Good article, and it reminded me of an amusing (if annoying) blood pressure related adventure in my own life. The year was 1970. I was 25 years old, the war in Vietnam was on, and I had reported to my local AFEES (Armed Forces Entrance Examination Station) for my draft physical. I remember a few of the other men talking about the measures they had taken to try to flunk their exams. Things like drinking a lot of vodka and running around outside for a while in the cold winter weather to try to make themselves sick. Although I had no great desire to be drafted, I couldn't bring myself to fake some kind of disability, so I just took my chances.
So we shuffled along from station to station in our underwear, carrying our valuables in a small paper bag (they provided lockers for clothes but advised not to leave wallet, keys, etc. in them). One stop involved a medic drawing some blood to check for whatever. But in my case this guy just couldn't find the vein in the inside of my elbow, and grew increasingly frustrated as he stabbed me over and over with the needle (and a second one, which didn't do any better) in a futile attempt to get enough blood in the syringe. After managing to fill it about half way, he gave up and handed me a cotton ball to press against the wound(s) so I wouldn't bleed to death. The whole incident wasn't really physically painful, but I grew a bit paranoid with the thought that the amount of blood he extracted wasn't going to suffice, and that before they let me go they would be forced to resort to more drastic methods of exsanguination (a vampire, perhaps?) to satisfy their needs.
As I proceeded to the next station I started feeling a bit woozy and light-headed. Twice I dropped my bag and had to pick it up again. Up to this time in my life I had never felt that I was on the verge of fainting, but now I was starting to understand how that could happen. Finally I reached a station with a bench that I could sit down on, and I immediately started feeling better. This station was for checking blood pressure and pulse rate, and after the medic checked mine he remarked that they were both too high and said he would come back in a little while to measure them again after giving me a chance to rest up. When he returned, my numbers had improved but were still above "normal" (I don't recall the exact figures but based on Dr. Liberman's article they weren't really much to worry about). At the end of the whole exam I was given instructions to visit a doctor of my choice to have my blood pressure and pulse checked twice a day for three days and report the results to AFEES.
Each time my doctor took my blood pressure, I could feel myself stressing out again as I recalled my experience at AFEES. The doc said my blood pressure was unusual: not just high but wandering all over the place. He said it would probably keep me out of the army, but I should really get it checked and treated if it continued like that. I received a "1-Y" classification from the draft board, meaning I was temporarily unfit to serve, but they could call me back later for a reevaluation (unlike "4-F", which meant permanently unfit).
Some months later I received two letters from the draft board on the same day. One was an order to report for another physical, and the other was the kind of initial letter they send to potential draftees who were not yet in the system. That second letter made me suspicious of bureaucratic error, and, sure enough, when I called to confirm it, I was told that they had screwed up: they had sent my file somewhere, and, not realizing why it was missing, mistakenly sent me those letters, which I should ignore. A few months later I passed my 26th birthday, which considerably decreased my chances of being drafted. That, plus a high number in the draft lottery, kept me from being inducted.
A couple of years later I went to a doctor to get a physical exam. The doc checked my blood pressure quickly so as not to give me a chance to get worked up over it, and it came out fine: (like 124/70, or maybe 120/74).
If this whole story sounds a bit like Arlo Guthrie and "Alice's Restaurant", the same thought occurred to me as well.
Thank you. Thank you . I wish this article was in the New York Times and every other big city paper. I have a very hard time, convincing patients and other positions.
In my state, dentists and hygienists are required to check blood pressure, although we have no substantive guidelines of what we are to do besides record it. I find it to be quite silly, since most patients have elevated BP coming to the dentist. And if we try to have a conversation about an elevated reading, patients become quite irritated which in turn doesn’t help the BP.
This is a pet peeve of mine! Absolutely no "data" to support this. Someone, somewhere who likely has no background in treating or monitoring high blood pressure felt we must "find" people with high blood pressure and maybe the dentist is the only medical office they go to. Hmmm. Sounds good in theory perhaps. Let's not consider the extra steps and slow down to dental visits. And definitely let's not consider the potential negative effects. I have numerous patients who come in for an appointment and tell me "I stopped my blood pressure med! My blood pressure was so low at the dentist that I don't need it anymore!" Super helpful. Now BP high again. (and dentist never is the one telling them to stop - they make this decision on their own).
