Dr. Daniel Jones discusses blood pressure management in the post SPRINT era. He will review what was learned in the SPRINT study and the 5 year follow-up recently written that addresses blood pressure management and blood pressure control. The focus will also be on how to treat younger and older patients in this CME.
@PennMDForum Yeah, Doctor Jones, we'll give folks a couple of minutes to, to join in and then, then I'll start with the introductions. So this is a picture. This is the main campus there at the University of Mississippi, right? I'm not sure if you're in slide show mode. Uh Mhm. Let's see. Thank you for that. How's that? That's it the better. Thank you for that. I've looked at it so, so, so many times in the other view that I didn't pay attention. Thanks for catching that. Ok. All right. Well, while folks are joining, why don't we go ahead and get started? Good morning, everybody. Welcome to pen cardiology grand rounds today. Um, we are having a, a slight C M E issue and so we're gonna keep track of the participants and hopefully, um, be able to award C M E credit, uh, after the fact and, and hopefully by next month, get this issue resolved with the C M E office, uh, moving forward. But for today, um, it's my great pleasure to announce Doctor Daniel Jones. He's a native Mississippian. He graduated from Mississippi College and then earned his MD and completed his residency at the University of Mississippi Medical Center. He later served at the University as the Vice Chancellor for Health Affairs and the Dean of the University of Mississippi School of Medicine. From 2009 to 2015, served as the 16th chancellor at the University of Mississippi and now serves as the Director and of Clinical and Population Sciences and is the endowed chair in obesity metabolic diseases and nutrition at the University of Mississippi. His research research activities have focused on prevent prevention of cardiovascular disease and racial and economic disparities in health outcomes. He was the first principal investigator for the landmark Jackson Hart study. And I think we all know him by name, um primarily for his work with the A H A. He's been very active at the A H A and was uh the president from 2007 to 2008. He served as the national spokesperson on high blood pressure and he's also represented the A H A on national guideline writing groups for high blood pressure, high cholesterol and heart um and stroke prevention. So, it's my great pleasure to announce, uh and turn over the screen to doctor Jones um to, to help educate us on treating hypertension. A good morning to all of you. And uh thank you for joining. Thank you for the privilege of uh presenting to you today. I look forward to our time together and particularly look forward to uh your, your questions and comments uh toward the end of, of the presentation. So, uh uh let's talk about the blood pressure management in the post sprint era with the sprint study. And we'll spend a little bit of time on, on the study, but primarily what led to the, the invitation for uh for this particular talk. Uh The five year follow up that was published fairly recently in an editorial that uh along with colleagues, I wrote that address the issues about the blood pressure management and blood pressure control. And so today, I want to focus on what I think are the the biggest challenges for us in clinical medicine, in managing blood pressure and that's treating the older and the younger patients. So here's some key points. I'd like you to focus on as we move through the presentation today, you know that blood pressure is an important cardiovascular disease, chronic kidney failure and stroke risk. And that's uh don't need to tell this audience that I know that many cardiologists might uh might have AAA stronger focus on uh on lipids than on blood pressure. But you know that blood pressure is an important risk factor for your disease process. I wanna be sure that you walk away from this presentation with a clear understanding that 100 and 30/80 is an important new number in blood pressure management. The data is so strong that lower blood pressures save lives, that lower blood pressures uh uh prevent card investor events. 100 and 30/80 is not being achieved in most patients. And that's say a difficult and uh uh challenging thing that uh the clinical community simply has to find a way uh to uh to achieve clinician knowledge and commitment is necessary for this new issue. And we'll talk at some length about this and, and I think we can use the diabetes as a, as a uh as a metaphor for this. Uh back in the old days when just uh a modest control of glucose was the goal, uh managing glucose was not so hard. But when we began moving toward tighter control, we had to worried not only about hyperglycemia but began to be worried about hypoglycemia. The same is true in blood pressure as we move lower and lower on our blood pressure goals, uh being concerned not only about hypertension, but hypotension becomes more of a day to day clinical issue. And so it's important that you be informed, uh and make informed decisions for your patients. And then, uh toward the end, I'll, I'll focus on what I think is a really important issue. And especially for large health systems like yours. The Africa is their beautiful change for years. Blood pressure has been managed in the acute care setting and it's not an acute disease. It's a, it's a, it's a risk factor and we simply don't do a good job of integrating it into our acute care health system. And thus, that's contributing to our uh low blood pressure control rates and we'll talk about some potential solutions for this. So why is this important for cardiologist? Uh Number one, you, you, you manage a good number of elderly patients with hypertension and they're not in your practice primarily because they're hypertensive, they're patients who have coronary artery disease or heart failure, uh some, some other cardiovascular problem, but they come to you with hypertension. And so you assume some responsibility and I just encourage you in those patients that are under your care for your disease process. Uh That, that you not be cavalier that the primary care physicians taking care of the blood pressure and that that's not your interest. The good outcomes for cardiovascular disease are dependent on good management of the blood pressure. And I just encourage you to embrace the responsibility for managing the blood pressure, either in collaboration with your primary care provider or yourself blood pressure treatment. Goal of 100 and 30/80 as I mentioned, is more challenging than 100 and 40/90. It takes more attention to management of the patient. The origins of your disease process of atherosclerosis are in childhood and young adults and you know the biology of this disease. And so in the younger patient, one of the things I want to really try to help uh you gain a commitment to is to be an influencer in your health system for good management of blood pressure control in the young, even if you're not managing those patients directly. And those cardiology practices don't have many young patients with hypertension, but that they follow. But you can be a strong influencer uh in your health system on what kind of blood pressure