SECOND OPINION | Controlling Hypertension Episode | BCBS
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SECOND OPINION | Controlling Hypertension Episode | BCBS

September 13, 2019

There once was a time when we were truly free. Free of worry. Free of fear. Far from down. That is strength. That is power. That is fearless. Second Opinion is brought to you by, Blue
Cross Blue Shield. Accepted in all 50 states. Live fearless. NARRATOR: “SECOND OPINION” IS PRODUCED IN ASSOCIATION WITH THE UNIVERSITY OF ROCHESTER MEDICAL CENTER, ROCHESTER, NEW YORK. (Dr. Salgo) This is Second Opinion. I’m your host Dr. Peter Salgo. This week, myth or medicine: does eating salt
cause high blood pressure? Hypertension is a very complex genetic disease
and genetic condition where people’s blood pressure goes up usually in their thirties
or forties. (Dr. Salgo) Special guest Connie is here. She has hypertension, she ignored it, and
the result was catastrophic. She’s here for Second Opinion. (Connie) I started getting dizzy. I couldn’t get back upstairs and I collapsed. (Music) (Dr. Salgo) Connie, thank you so much for
being here. (Connie) Thank you for having me. (Dr. Salgo) We are delighted of course and
we have got two amazing docs for you to talk to. You are going to get your second opinion from
Dr. Lisa Harris of the University of Rochester Medical Center and Dr. Samuel Mann of New
York Presbyterian Hospital in New York City. I want to thank both of you for joining us
too. Connie, take us back to just before your diagnosis. What was it like? (Connie) I was a fitness coach. (Dr. Salgo) You were in great shape. (Connie) Yes. I ate perfectly. I ran 4 miles three times a week. I lifted weights three times a week. I thought nothing could happen to me. (Dr. Salgo) You were athletic. 44 years old? (Connie) Yes. (Dr. Salgo) You went to the doctor, and what
did the doctor tell you? (Connie) That I had hypertension. My blood pressure was about 140 over 90. He gave me beta blockers. (Dr. Salgo) And that’s fine. First of all, 140 over 90, I know when we
talked earlier, you used an interesting word to describe that. You said your doctor said you were borderline
at 140 over 90. Is that borderline? (Dr. Harris) Not in my book. (Dr. Salgo) Not in your practice either. (Dr. Harris) Not in my practice either. (Dr. Salgo) That’s hypertension. Our audience is going to hear those two terms
over and over again in the broadcast. Hypertension, high blood pressure, mean the
same thing right? 140 over 90 is that borderline for you? You are the hypertension expert. (Dr. Mann) It is borderline. It depends on what other risk factors are
there. Does someone have a family history of coronary
disease. Does someone have a history of elevated cholesterol? Other factors. More important than that, if your pressure
is 140 over 90 at the doctor, well what is it outside the doctor’s office? If you are 140 over 90 at the doctor and 120
over 80 at home, I wouldn’t rush to treat. On the other hand if you are 135, 140 at home. (Dr. Salgo) Is it fair to say that the blood
pressure is the pressure that the blood exerts on the walls of the arteries of your body
and that there are two numbers. The top number, the high number, is the pressure
you see when the heart is squeezing blood out, and the lower number is the pressure
you see in the artery when the heart is relaxing with the tonic pressure that sits there. How did I do on that? (Dr. Harris) Very good. (Dr. Salgo) So, they put you on medicine for
this hypertension, this high blood pressure. (Connie) They did. My pulse was very low because I exercised
every day that my pulse was about, resting, 45-50. It was very very low. (Dr. Harris) They put you on beta blockers? (Connie) Yes. (Dr. Salgo) A beta blocker is a drug which
can lower your blood pressure but it has, not even a side effect, a direct effect. It makes your heart beat slower in many people. (Connie) Oh. I didn’t know that. (Dr. Salgo) Oh yes. Well, tell me how you liked being put on a
beta blocker. (Connie) I was used to lifting 100lbs. I could not bench press, I was tired all the
time, so I stopped taking the drug. (Dr. Salgo) So instead of going back to your
doc, and saying the drug that you put me on makes me feel terrible, you took yourself