As I pointed out, there is a very specific way that blood pressure should be measured. Sitting at the dentist office is not the right scenario.
at a minimum, I'd accept this more if they only checked BP on a patient who says they don't have a PCP, never see a doctor - - those particular people might be reasonable to do a blood pressure and encourage to find PCP if elevated. But I doubt all the busy work dentists do with BP checks is doing anything to improve population health and I would advocate for not checking at all. Not helpful and slows the process as you describe.
The measurement of blood pressure has always been an area of great focus for me. After years of checking blood pressure in the office and recognizing that the nurse got one value, I got a different reading made me realize that there is a lot of variability in the results we get. Yet we place a LOT of value in these numbers and we either treat or don't treat. So they are important. After further digging and research, this is what I've gleaned and how I manage blood pressures in my practice.
The method and the procedure by which we actually check blood pressure is supremely important! What any clinic should focus on (and patients doing their own home BP monitoring) - try to follow the recommended method/procedure as best you can. This will give us the most accurate data. Using an AUTOMATIC CUFF (not a hand held or wall mounted) is recommended. For home blood pressures, finding a basic automatic cuff that has been validated.
You should be in a room by yourself; not talking; legs not crossed. Wait 5 minutes before the check.
Doing some home checks gives more data points to supplement what your doctor gets in the office. (again, follow accurate procedure when checking)
The other thing that really frustrated me re: blood pressure was managing HTN becomes a great parameter to focus on per Quality Metrics. Our big health care system set a policy that the last blood pressure a patient had in the record by the end of the year was the one that would count for measuring the doctor's quality of care! This is such an arbitrary number since this is a highly variable reading. I could only see the negative effects: doctors pushed to randomly call patients back into clinic to get another BP reading to "make sure" their number met the metric. I would not doubt it drove some physicians to just write in a number that fit. It would push other doctors to start medications when they otherwise wouldn't. Just a great example of the very real negative effects the silly "quality metric" "pay for performance" and proving our "value" is not only a waste of time but potential leading to suboptimal care.
Robert, thanks for your comment. I would not bet against the black swan; "all" is too much, so that I would say "most". It wouldn't be fair to take your money. The prevalence of hypertension in centenarians varies from 19% to 60%. Cohorts of centenarians are not common, but they support the view that BP increases late in their lives. Please take a look at Figure 2 in the first reference I mentioned earlier. It is not possible to paste it here, apparently.
As a radiologist I see imaging biomarkers that could reliably prognosticate hypertensive complications, such as prominent arterial ectasia on angiographic studies and brain microhemorrhages and white matter hyperintensities on MRI. It seems as though lack of such permanent structural changes could mitigate against major patient anxiety about transient BP elevations.
If I'm having trouble deciding if we truly have "white coat HTN", I do look for signs of end organ effects. At times I've gotten an Echo to look for LVH. Certainly any brain changes would encourage more aggressive control of blood pressures!
Question: Reperfusion injury is considered a risk of rapidly lowering blood pressure. How does this differ fron the following:
1) Exercise where BP goes very high, and may rapidly decline upon resting.
2) Emotional BP which goes up and down quick.
Why aren't people injured by those rapid BP drops? I would guess some elderly people with chronic high BP or small vessel disease could be harmed by such day to day events?
The specific situations you describe are normal physiologic responses and the body is so good at managing these changing situations. The risk of rapid lowering of blood pressure really occurs when we are lowering blood pressure artificially with medications - then we override the body's own mechanisms and can definitely cause harm.
The body's finely tuned mechanisms to modulate blood pressure can be affected by age and certain medical conditions. Elderly people are at risk for "autonomic dysfunction" when the mechanism to manage and control blood pressure and heart rate response are no longer well-coordinated. They become at risk for falls/passing out and often have bothersome symptoms of dizziness. They are more sensitive to the effects of blood pressure medicines. Parkinson't disease and POTS are other situations people have these problems.