management takes place. So uh just a quick look at the uh uh the concept of the sprint study, it was simply a goal of 100 and 40 systolic uh versus the goal of 100 and 20 systolic. And there was great separation. The it was really, really nice. There was AAA several year separation of these two groups, the standard group and intensive treated group and the outcomes were just great. Uh The intensive group had fewer cardiovascular events and total mortality was better in the intensive treated group as well. And that the, the fact that the total mortality uh was better as well as cardiovascular events. It's a little bit reassuring about adverse events with the treatment. So here's what, what happened to blood pressure during the study and after the study, the dotted lines, the dotted lines, the top and blue represents the research, blood pressure measurements during the sprint study. And you see that those with a goal of under 100 and 40 most of the time maintain the blood pressure around 100 and 35 in the clinic. If you look at the line above that, that's what their electronic health records was reporting from clinic visits in their own health system, not at the, not at the study visits. And, and because of the difference in blood pressure measurement uh methodologies, uh higher blood pressures recorded in the electronic record, the same for those in the intensive group. Uh The study measurements were in the range of 100 and 20. Uh And in, in the uh electronic health record recorded about 100 and 30. There was a separation of the two groups even in the uh outside of the study uh evaluation. But then importantly, uh on the right side is what happened in roughly five years after the end of the sprint study, they left the study environment, went back to whoever was caring for their blood pressure before sometimes that was the same people who were following them in the study. Some it was going back to another provider. And you can see the, the uh the the yellowish line at the bottom uh that represents the blood pressures in the intensive group move right back up to be exactly even with those in the standard group. And this was so discouraging to me and so many other people, one more, the patients who were in the sprint study and were fully informed of the benefit of lower blood pressures would have been very compliant patients and would have uh worked hard to keep their blood pressure. Low. You would have thought the clinicians who had followed them during that period of time would have been keenly interested in keeping blood pressures lower. But even with all of that strong data and even in the practices of the people who were in the study, look at those results, it was difficult, impossible. It didn't happen, didn't maintain blood pressure down in the lower ranges. And of course, I won't show your date on this that there was no residual benefit and not a surprise to this audience. I think in all of our reversible cardiovascular risk factors, cholesterol, blood pressure, smoking. Uh if the intervention is successful for, for a period of time but discontinued. Uh the benefit goes away fairly quickly. So blood pressure control generally is, is uh has been a problem for a long time in our society on the left. It's the graph from the in Hanes data that shows blood pressure control rates in all uh people with hypertension and we've uh peaked out uh somewhere in the 50% range. Not, not very good numbers, a few uh years, those numbers have begun to come down. Let me point out these are all based on a system. Blood pressure go of 100 and 40. These are, these are not going down because of the change in standards. These are all still based on 100 and 40 and the same thing happens on the right. Uh the uh rates uh approached uh 70% among those being treated for hypertension, but now are on a decline and something has happened that makes blood pressure control even more difficult than it's been in years past. So why, why do clinicians struggle with blood pressure management, especially at the ends of the age spectrum? So in older patients, some of the problems that I see they're conflicting guidelines will review those. There's a problem of, of bias that comes from um those of us who are older, our education process and the ideas that were planted in our brain. Then the idea of aversion to risk and the old adage of first do no harm in younger patients is the absence of evidence from randomized controlled trials. About 10 year risk benefit in those patients, the absence of guideline direction and the failure to consider lifetime risk for hypertension and cardiovascular disease. So let's take a deeper dive. So here are the, the major guidelines uh from the last few years, as was pointed out, I've, I've had the privilege of representing the American Heart Association on National Blood Pressure Guidelines for the last several years. So I was a participant in J N C seven, uh J N C eight and the most recent AC C A H A guidelines published in 2017. So J N C seven had a systolic blood pressure goal for people over 60 people, 60 to 75 of 100 and 40 millimeters of Mercury, J N C eight made a huge mistake. Uh The data was misinterpreted. I along with uh a third to a half of the committee members resigned from J N C eight. You may remember that J N C eight was never officially released as a report from NHL B I who had responsibility for this study because so many of the committee members uh left, left the, the, the task force uh to that was writing the guidelines and a group, uh a group of uh of participants uh did publish a paper in Jama with a, a published goal of 100 and 50 over millimeters of work. I think that was very harmful to blood pressure control in our country. And I think it was simply a misinterpretation of the data at that time. And then in 2017, uh several other studies had been published uh since the, the J N C seven and J N C eight had been published including Sprint and a few other studies. And so we adopted uh we adopted uh a $6 blood pressure goal of 100 and 30 millimeters of mercury. And I can't tell you how strong the confidence of that it was that this was the right number. Recognizing that it's not an easily achievable number, but recognizing that it was the right number for prevention of cardiovascular disease. Soon after our guidelines were published, the American College of Physicians and American academy of family physicians took the same kind of approach to interpreting the data uh that as J N C eight group had done and published a, a goal of 100 and 50 millimeters of mercury. And again, I think that's simply simply wrong and I encourage you to trust your colleagues uh uh from the AC C and the American Heart Association and our integrity uh in, in uh in, in recommending the goal of 100 and 30 it just blood pressure. So let's talk a little bit about the bias that we carry in our version of risk and, and uh being wedded to the idea of first doing no harm. So this is what I was taught in medical school. So I'll, I will, I will tell you that uh uh that anybody who's over uh 60 probably was exposed to, to, to this, that the, the gold blood pressure should be 100 plus the age of cysto blood pressure go should be 100 plus the age. And so for a 70 year old, we were accepting that a reasonable goal. Blood pressure was a blood pressure. 