https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home
LovinTexas here is a link to appropriate way to measure blood pressure:
https://www.heart.org/en/news/2020/05/22/how-to-accurately-measure-blood-pressure-at-home#:~:text=With%20the%20cuff%20on%20your,minutes%20before%20taking%20a%20measurement.
What is the five-minute wait after? Arrival to exam room, or what?
5 minute wait is to let you be more relaxed - they did this in the Sprint trial. Rushing into an appointment or running up the stairs and checking BP immediately is not the data point we are looking for. The more consistent you can make this method of checking blood pressure, the more accurate your results will be. Better data, better decisions.
Amish proverb: Can’t make good hay with bad grass.
It’s embarrassing to me that as a nurse, I wasn’t trained on taking a proper BP in nursing school. It was reading a doctor’s blog many years ago where I learned about waiting 5 mins, feet flat on floor, back supported, arm at heart level, and no talking. It amazes me that I’ve NEVER had it taken properly when going to a doctor appointment. Now I don’t shut up about it when I see another nurse or CNA do it incorrectly, and I don’t care who it pisses off. This is important stuff!
In our large health care system, they trained the LPNs or CMAs to do an extensive "check in" process that involved at least 27 steps! Asking all kinds of questions, measuring height and weight at every appointment, then reviewing complicated medication lists. I cannot blame these hard working people for not recalling this specific (and somewhat cumbersome) routine as the months/years go by. It is just not reasonable to do it this way. (so I don't get irritated at these people). The "system" should come up with a better method. Having a "blood pressure station" for patient to go into when they arrive and follow this procedure on their own w/ an automatic cuff makes much more sense. And you can control the method with your own home BP checks and get good data points that way.
Wow. Had no idea this was the case. Thanks for sharing something new
After the last several years those of us actually looking for truth in the science need to return to the old standard, multiple independent RCTs not funded by pharmaceutical companies before we change policy.
And let’s not forget what we know from the Million Hearts Model. Pharmacologically keeping blood pressure low might be better for the heart, but comes at a cost of more ER visits, kidney injuries, electrolyte abnormalities, falls, medication side effects. Sure am glad grandma’s Cardiologist kept her blood pressure low so she could die in a nursing home 3 months after breaking her hip!
Remember that ACCORD was unable to replicate SPRINT’s results. Causes of death during SPRINT are in the link below. Of the 365 deaths, 200 of them were cancer, accidents, unknown, unclassified, dialysis, suicide/homicide. The trial only lasted 3 years. The NNT for cardiovascular death was 175. That’s an awful lot of extra medication.
https://www.nejm.org/doi/suppl/10.1056/NEJMoa1511939/suppl_file/nejmoa1511939_appendix.pdf
It’s harrowing how many docs out there are treating based on SPRINT.
""The NNT for cardiovascular death was 175.""
Interesting comment. Can you confirm my understanding of it? Are you saying that we would have to pharmaceutically treat 175 patients, getting their systolic below 120/80 in order to prevent 1 cardiovascular death? If yes, in how many years would that NNT apply to?
That is correct. Treat 175 people to prevent one of them from dying of a heart attack. Better buy your lottery tickets while you’re at it.
175 isn’t astoundingly bad in the scheme of medical interventions. Similar to statins for primary prevention, depending on the data set you look at. Nearly an order of magnitude better than a pneumonia vaccine.
The trial lasted 3 years, so we can draw conclusions for that period. But, you know, pull the timeline long enough and all your trial enrollees will be dead anyway.
Thank you Chaz. Your comment on statins is spot on. I will never subject myself to that poison
I wasn't aware that many doctors treat to target < 120 SBP.
Hopefully CMS doesn't incentivize this practice.
Fascinating - I did not know this. A very important detail and example of how RCTs can be gamed to favor the study hypothesis. Would like to know your take on the pivotal trial for Entresto, which used a run in period for the study drug, selecting out those destined to have an adverse reaction. Does this negate the findings?