My sister-in-law in her late 70s, following the long illness of her husband and his death was having these horribly high blood pressure spikes in the middle of the night, systolic over 200. Ambulances were called, She was seen by multiple physicians including internal medicine who could not identify a way to treat it without tanking her blood pressure during the day. Being only a nurse 😉. I held my tongue for a while, and then I asked her why she was checking her blood pressure in the middle of the night. Did she have a pounding headache that woke her up or some other symptom that could be attributed to blood pressure? No she said, I wake up, feeling panicked and anxious, and then I check my blood pressure…
Well, perhaps you are checking your blood pressure in the middle of a panic attack, which would obviously be high….
“Huh”-she said… I think I’ll stop doing that and perhaps do some journaling about my grief and see if the panic attacks go away…and they did… and her BP is lovely.
More data is not necessarily helpful and I would whole heartedly agree we that we need to understand why and when we treat - with great confidence because the new era of personal health monitoring is throwing a whole lot of data points at us and creating anxiety and feedback loops and eroding the confidence of patients in their caregivers… we need to be solid in our assessments and listen well so that our patients may listen to us.
My sister-in-law in her late 70s, following the long illness of her husband and his death was having these horribly high blood pressure spikes in the middle of the night, systolic over 200. Ambulances were called, She was seen by multiple physicians including internal medicine who could not identify a way to treat it without tanking her blood pressure during the day. Being only a nurse 😉. I held my tongue for a while, and then I asked her why she was checking her blood pressure in the middle of the night. Did she have a pounding headache that woke her up or some other symptom that could be attributed to blood pressure? No she said, I wake up, feeling panicked and anxious, and then I check my blood pressure…
Well, perhaps you are checking your blood pressure in the middle of a panic attack, which would obviously be high….
Thank goodness for a sensible post re high BP! We treat thousands because of statistical risk and a huge proportion of them would never have a problem from their raised BP but they do suffer from their medication.
Great post. I still get calls from CCU about SBP 180 and asymptomatic.
This OP could be added to a large series of clinicians treating ourselves to make us feel better, whilst achieving nothing for our pts (except maybe causing side effects).
Excellent article. The same sensible reasoning should be applied to surrogate markers such as A1C and lipid levels. The figures commonly quoted for risk of stroke, heart attack, etc. are almost always relative risk and are of no practical significance despite achievement of "statistical significance" on observational data of dubious accuracy.
Another BP issue is operator variability: the same patient often has disparate numbers when measured by different examiners: often by 10-20 mm. Hard to know what to make of studies that tout 5-10 mm of BP reduction as beneficial??
Hello all, as a new subscriber, I'm unsure how I'll be identified; it may be Danni, my middle name, but I prefer F Fuchs. I appreciate Dr. Joshua's comment, but I would like to address this issue from a different perspective. High blood pressure is the major risk factor (contributing to more than 50% of attributable risk for CHD, stroke, valve diseases, AFib, HFpEF, dementias, CKD, etc.). Vascular aging is not inevitable, and all centenarians had blood pressure below 110 mmHg throughout their lives. I am sharing these ideas, acting as a scientific advocate. If the editors are interested, I can expand on this here, but the ideas are published in two manuscripts I wrote with Paul Whelton (the first link) and with Whelton, S. Fuchs, and O. Berwanger (the second link). The manuscripts are open for view: https://doi.org/10.1161/HYPERTENSIONAHA.119.14240; https://doi.org/10.1161/HYPERTENSIONAHA.124.21361
Your piece is spot-on! Having served a retirement community for >30 years, and literally seen >100K senior citizens (conservative estimate), your post so resonates with my clinical experience. I have spent hours and hours taking my time explaining to the generally frightened and worried seniors the subtleties of BP treatment and, more so, BP management. It's difficult to do in a high-acuity, busy ER. It takes so much time. It'd be much faster to just give a pill to lower the BP and superficially treat the patient's concern, then go on to the next patient. But, I can't help myself and start explaining and educating. Oh, and when they start off by saying, "I always know when my BP is high..." OMG, here I go with my lecture on hypertension...