100 and 70. Wow. Was that wrong? And that was so wrong. It was never founded in the evidence. It was based on the idea that most people raised their blood pressure as they got older. And so it must be a natural phenomenon. We know we know from good studies that in primitive populations that don't eat so much salt and don't gain so much weight that blood pressure does not rise with age. And this is just simply incorrect information. And then we've lived with, with a strong aversion to risk in cardiovascular medicine. I'm gonna talk about uh the contrast of cancer management versus cardiovascular management and, and, and the approach that we take uh in making uh uh clinical decisions in those patients. So the, the risk of stroke from hypertension is one that's always there in the minds of people who are treating blood pressure to lower levels. And so let's let's focus for just a moment on the concept of adjusted auto regulation uh and the J shape relationship and observational studies. So you've seen this before and I hope I'm not insulting anyone by, by uh bringing up this uh this physiologic concept that you're familiar with. But over a wide range of blood pressure, brain flow, cardiac cardiac flow, kidney flow remains relatively constant. But on the, on the two ends, on the low end and on the high end, uh we can get into clinical problems. We see this enormous tens of patients on a day to day basis. Uh on the left end uh dehydration and will lead to syncopy. We see that in athletes frequently and then in young healthy women who are pregnant, we see in preeclampsia, hyperperfusion of the brain with preeclampsia and eclampsia with blood pressures as low as systolic 100 and 80 uh people with hypertension, move this auto regulatory curve to the right and they can tolerate higher pressures but are less tolerant of lower pressures. Uh And as we uh treat patients who have some vocal uh lesion in a a brain vessel, then we can sometimes experience a hypoperfusion of the brain resulting in a stroke. So, one of the key things in managing these older patients in your practice is to lower blood pressure slowly to allow the auto regulatory curve to readjust. And indeed, it will readjust uh give an opportunity to do that over a period of weeks and months that will happen. And you can take an older patient and move them from a systolic blood pressure of 100 and 80 to 220 move them safely if you do it slowly to assist the blood pressure of less than 100 and 30. And the data is strong that they will, will have a lower risk for cardiovascular event. Uh for the sake of time, I'm gonna skip the jake curve relationship. It simply just to say that this is a reverse causation issue. People who have cancer and who have heart failure often have lower pressures at the end stages of life. And it, it makes it appear uh that the low pressures may be causing uh problems there, but they are actually uh uh caused from the uh uh in the patient. So the as often happens in my presentations. The the the the the time is slipping away. I'm gonna make a conclusion here about the managing the elderly and just leave you with one simple message about uh about the young. And that is to, to be an influencer in your health system for primary care physicians, adopting the goal of 100 and 30/80 in the youngest patients and to uh to, to try to convince them to have your patients come to you at an older age and perhaps fewer coming into your practice with atherosclerosis. So think for a moment about the contrast of, of, of management of the cancer patient and the patient with cardiovascular disease. So in cancer management, we expect adverse uh events to happen. Some will die of the treatment. We accept that. But when you look at a randomized controlled trial and the benefit is greater than the risk. The cancer physicians of course, move forward because the disease itself will kill them. The same is true. The same is true in cardiovascular disease first, do no harm can sometimes mean treating the patient and getting the blood pressure lower because failing to lower the blood pressure can certainly lead to cardiovascular event. So you've been AAA patient uh uh audience. Um oops my bad. I am misreading my time here. I was thinking we were, we were on the uh on the hour. So I'm gonna slow down now and give you what I need to give you in the, in the hypertension for the young again. I apologize for misreading my time. It's, it's uh we began this at 6 30 my time. So my brain is still a little bit early in the morning. So let's just review and I'll slow down a little bit to do this. Let's review in the, the, the sprint study, the adverse events. So, the key thing on this slide is that serious adverse events were the same between the intensive treated group and the standard group. Uh hypotension was more frequent for sure. And the intensive group syncopy was a little bit more frequent. But uh things like uh injurious falls or long term dialysis were no different between the two groups, adverse effects that can be accepted uh uh for the benefit of lower cardiovascular risk and a big bonus in lowering blood pressure in the older patient is that more intensive therapy may reduce the risk for dementia. Uh The data on this is a little bit squishy. I'm a believer uh that that lower blood pressures, especially beginning to lower those blood pressures uh early in life, uh can lead to better outcomes for dementia. Certainly, the evidence from this current study demonstrates that that the intensive treated group to a systolic of 100 and 20 had no worse outcomes on dementia and probably better outcomes on dementia. All right. So now we shift our thinking a little bit to management of blood pressure in younger patients with elevated blood pressure or stage one hypertension. So, uh I'll remind you that elevated blood pressure is a systolic between 1 21 30 and stage one hypertension is between 1 31 40. These are patients that we've ignored for many years. And again, I want to encourage you to be influencers in your system of, of clinicians taking this seriously. So, here's from the, the 2017 AC C A H A guidelines when medication therapy should uh the and, and uh and what the blood pressure goal should be. So, for all of these groups, the blood pressure goal should be 100 and 30/80. Uh and for most of the groups beginning in treatment with drugs should begin at 100 and 30. The two exceptions to that the patient immediately after a stroke. Uh The recommendation is that though those patients be given a little bit of time on lifestyle therapy if they're below 1 40 but above 1 30 before uh medication is added or before medication is initiated. And in those with a 10 year coronary artery disease risk or atherosclerotic risk of less than 10%. Now, if you're treating a 30 year old with a cysto blood pressure of 100 and 3400 and 38 you know, the 10 year risk in that patient is gonna be low because the primary driver of 10 year risk is age. Uh And so, uh here's one that I want to be sure uh uh that we deal with before uh before we, we uh we end our time together. So here's some of the challenges and there, there's no randomized control evidence that treating a younger patient with a cysto