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Getting Your Blood Pressure Even Lower: Here Are The Risks And Rewards

Getting Your Blood Pressure Even Lower: Here Are The Risks And Rewards

By Melissa Healy, Los Angeles Times (TNS)

Two months ago, U.S. officials crowed that a federally funded study gauging the impact of stricter blood pressure control had produced such dramatic results, they were bringing the clinical trial to an early close.

On Monday, those dramatic results got medicine’s version of a ticker-tape parade: a research article and not one but three editorials in the New England Journal of Medicine detailed and dissected just how steeply heart disease, strokes and deaths from any cause declined in patients who aimed to get their systolic blood pressure reading to 120 mm of mercury.

The upshot: For people between 50 and 75 who are at higher than usual risk of cardiovascular disease but don’t have diabetes and have not already had a stroke, it’s probably no longer defensible to be satisfied with a systolic blood pressure reading just under 140. (Earlier this year, the American Heart Association and American College of Cardiology set a 140/90 mm reading as the correct goal for most patients under 80 years of age with coronary artery disease.)

But getting all such patients’ systolic blood pressure readings to 120 may not be entirely realistic either, said experts assessing the significance of the study, called SPRINT (Systolic Blood Pressure Intervention Trial).

Many of the 4,678 subjects assigned to shoot for a systolic reading of 120 couldn’t quite make it to that goal, despite an escalation in the number of medications they took and an average increase in such side effects as dizziness, electrolyte abnormalities, and injury to or failure of the kidneys.

Still, the trial’s results suggest the benefits of trying were undeniable.

In a follow-up period of just over three years, people between 50 and 75 who make efforts to get that top reading 20 points below 140 mm of mercury reaped a welter of benefits, researchers revealed: Their likelihood of dying of any cause dropped by 27 percent, and they reduced by roughly 25 percent their likelihood of suffering one of a range of cardiovascular outcomes, including heart attack, stroke, heart failure and acute coronary syndrome.

On average, study physicians had to prescribe 2.8 medications to get a study subject’s systolic blood pressure reading to 121.4. Subjects who were assigned to get their systolic blood pressure reading under 140 took, on average, 1.8 different prescription medications, and their systolic blood pressure reading settled at an average of 136.2.

By a key measure — the “number needed to treat” — of those outcomes made it a pretty easy call to shoot for the lower systolic reading in treating a patient over 50 with high blood pressure.

Study authors reckoned that for every 61 patients medicated to achieve the lower systolic number for just over three years, there would be one less cardiovascular event (a heart attack, stroke, heart failure, acute coronary syndrome or death). For every 90 patients who got the more aggressive treatment, one death from any cause would be averted. To avert a death from cardiovascular causes, 172 patients would need to get the more aggressive treatment for a little over three years.

(To put that number in perspective, it took 83 patients treated with a statin medication for five years to prevent a single death, 39 patients treated with a statin to prevent a single non-fatal heart attack and 125 to prevent a single stroke. Treating 50 people at high risk of cardiovascular disease for a year with clopidogrel, known also as Plavix, has been found to prevent one cardiovascular event. But 333 would have to be treated with Plavix to prevent a single death.)

“This clinical trial will change practice,” wrote four senior NEJM editors, led by Editor in Chief Dr. Jeffrey M. Drazen.

But whether physicians should accept a systolic reading of 120 as a rigid and immediate requirement was not so clear.

“In my opinion, the results from SPRINT warrant reducing the treatment goal for systolic blood pressure to less than 130 mm HG” in most hypertensives over 50 with no history of stroke and no diabetes, wrote Dr. Aram V. Chobanian, a cardiologist, blood pressure researcher and former dean of the Boston University School of Medicine.

Even if the systolic target were reduced to that interim level, wrote Chobanian, a majority of Americans with hypertension would be considered to have “uncontrolled” high blood pressure. And physicians, he added, know all too well that when they must prescribe more than two medications to bring blood pressure under control, patients are less likely to stick to their medication regimen.

The SPRINT study, wrote Vlado Perkovic and Anthony Rodgers in an invited editorial, “redefines blood-pressure target goals and challenges us to improve blood-pressure management.” Despite its name, however, the SPRINT study cannot change treatment overnight, they added.

©2015 Los Angeles Times. Distributed by Tribune Content Agency, LLC.

Photo: Quinn Dombrowski via Flickr

 

Maximizing Your Health Benefits Before Year’s End

Maximizing Your Health Benefits Before Year’s End

While the holiday season usually involves spending on gifts, feasting, and parties along with other festive (and perhaps not so healthy) indulgences, the end of the year can also bring significant savings on annual health costs — especially for consumers who understand the details of their own insurance coverage.

The first and potentially most lucrative target is the annual deductible – the amount that your plan requires you to pay in out-of-pocket costs for medical procedures, tests, or other services before the insurer pays all (or almost all) additional health expenses. Knowing the amount of your plan’s deductible, which can vary widely from hundreds to thousands of dollars annually, apportioned either individually or for your entire family, is essential to minimize costs and maximize benefits.

For most plans, the deductible rolls over again on January 1, meaning that you will need to climb that same financial hill again as soon as the new year begins. (Some plans, such as those obtained through a school or university, may use the academic year instead – check with your insurer to be certain.) And most consumers are likely to meet the deductible toward the end of the year – which means that now is the time to take advantage of whatever elective procedures or services you or your family members may need that can be obtained for free or very low cost.

As soon as your health spending reaches the deductible amount — whether that comes to $500 or $5,000 — it makes eminent sense to arrange those procedures or services in most cases before December 31. Medical providers know by now to expect a rush of visits before year’s end, and many will set up additional office hours to meet the demand.

But be certain that you know the specific rules governing your plan before making any appointments, because various preferred provider plans may require separate deductible amounts for in-network and out-of-network care. The same caution applies to family policies, which may include either combined or separate deductibles for each covered family member.

Even if you have reached the in-network deductible, you may still have to pay for out-of-network providers, or vice versa. And always find out whether the physician you’re seeing is in or out of network before your appointment – neglecting to check can turn out to be very expensive. It’s also wise to check that everything involved is in network… even if your initial appointment is with an in-network physician or facility, you may well get a surprise bill later if they send your tests (especially in the case of MRI or X-ray films) to an out-of-network provider to be read or evaluated.  

Similarly, dental and vision plans as well as flexible spending accounts almost always offer benefits that must be used before the new year begins. Check with your insurance plan’s customer service department, either by phone or online, to determine whether you are eligible for unused benefits – for instance, a new pair of glasses or contact lenses, or a dental cleaning.

Every insurance plan must now provide a simple summary of benefits and coverage, similar to this sample sheet published by Consumer Reports. The summary should quickly enable you to find the deductibles, benefits, and co-payments included in your plan. But you are still likely to have questions, so don’t hesitate to contact your insurer for clear and specific answers.

With the passage of the Affordable Care Act, nearly every insurance plan is now required to provide a schedule of free or very low-cost preventive health benefits for men, women, and children  including annual checkups, blood pressure and cholesterol screening for adults, several kinds of vaccinations, tobacco cessation services and more – a complete list can be found here.

For Medicare Part B patients, a yearly “wellness” visit  designed to monitor your vital signs, weight, and other health indicators is also free, with no co-pay. Patients newly signed up for Part B are entitled within their first 12 months of coverage to a “Welcome to Medicare” preventive care visit that includes height, weight, and blood pressure measurements, a body mass index calculation, a vision test, a review of depression risk, a discussion of advance directives, and a written plan that outlines the screenings, inoculations, and other preventive services you may need in the coming year.

AFP Photo/Joe Raedle