Good article, and it reminded me of an amusing (if annoying) blood pressure related adventure in my own life. The year was 1970. I was 25 years old, the war in Vietnam was on, and I had reported to my local AFEES (Armed Forces Entrance Examination Station) for my draft physical. I remember a few of the other men talking about the measures they had taken to try to flunk their exams. Things like drinking a lot of vodka and running around outside for a while in the cold winter weather to try to make themselves sick. Although I had no great desire to be drafted, I couldn't bring myself to fake some kind of disability, so I just took my chances.
So we shuffled along from station to station in our underwear, carrying our valuables in a small paper bag (they provided lockers for clothes but advised not to leave wallet, keys, etc. in them). One stop involved a medic drawing some blood to check for whatever. But in my case this guy just couldn't find the vein in the inside of my elbow, and grew increasingly frustrated as he stabbed me over and over with the needle (and a second one, which didn't do any better) in a futile attempt to get enough blood in the syringe. After managing to fill it about half way, he gave up and handed me a cotton ball to press against the wound(s) so I wouldn't bleed to death. The whole incident wasn't really physically painful, but I grew a bit paranoid with the thought that the amount of blood he extracted wasn't going to suffice, and that before they let me go they would be forced to resort to more drastic methods of exsanguination (a vampire, perhaps?) to satisfy their needs.
As I proceeded to the next station I started feeling a bit woozy and light-headed. Twice I dropped my bag and had to pick it up again. Up to this time in my life I had never felt that I was on the verge of fainting, but now I was starting to understand how that could happen. Finally I reached a station with a bench that I could sit down on, and I immediately started feeling better. This station was for checking blood pressure and pulse rate, and after the medic checked mine he remarked that they were both too high and said he would come back in a little while to measure them again after giving me a chance to rest up. When he returned, my numbers had improved but were still above "normal" (I don't recall the exact figures but based on Dr. Liberman's article they weren't really much to worry about). At the end of the whole exam I was given instructions to visit a doctor of my choice to have my blood pressure and pulse checked twice a day for three days and report the results to AFEES.
Each time my doctor took my blood pressure, I could feel myself stressing out again as I recalled my experience at AFEES. The doc said my blood pressure was unusual: not just high but wandering all over the place. He said it would probably keep me out of the army, but I should really get it checked and treated if it continued like that. I received a "1-Y" classification from the draft board, meaning I was temporarily unfit to serve, but they could call me back later for a reevaluation (unlike "4-F", which meant permanently unfit).
Some months later I received two letters from the draft board on the same day. One was an order to report for another physical, and the other was the kind of initial letter they send to potential draftees who were not yet in the system. That second letter made me suspicious of bureaucratic error, and, sure enough, when I called to confirm it, I was told that they had screwed up: they had sent my file somewhere, and, not realizing why it was missing, mistakenly sent me those letters, which I should ignore. A few months later I passed my 26th birthday, which considerably decreased my chances of being drafted. That, plus a high number in the draft lottery, kept me from being inducted.
A couple of years later I went to a doctor to get a physical exam. The doc checked my blood pressure quickly so as not to give me a chance to get worked up over it, and it came out fine: (like 124/70, or maybe 120/74).
If this whole story sounds a bit like Arlo Guthrie and "Alice's Restaurant", the same thought occurred to me as well.
Thank you. Thank you . I wish this article was in the New York Times and every other big city paper. I have a very hard time, convincing patients and other positions.
In my state, dentists and hygienists are required to check blood pressure, although we have no substantive guidelines of what we are to do besides record it. I find it to be quite silly, since most patients have elevated BP coming to the dentist. And if we try to have a conversation about an elevated reading, patients become quite irritated which in turn doesn’t help the BP.
Appreciate this article!
This is a pet peeve of mine! Absolutely no "data" to support this. Someone, somewhere who likely has no background in treating or monitoring high blood pressure felt we must "find" people with high blood pressure and maybe the dentist is the only medical office they go to. Hmmm. Sounds good in theory perhaps. Let's not consider the extra steps and slow down to dental visits. And definitely let's not consider the potential negative effects. I have numerous patients who come in for an appointment and tell me "I stopped my blood pressure med! My blood pressure was so low at the dentist that I don't need it anymore!" Super helpful. Now BP high again. (and dentist never is the one telling them to stop - they make this decision on their own).