blood pressure as low as 100 and 30 is, is gonna make a difference in 10 year risk. And why is that? Well, you understand how clinical trials are done. It takes a huge sample size to get the answers in patients who have a very low risk for a 10 year disease takes a long duration. And these, these trials are very expensive. And so uh nobody in A N I H is not gonna do this and the drug companies are not gonna make this investment in this population. So what do the guidelines recommend? So, uh this is, this is the language from uh the 2017 ac CAA guidelines, adults with an elevated blood pressure or stage one. Again, that's 1 20 to 1 40 who have an estimated 10 year risk, less than 10% should be managed with nonpharmacologic therapy. They should be told to lose weight, to eat less salt, uh to manage alcohol and then have a repeat evaluation within 3 to 6 months. And there's no language that gives direction for what to do. If the blood pressure is 100 and 30/80 systolic uh at the end of six months, it's because of the how we the guideline process is to tenure risk. So how do we make decisions in the absence of evidence from randomized controlled trials and a lack of guideline clarity for the low risk adult patient who has uncontrolled blood pressure. So, uh I asked the question, does an evidence based approach based on 10 year risk only cause us to miss a large opportunity to prevent cardiovascular disease? Should we focus more on lifetime risk and prevention of progression of hypertension? Well, you know, my, my my thinking on this already. So uh we need to think about lifetime risk. You know, when the disease process begins for atherosclerosis. Uh And if we wait until the mid fifties to begin therapy for either lipids or for blood pressure, we've missed a huge opportunity to alter the disease course by managing those risk factors earlier, simply because we're not using tools that allow us to look long term at lifetime risk or cardiovascular disease. So, this is data from uh the cardia study. And uh the top line shows the uh clinical outcomes for patients with stage two hypertension that's uh above 1 40. And then the then the two middle lines show stage one hypertension and elevated blood pressure and the bottom line normal blood pressure. Now, the gap is not as large for stage two, for stage one and elevated blood pressure as it is for stage two hypertension. But there is a clear separation of events uh in stage one and elevated blood pressure over a 20 year period. If you look at 10 year period, there's hardly any difference between risk. But if you look at at 20 years as the cardia investigators did, there is a separation. So to me, it makes no sense to wait until year 15 to begin therapy to try to manage what's gonna happen at year 20 in these patients that uh these patients who have the elevated blood pressure and stage one hypertension need to be treated earlier. I'm gonna skip that one. So it is important that we recognize that the rise in blood pressure with age, neither physiologic nor inevitable. The rise in blood pressure with age can be prevented with both lifestyle therapy and with medications. So here's what happens in all industrialized societies, all Western societies, all non primitive societies, systolic blood pressure goes up as we age. Dyal blood pressure rises until about age 50 to 60 and then begins to decline. And so mean arterial pressure rises until about age 50 to 60 and then levels off. Uh and then pulse pressure of course rises with aging continues to, to rise. And in primitive populations, you don't see this pattern of blood pressure change with age. So I hope I've convinced you that lower blood pressure gives better outcomes for our patients. Uh And I've also acknowledged that it is difficult to do both from a physiologic standpoint in the older patient and from the standpoint of, of data that supports aggressive treatment in younger patients. So how do we do this? I think it's time for us to accept that the current management of blood pressure in the acute care system is not working and system change is necessary. So we've just been through a pandemic and we, we have gone through a period of time of, of changing the way that we use vaccines and prevention of infectious disease. So when I was young, uh and it was time for me to receive a vaccine, a polio vaccine, a a measles a mumps, a rubella vaccine. I went to my health department and got my vaccine today. Uh When I get my flu vaccine or when I get my COVID vaccine, I go to my local pharmacy and get that done. And there's a transition that's being made in the way we're caring for and working our health care system around trying to prevent disease. We need some similar changes in the way we're managing cardiovascular risk as well. So here's an important study. Uh sorry, this is a, a scientific statement that, that uh I led uh by the American Heart Association, the scientific statement on management of stage one hypertension in adults with a low 10 year risk, but with a high uh lifetime risk of cardiovascular disease. And this is this, this for those of you who have participated in the guideline process for the American Heart Association or for the AC C recognize that there is a strong, strong, strong commitment to 10 year risk. And this scientific statement is a little bit um has less gravitated than a guideline. Uh But uh at least passes the measure of a credible science uh to be published by those who are viewed in the American Heart Association. So here's the recommendation in this one, number one, if the blood pressure is still over 100 and 30/80 after six months of lifestyle therapy, it's time to begin medication. And I believe strongly this is the right thing to do. And importantly, another recommendation in this scientific statement is that system change is necessary that if we continue to try to manage blood pressure in an acute care setting, we're going to continue to fail to do that. So this is the, this is the editorial that we wrote uh in response to the lack of continued blood pressure control after the Sprint study. And again, the premier recommendation uh in this editorial was that system change is necessary large systems like yours are the ones who can lead the way in this. You have the resources to do this and you have the infrastructure to be able to do it. So uh this is a uh study from uh mass general, uh their uh uh their large system and then more than 10,000 patients. Uh they ran randomized some patients to receive standard therapy. Come to the clinic, see the doctor get your blood pressure measured, uh get your blood pressure medicine adjusted if necessary standard approach. And then uh half were randomized to have home blood pressure measurement and have protocol driven decisions made by nurse practitioners or pharmacists on a more frequent basis to have better control of blood pressure. And those in the remote monitoring group had a decrease in blood pressure of minus nine point 7/5 9.0.2. And in the standard group, essentially no change in blood pressure. Uh We've done this kind of study in rural areas in Mississippi and have exactly the same kind of results. We we see uh 10 to 15 millimeters of mercury improvement in blood pressure generally. Uh the idea of measuring