As I pointed out, there is a very specific way that blood pressure should be measured. Sitting at the dentist office is not the right scenario.
at a minimum, I'd accept this more if they only checked BP on a patient who says they don't have a PCP, never see a doctor - - those particular people might be reasonable to do a blood pressure and encourage to find PCP if elevated. But I doubt all the busy work dentists do with BP checks is doing anything to improve population health and I would advocate for not checking at all. Not helpful and slows the process as you describe.
The measurement of blood pressure has always been an area of great focus for me. After years of checking blood pressure in the office and recognizing that the nurse got one value, I got a different reading made me realize that there is a lot of variability in the results we get. Yet we place a LOT of value in these numbers and we either treat or don't treat. So they are important. After further digging and research, this is what I've gleaned and how I manage blood pressures in my practice.
The method and the procedure by which we actually check blood pressure is supremely important! What any clinic should focus on (and patients doing their own home BP monitoring) - try to follow the recommended method/procedure as best you can. This will give us the most accurate data. Using an AUTOMATIC CUFF (not a hand held or wall mounted) is recommended. For home blood pressures, finding a basic automatic cuff that has been validated.
You should be in a room by yourself; not talking; legs not crossed. Wait 5 minutes before the check.
Doing some home checks gives more data points to supplement what your doctor gets in the office. (again, follow accurate procedure when checking)
The other thing that really frustrated me re: blood pressure was managing HTN becomes a great parameter to focus on per Quality Metrics. Our big health care system set a policy that the last blood pressure a patient had in the record by the end of the year was the one that would count for measuring the doctor's quality of care! This is such an arbitrary number since this is a highly variable reading. I could only see the negative effects: doctors pushed to randomly call patients back into clinic to get another BP reading to "make sure" their number met the metric. I would not doubt it drove some physicians to just write in a number that fit. It would push other doctors to start medications when they otherwise wouldn't. Just a great example of the very real negative effects the silly "quality metric" "pay for performance" and proving our "value" is not only a waste of time but potential leading to suboptimal care.
Robert, thanks for your comment. I would not bet against the black swan; "all" is too much, so that I would say "most". It wouldn't be fair to take your money. The prevalence of hypertension in centenarians varies from 19% to 60%. Cohorts of centenarians are not common, but they support the view that BP increases late in their lives. Please take a look at Figure 2 in the first reference I mentioned earlier. It is not possible to paste it here, apparently.
As a radiologist I see imaging biomarkers that could reliably prognosticate hypertensive complications, such as prominent arterial ectasia on angiographic studies and brain microhemorrhages and white matter hyperintensities on MRI. It seems as though lack of such permanent structural changes could mitigate against major patient anxiety about transient BP elevations.
If I'm having trouble deciding if we truly have "white coat HTN", I do look for signs of end organ effects. At times I've gotten an Echo to look for LVH. Certainly any brain changes would encourage more aggressive control of blood pressures!
Question: Reperfusion injury is considered a risk of rapidly lowering blood pressure. How does this differ fron the following:
1) Exercise where BP goes very high, and may rapidly decline upon resting.
2) Emotional BP which goes up and down quick.
Why aren't people injured by those rapid BP drops? I would guess some elderly people with chronic high BP or small vessel disease could be harmed by such day to day events?
The specific situations you describe are normal physiologic responses and the body is so good at managing these changing situations. The risk of rapid lowering of blood pressure really occurs when we are lowering blood pressure artificially with medications - then we override the body's own mechanisms and can definitely cause harm.
The body's finely tuned mechanisms to modulate blood pressure can be affected by age and certain medical conditions. Elderly people are at risk for "autonomic dysfunction" when the mechanism to manage and control blood pressure and heart rate response are no longer well-coordinated. They become at risk for falls/passing out and often have bothersome symptoms of dizziness. They are more sensitive to the effects of blood pressure medicines. Parkinson't disease and POTS are other situations people have these problems.
My sister-in-law in her late 70s, following the long illness of her husband and his death was having these horribly high blood pressure spikes in the middle of the night, systolic over 200. Ambulances were called, She was seen by multiple physicians including internal medicine who could not identify a way to treat it without tanking her blood pressure during the day. Being only a nurse 😉. I held my tongue for a while, and then I asked her why she was checking her blood pressure in the middle of the night. Did she have a pounding headache that woke her up or some other symptom that could be attributed to blood pressure? No she said, I wake up, feeling panicked and anxious, and then I check my blood pressure…
Well, perhaps you are checking your blood pressure in the middle of a panic attack, which would obviously be high….
“Huh”-she said… I think I’ll stop doing that and perhaps do some journaling about my grief and see if the panic attacks go away…and they did… and her BP is lovely.
More data is not necessarily helpful and I would whole heartedly agree we that we need to understand why and when we treat - with great confidence because the new era of personal health monitoring is throwing a whole lot of data points at us and creating anxiety and feedback loops and eroding the confidence of patients in their caregivers… we need to be solid in our assessments and listen well so that our patients may listen to us.
Great example! I agree with your assessment and conclusions.
My sister-in-law in her late 70s, following the long illness of her husband and his death was having these horribly high blood pressure spikes in the middle of the night, systolic over 200. Ambulances were called, She was seen by multiple physicians including internal medicine who could not identify a way to treat it without tanking her blood pressure during the day. Being only a nurse 😉. I held my tongue for a while, and then I asked her why she was checking her blood pressure in the middle of the night. Did she have a pounding headache that woke her up or some other symptom that could be attributed to blood pressure? No she said, I wake up, feeling panicked and anxious, and then I check my blood pressure…
Well, perhaps you are checking your blood pressure in the middle of a panic attack, which would obviously be high….
Thank goodness for a sensible post re high BP! We treat thousands because of statistical risk and a huge proportion of them would never have a problem from their raised BP but they do suffer from their medication.
Great post. I still get calls from CCU about SBP 180 and asymptomatic.
This OP could be added to a large series of clinicians treating ourselves to make us feel better, whilst achieving nothing for our pts (except maybe causing side effects).
Excellent article. The same sensible reasoning should be applied to surrogate markers such as A1C and lipid levels. The figures commonly quoted for risk of stroke, heart attack, etc. are almost always relative risk and are of no practical significance despite achievement of "statistical significance" on observational data of dubious accuracy.
Bravo. this is what I teach our students and nurses and agree that the pills are reached for too often and too quickly.
Another BP issue is operator variability: the same patient often has disparate numbers when measured by different examiners: often by 10-20 mm. Hard to know what to make of studies that tout 5-10 mm of BP reduction as beneficial??
Hello all, as a new subscriber, I'm unsure how I'll be identified; it may be Danni, my middle name, but I prefer F Fuchs. I appreciate Dr. Joshua's comment, but I would like to address this issue from a different perspective. High blood pressure is the major risk factor (contributing to more than 50% of attributable risk for CHD, stroke, valve diseases, AFib, HFpEF, dementias, CKD, etc.). Vascular aging is not inevitable, and all centenarians had blood pressure below 110 mmHg throughout their lives. I am sharing these ideas, acting as a scientific advocate. If the editors are interested, I can expand on this here, but the ideas are published in two manuscripts I wrote with Paul Whelton (the first link) and with Whelton, S. Fuchs, and O. Berwanger (the second link). The manuscripts are open for view: https://doi.org/10.1161/HYPERTENSIONAHA.119.14240; https://doi.org/10.1161/HYPERTENSIONAHA.124.21361
"all centenarians had blood pressure below 110 mmHg throughout their lives"
If there was a way to prove or disprove that, I'd be willing to bet you money on that.
Your piece is spot-on! Having served a retirement community for >30 years, and literally seen >100K senior citizens (conservative estimate), your post so resonates with my clinical experience. I have spent hours and hours taking my time explaining to the generally frightened and worried seniors the subtleties of BP treatment and, more so, BP management. It's difficult to do in a high-acuity, busy ER. It takes so much time. It'd be much faster to just give a pill to lower the BP and superficially treat the patient's concern, then go on to the next patient. But, I can't help myself and start explaining and educating. Oh, and when they start off by saying, "I always know when my BP is high..." OMG, here I go with my lecture on hypertension...
Agree spot-on. Every ER in America has this scenario.