blood pressure more frequently in the home environment, uh using a protocol to drive decisions exactly as we would do in a clinical trial. And just as we would do in a clinical trial, not waiting for the next physician visit for changing medication to move forward with uh changing medications uh uh per protocol uh and allow a nurse practitioner or pharmacist to make those changes. Uh I do think this change in our system approach will be key in the era of goal of 100 and 30/80 to getting more patients controlled uh to prevent cardiovascular disease. Here are the important issues related to remote monitoring, frequent home blood pressure measurements reporting system. There, there does need to be an electronic component of this. Uh The simplest way to do this is with cell phones. Uh not everybody has a pad at home, not everybody has all that they need. But there are applications that can be put into a cell phone. And the the use of smartphones in American uh homes now is very, very high and then a protocol driven decisions by a nurse practitioner or pharmacist. Now, uh some of the challenges that you face in some systems, uh this takes away uh some visits for primary care physicians and some specialty physicians and some resistant based on that. Uh But uh this is so much more successful at controlling blood pressure uh than others. And in this study, uh uh from mass general, uh the cholesterol numbers were just as improved using uh remote decision making with the with cholesterol as well. So uh let me tie this up and then uh take some uh take some questions from you uh in managing older patients treat older patients according to the 2017 AC C A H A guidelines. 130 over 80 as your initiation point for uh medication in most patients. And a goal, blood pressure of 100 and 30/80 in almost all patients lower blood pressure slowly in older patients monitor blood pressure carefully while lowering blood pressure in older patients, including seated in standing blood pressures and in office and out of office blood pressure measurements. And remember that in treating the elderly, the best management of treating hypertension in the elderly begins in good management of hypertension in the young adult and blood pressure management. In the young adult with a low 10 year risk for cardiovascular disease, initiate drug therapy for all with cystic blood pressure, greater than 100 and 30/80 after six months of attempts of lifestyle therapy and always, always use lifestyle therapy regardless of when you add medication. Finally, let me ask you to think about in your health care system, whether system change is needed for better control of blood pressure as well as better control of lipids, remote monitoring with a protocol driven. Uh, physician management is one useful tool in getting us to where we need to be. And I thank you for your attention today and I look forward to uh answering questions and uh uh hearing your comments and having a discussion. Thank you very much, Doctor Jones. Fantastic talk. Um I'm just gonna change our view here and let Doctor Waxman here. Um get started with any Q and A and I'll monitor the chat here for a minute. Ok? I'm gonna try to get my screen share off the fucking figure it out how to get it off. Doctor Jones. Great talking and thanks for your guidance and great evidence on 1 30/80 and obviously it's a critical number. My question to you is I look as you well know, blood pressure management can be a time sink. And one of the things we struggle with, I think your home management is obviously fantastic. And the way to go, the problem becomes there's, it's, there's no reimbursement for it. So it can tie up pharmacist, nursing and a P P time. It can be an incredible amount of phone calls and emails and messaging and calling the pharmacy or emailing the pharmacy, et cetera, et cetera, et cetera. Forget even, I don't think losing the office visit is so important because we're so we have so many patients that want to be seen. It's just the cost of that program. I just wonder from you as you look around the country and your global view of how other people do this. Do you have any, any advice or have you seen ways that people have managed to financially support this kind of program which is obviously the way to go? Yeah, it's so, so the, the, the, the, the the answer is right now, right now, we're collecting the evidence to try to convince the third party payers that they need to do it. Uh The, the early studies, almost all have a economic impact um and a business impact uh uh portion of it, what we're doing in Mississippi. Certainly, we're, we're collecting the evidence to try to convince the payers that they need to pay for this. Uh, a a as you know, it took, um, uh a lot of evidence in many years to even get the insurers to pay for home blood pressure management for, for just measuring blood pressure at home, for paying for the, the, the blood pressure uh manometers for patients to use at home. Uh, and it is tough to, to, to get this done. But it, it, you know, I think that the, the, the way we do it is those of us who can afford, who can afford to, to, to do it, uh, on the front end is to provide the evidence for the rest of the, uh, the rest of, of the clinical world. Uh, and the third party payers that it has to be done. It's right now it's, it's a financial loser for sure. No, no question about it. Thank you. That, that's helpful. And it's a time it comes at a time unfortunately when a lot of health systems are struggling financially. No. No, absolutely. I do well know that. Yeah, it, it is, it's, it's tough to take on new programs like this in, in a time, uh, in a time in a time. And, and, uh, it does take, you're really shifting money and shifting money in health care is a, is a painful thing to do. And I, you know, one of the things that I encourage, uh, when I'm in the right format is to encourage groups like the American College of Cardiology to not resist this change. Uh, and the American American Academy of Family Physicians, uh, uh, uh, the, the, uh, American College of Physicians, they need to be supporting these changes. But, but unfortunately, they resist some of these changes because it does take money out of the pockets of, of, of themselves. Doctors don't like giving money up to nurses and to pharmacists. I can assure you, oh, I just, since I take prerogative and ask one more question, um, since I'm on, on, on mute here, you know, I see so many patients in the office where I'll take the blood pressure and it's 1 50/90 and they'll bring in 20 blood pressures from home where it's 1 20/80. Uh And so my question to you is that I, I truthfully, um, think the home blood pressure is the way to go. These cuffs are pretty good. We, we calibrate them in the office, we make them bring the cuffs in and show their readings on their home blood pressure cuff is the same as ours. And so is that, is that your sense that these home blood pressures, even though we see them in the office, they're higher, even if I repeat it three times in the office from, it's sometimes still high. Is the home blood pressure medicines. What we uh blood pressure is what we should be using the guy therapy. Yeah. As, as you know, the evidence on, on what, what we'll call the white coat effect is, is, is mixed. Uh I, I'll just say that uh, that I think the evidence is strong that the most predictive blood pressures that we have in today's options is the home blood pressure and, and you stated exactly what needs to be done, it's critical that those monitors be uh uh be confirmed as being accurate. Uh That's very important. And when we do it in, in, in our clinics, we try to have the patient do exactly like they do at home, we measure the blood pressures uh as we do in the clinic. And um uh and uh those are all important, those are all important pieces of it. But the evidence is strong that home blood pressures are more accurate in predicting cardiovascular risk than the office blood pressures are. And it is disconcerting to a clinician uh to ignore 100 and 50/90 taken in their, in their clinic. Uh But I think the evidence is strong that the home blood pressures are, are the way to go. Now. I I'll give you a personal example on this. So probably 20 years ago, uh I became interested in, in uh more aggressive control. This is before any of the guidelines went there. Uh And so I had a patient uh who, who, who had uh a history of polycystic kidney disease. And I evaluated her, she had some cyst, uh, she had, she had AAA blood pressure in the range of the mid one thirties, systolic. And I had a long talk with her and I was honest that I did not have clear evidence. Uh, but that my belief was that the lower her blood pressure, the longer her kidneys would last, that eventually she likely would need dialysis and replacement. Uh, but that I wanted that to be uh as far out as possible. She and I agreed together to have a goal of, of getting her sister blood pressure to less than 100 and 20. And we were primarily using office blood pressures during that time. Uh And I was not doing uh uh much in the way of home monitoring. And um she came to me after a few visits and her clinic pressures were in the 1 18 to 1 22 range. And her ophthalmologist sent me a note and he said that she had normal pressure, glaucoma from hypoperfusion of the retinal artery. And uh I, I then did a 24 hour blood pressure monitor on her and her daytime blood pressures at home were almost exactly what the office blood pressures were. 1 18 to, to the low one twenties. But her nighttime blood pressures were in the seventies. And right. So, uh this is this is an example of how smart we need to be, how careful we need to be as we're trying to get people down and into the 1 30 range, most patients will tolerate this well, but as we know, there's a AAA wide range of what happens to blood pressure at night in patients. And it's not only in the severely hypertensive, they have problems with hypertension uh at night, night time, but uh lower pressures and, and so, uh uh we, we, we don't, we don't have a good solution uh to, to that yet there's not a, an easy to use a nocturnal while you're asleep. Uh, blood pressure measurement. I, I continue to hope that uh, some company is going to give us a patch that will give us reasonable estimates uh based on flow uh uh to, to, to use as nighttime monitors on patients. But anyway, uh the, the, the home blood pressures are, are the way to go. And I think if I had been measuring her blood pressure more at home before bedtime and just on rising, I might have avoided that problem. By the way, she had a good clinical outcome. Once we let her blood pressure rise a little bit, her eyes were fine. Fascinating. Samir. Uh, wanna take up the chat and the questions from there. I'm sorry, I don't want to occupy the, if they see there's something in the chat. Yeah. No, this is perfect Doctor Jones. Great talk. Um I'm gonna start with a question on the sprint study. You, you know, I think when it first was published, um, it was very compelling for this more intensive treatment. And then the five year data came out and we saw that the, the two groups started to come back together again in terms of their blood pressure. Is that why is that? And what does that tell us? Does that tell us that it's, it's just not practical to maintain this? Does that tell us that over time, even on the same medication, the patients will need constant titration because on the same medications, their blood pressure will go up. Um, and is there going to be longer term outcomes data in that group? So will we in another five years know what clinically happened to those patients? Yeah, I, I, I, um, yeah, so great questions and thank you. Thank you for those. So we, we, we must not accept that this is inevitable. Uh, so we don't have data from the five year study, five year follow up, but I, I think they will try to collect it later. Uh, we don't know whether the medications were changed or not. Uh, my suspicion is that they, that they were, uh, that they were changed and there, there will be more problem with, with the poor clinical decisions of changing medication or non-compliance on the part of patients, uh, than on the failure of the medications. I, I, I'll say that, uh, uh, for old people like me who begin treating with uh propranolol and Alder and recur as our primary tools uh in, in treating hypertension uh that we love our modern blood pressure medicines with calcium antagonist, an ace inhibitor or an ARB and a diuretic dog, you can control a lot of blood pressure. Uh and uh for the few patients who have the unusual problems, say, and aldosterone blocker uh will, will solve a lot of those resistant hypertension problems. So I I I would just say that clinicians should not be wimps. We should, we should not accept that uh that we can't control blood pressure better, we can. This was I think this simply represents a clinical failure. Uh Some of the failure on the part of the patients, some of the failure on the part of the clinicians. Uh I don't think it's a failure of tools that we have available to us to control blood pressure. I'm sorry to be so evangelistic about this. But I, I do, I I do think this is uh I do think this is our responsibility to, to keep our patients there. Your thoughts on patients that have very labile blood pressures and this is both in opposite at home, but their blood pressure may go from 1 30 to 200 or from 100 to 1 40 they feel ok at, you know, 1 31 40 but they don't feel well at lower ranges. How do you manage those patients? Yeah. So uh yeah, So, so when I began um practicing medicine, my, my, my goal was to practice primary care. I, I, I, I got interested in, in blood pressure. And before long, I was running a uh referral uh hypertension clinic. And um what you just described was the most common patient. I saw uh somebody who, who has volatile blood pressure and I, and I can tell you they are tough to manage, they are tough to manage, but most of them have some have, have something that you can identify that is related to the volatility of their blood pressure. Some and the most frequent one is blood pressure measurement problems. They simply aren't measuring their blood pressure correctly. Uh And, and you get a lot of bad data uh because of that and one of the tools that I use uh to work on that is a 24 hour ambulatory blood pressure monitor that gives uh take, takes away some of some of those, some of those problems. Uh And, and then uh a frequent problem that I find is, is misuse of medication. So I'll just give 11 quick uh patient scenario. So I had a patient who came to me, uh and he was uh uh he was on six drugs and one of those was one with a very short half life. Uh And so uh this drug, he, he, he, his physician had not instructed him to do it, but he found that this drug would make his blood pressure go low. Uh, when it was very high, would, would quickly lower it. And so he got into the habit of his, when his blood pressure was elevated, when he was measured, he'd take one of these, one of these pills. And so my solution was for him to stop, uh, taking that medication. Well, uh, he, he was, he was so convinced that that was the only thing that was gonna help his blood pressure because it worked quickly and, and he could see the change in his blood pressure. And it took me six months to convince him to drop that drug. And I, I had to call his pharmacist and ask him not to prescribe it anymore. This guy was committed to that drug. And then a finally after we got him off that drug, he was down to two drugs with good control and he was just simply on a roller coaster with a short acting drug. Uh uh and, and there, there are other scenarios uh with that uh uh salt loads is a big problem in, in these people. Uh And then, and, and the 80 year old woman who, who has stiff vessels, sometimes there's just, just no solution to it. They're just gonna be volatile and there's not a, there's not an easy way to manage these, these patients, autonomic dysfunction is a problem in some of these patients. But, but there are certainly 80 80 and I rarely see this in men, but there are lots and lots of 80 year old women who have stiff vessels who are just uh really hard to control the good news about those. If they live to 80 with that problem, they sometimes live to be 90. Um Another comment which I think is, is actually very interesting. Um is that, you know, the, we refer to certain populations around the country as being primitive, but uh they're really not primitive in their approach to health. They focus on less salt, more exercise, family time or just more active overall. And as we see this globalization occurring and the more traditional western diet, western way of life um spreading, we're going to see uh it sounds like, you know, an increase in cardiovascular diseases. Um and the prevalence of, of these events, thoughts on that. Um I think it's more of a comment than, than a question, but nonetheless, an important one right on the mark. We, we are, we are exporting uh uh around the globe uh in, in, in the form of mcdonald's and Kentucky Fried Chicken. And um the, the um uh I practiced medicine in South Korea from 1985 to 1992. And um in 1985 when I arrived there, uh um heart disease, cardiovascular disease, atherosclerosis was very, very uncommon. Stroke was, was very common. Uh and they ate a diet that was very high in salt and almost no fat, uh, almost no fat. So, if you go back to the, uh, uh, to the study that, uh, um, blocking on the, on the name of the study, it's, uh, the study was done in, in, uh, Japan, in Hawaii, uh, and in San Francisco and basically followed Japanese patients who lived in those three environments and, you know, not surprisingly to us now, uh, the ones in San Francisco had cardiovascular rates exactly like other Americans did and the ones in Japan had very low heart disease rates and the ones in Honolulu kind of had a mixed, uh and it, it just pointed out the critical importance of, of environment and now that environment uh that was in that study in San Francisco is worse in San Francisco and it's around, it's around the world. And, um, I, I do think, I do think that, um we, we who are part of, of uh American health care need to need to feel some responsibility for what's happening around the world. This is not exactly an American problem, but it is largely an American problem. Uh And we need, we, we, we need to be interested in cardiovascular disease around, around the world. But uh absolutely, it is the diet and the change in lifestyle. That's, uh that's, that's making a huge difference in cardiovascular bits around the around the world. Doctor Jones, your, your thoughts on masked hypertension and how it should be managed I think the idea of being the opposite of white coat hypertension. Yeah, this is a tough, this is a tough problem and, and it, it, it points out not just the utility but the necessity of home blood pressure measurements in every patient who has hypertension. Uh I, I think now it, it is a large clinical error to not measure blood pressure at home uh in our patients. And we, we don't yet have uh good recommendations on on screening. But certainly there are patients who don't come to our attention. But because, because, you know, we don't identify them in the clinic as being hypertensive. And so I think eventually we'll come to a place where measurement of blood pressure at home in young adulthood will become a standard uh a standard clinical approach because there, there are more and more uh the the numbers on mask hypertension continue to rise every time there's a new study, uh the looking at this, looking at this problem. Um uh And again, I think the we we simply have to make decisions on these patients based on their home blood pressures and ignore the lower uh pressures in in the clinic. And uh I wish I understood the causes of this more. I wish I could explain it, but I'm, I'm fascinated by it, but I don't, I don't have good explanations for it, but it, it is a real clinical problem and it is associated clearly associated with cardiovascular risk. Um, I, I guess more of a practical question when you get the call at two in the morning, when, when you're on call and the blood pressure is 1 80 over 100 no symptoms. Um, what are your recommendations at that point? Yeah. So it, it depends very, very much on what the clinical situation is otherwise. Uh, if this is a patient who I saw in clinic, uh, a month ago and they had a similar blood pressure uh or, or they have a history of blood pressures in that range, then the the the the middle of the night call is to reassure the patient and to see them in the clinic uh in the next few days. Uh If this is a young new patient, uh then they, they need to be seen, they need to be sent to the emergency room for evaluation because they may have an acute event. Uh uh that's, that's causing that, but it depends very much on the history of the blood pressure of the, of the patient. And um one of the big mistakes that I see made is is when somebody shows up in the emergency room with a, with a 1 80 or 100. Uh and someone gives them a medicine that will acutely lower the blood pressure. This is going back to the guidance auto regulation. This is where you run into problems is is when somebody is overly aggressive at lowering blood pressure or acutely uh and, and a patient like this. Yeah. And that's a, that's a hard thing to, uh it's a hard thing to convince some, you know, everybody wants numbers to be normal. Uh And, and it's a hard thing to convince emergency room physicians to not, not overtreat those patients. Um The question here has to do with, with lifestyle. Um We have many patients who live in food deserts for whom it's very difficult to limit sodium. They may just not have access to fresh fruits, vegetables and healthier choices. They also live in areas where exercising may be challenging or even dangerous specifically. What kind of lifestyle changes do you recommend to these patients? And would you be more aggressive with medications rather than attempting lifestyle changes? Yeah. So, so, um, yeah, thanks for the, for the, for the second part, whoever answer, ask that question for the second part. I, I do think that, uh, we should use medication on our pathway to getting patients to adopt, uh, uh, a better lifestyle and you, you've described reality for a lot of Americans. Um, so I, I, I, I live in a small town in, in, in Mississippi, 4000 people. There's not a sidewalk you can safely walk on in my city. Uh, and, uh, but, uh, I, I can, I can be careful on the sidewalk for about 100 yards and get to my city cemetery and I can exercise there and I, I'll say that I rarely find a patient who I can't help them work through a safe way to exercise. People can exercise. You, you could do, uh, e even inside a home there are things that people can do to, to, to get a good bit of, of aerobic exercise. And so I, I, I don't accept excuses for no exercise. The salt and the, the food desert is, is a, is a big problem. Uh But a good dietician who is familiar with, with their circumstances can help them a lot. And I, I, I think our dieticians are underutilized and, and sometimes under under prepared to deal with, with people in that, in that kind of situation. But I've found with a dietician who, who, who understands the environment can, can be a big, big help to help people get there. And then I, I, I, I try to uh uh we, we use the food baskets, you know, with some of our patients and so we provide them a month's worth of food uh uh with the kind of diet that, that we want them to be on and, and uh it doesn't always happen, it doesn't always happen. But, but frequently those patients will come back after that month of eating the food that we have not just recommended but provided for them. Uh uh and they will, they will see the improvement in blood pressure uh with it and they will become convinced to be more aggressive themselves at following those lifestyle. Uh the the lifestyle thing, it's a, the, the the benefit of losing weight and lowering salt are hugely underestimated by most people in society. And frankly, by most clinicians, most clinicians don't really believe that. Unfortunately, the the critical level of of salt intake is different from person to person, you know, so some people who are eating 3500 mg of sodium a day can get below 2500 and they get a huge benefit for some people. They get under 1500 that, that, you know, there's no difference between 5500 in terms of their, in terms of their blood pressure. And so you just have to, you have to be committed to seeing what that threshold is for that patient and, and getting them there. Um your thoughts on the, the idea of a poly pill, you know, I think there are some, some clear benefits and, and some limitations to that. Yeah, so, so the, the, yeah, there, there's, you know, there's good and bad and, and, and everything and I think the poly pill is better than uncontrolled blood pressure. Uh I, I, I, I don't see huge downsides uh to, to it. Uh I've spent a good bit of my uh of my uh career practicing medicine in fairly remote areas where you couldn't measure potassium beer frequently. Uh where you didn't always know what the creatine was and, and uh I'll say that especially in, in those low income areas that the poly pill is a good idea. Uh And, and I think there is some evidence that lower doses of multiple drugs gives fewer adverse effects than big doses of, of, of single drugs. And, and so there always clinician judgment has to come into, has to come into it some. But yeah, I think the poly pill is a, is, is a uh a reasonable tool for clinicians to consider in some patients. And, uh, you know, the, the with the shifting landscape on aspirin, it's, it's a little bit a little bit hard to now incorporate the ones that, you know, there, there's some poly pills with statins and with aspirin uh uh in, in them and, and uh, so probably the, the aspirin is a little bit more complicated. I, I would have no problem with the poly pill that also included a statin uh, too. That's, uh, yeah, I'm a uh, yeah, I've, I've already declared myself of being aggressive in people with a low 10 year risk who are young, who have some elevation to blood pressure. And I feel the same way about a, about cholesterol. I just, uh, I think statins are really, uh you know, in the grand scheme of things pretty safe drugs and most of our blood pressure medicines these days are as well. Um, if you have time for, for another question or two here. Um Do you ever use mood stabilizers to treat hypertension? And I think this is getting at the idea of anxiety with, with the ongoing pandemic, there's been a tidal wave of mood disorders. Um a lot more anxiety and many office visits um with higher blood pressures that may be in part due to these other disorders. Yeah, boy, this is a complicated area uh for, for sure. Um I, I, I personally don't think that anxiety has much impact on long term blood pressure. Um And, and so I don't think that uh mood modifiers are appropriate antihypertensive therapy. That being said, I certainly have used mood modifiers in many patients with hypertension, not, not to manage their blood pressure, but sometimes to manage their anxiety about their blood pressure if that makes any sense. Uh And, and it does, it does tend to uh to um to stabilize the changes the the rat changes in, in, in blood pressure. But I, I'm yet to see strong evidence that people with, with acute anxiety disorder have higher cardiovascular risk because of those intermittent elevations of blood pressure. But uh I'm, I'm waiting on better blood pressure monitoring systems to uh to allow us to do the research that really will give us the answers to that. Well, I think uh with the hour being uh here a little after 8 30 however, we can wrap up unless you have any other questions or comments here Um I think nothing, nothing else for me, but I'll let you wrap up, but just, I personally want to thank Doctor Jones for his wonderful talk and his leadership over all these years and hypertension and, and I look forward to your convincing insurance companies to pay for the support so we can provide the kind of care we'd all like to provide to our patients. But thank you. So I, I won't, I won't quit. I won't quit on that. Thank you. Thank you. And, and let, let me say what a privilege this, this has been for me to uh uh to, to present to this group. Uh I, I'm a great of uh of your institution. Uh both both on the medical side and, and otherwise. And uh uh yeah, it's, it's a privilege to do this. So, thank you for the opportunity. Well, thank you very much. Fantastic talk, great insight. And uh once again, thank you for your leadership over the years and, and really getting us to this position to being able to help patients and, and furthering our understanding of how important it is. So, um once again, thank you for joining us early in the morning and I hope we'll see you soon. Thank you guys. Take care. Bye, everyone.