off the drug. (Connie) Yes. And I thought I was fit and I really didn’t
need it. I didn’t smoke, I didn’t drink. I ate perfectly. Why did I really need it? I was fit and most women, 45-45 could not
bench 100lbs. (Dr. Salgo) Well let’s get to that, actually,
because that’s an awfully good question. Does being fit, eating right, having 12 percent
body fat, bench pressing your weight, does that have anything to do with your blood pressure
in your practice? Have you ever seen that related at all? (Dr. Harris) Sure. People, generally, that are fit tend to be
healthier over all, but that doesn’t preclude them from having a medical problem such as
hypertension and as Sam already alluded to, what is the family history? Was there any other history of heart disease
or high blood pressure in anyone else in the family? It has a huge impact on whether or not you’ll
develop hypertension. (Connie) And that did have an effect. My father had his first heart attack at 35
years of age and always had high blood pressure. (Dr. Salgo) This is a red flag for sure. Now, whether or not you would have put her
on a beta blocker, what would you have done differently, perhaps, to make sure she was
tolerating that beta blocker? She stopped it. Did you tell your doc you were stopping it? (Connie) No I did not. (Dr. Salgo) But in the meantime, she’s on
a beta blocker, she’s not feeling well, and apparently her doc doesn’t know. What would you have done if you were her primary
care physician to follow up better? How would you have managed it? (Dr. Mann) That’s a very important question. A lot of the problem in treating hypertension
is that the patients are not taking the medication. Sometimes it’s cost. Sometimes it’s side effect. Part of it is doctor, patient communication,
although, thinking as the physician if I prescribed a medication for you, and by the way, I would
not have prescribed a beta blocker for a number of reasons. But if i prescribed a medication, I would
communicate if you had a problem with it, let me know. That has to be a given. (Dr. Harris) In addition to that, I have folks
that come back within three to four weeks of starting a medication. One, to make sure they don’t have questions
and issues, and two to reinforce the effect of their diagnosis. Hypertension is essentially asymptomatic. Folks think they are going to be fine. (Dr. Salgo) Can we get this on the table here,
it’s known as the silent killer. You can’t feel it if you have it, and yet
it’s dangerous, it’s doing bad things to your heart, your blood vessels, your brain, all
the time. (Dr. Mann) As Lisa was saying, did you have
a follow up appointment with him? (Connie) No, I didn’t. I never went back to him. It was a one year physical. (Dr. Salgo) In the meantime, the beta blocker
made her feel terrible. Why do you think it made her feel awful? (Dr. Mann) There are a few hypertensive drug
classes that can cause fatigue and beta blockers are high on that list. It slows the heart rate. Why do people feel tired? It’s not entirely clear. It does lower the cardiac output. The amount of blood put out per minute by
the heart. But that’s not the whole story. It also reduces blood flow to the small arteries. I think that’s part of it also. When you exert yourself, you have muscle fatigue
also. You can do, even though it lowers your heart
rate, by about 10 or 15%, you still can do almost everything you did before, but a lot
of people just don’t feel like doing it. (Dr. Salgo) That sounds to me, the sense of
what you’re telling me about this beta blocker, and then you took yourself off it anyway. (Connie) Yes. (Dr. Salgo) So let’s go on from there. Because you are off the beta blocker, you
are back training. You are lifting weights, then what happened? (Connie) Then I basically got dizzy and collapsed
one day when I was lifting weights. I had a great workout, I started getting dizzy,
I couldn’t get back upstairs and collapsed. (Dr. Salgo) You told your daughter you were
going to lie down for a while. (Connie) Yes. We were going hiking right after I weight
trained and I told her to give me a few minutes and i’ll be fine. (Dr. Salgo) Then what did you do? You tried to stand up? (Connie) And fell, and my daughter came in,
saw me on the floor, and called my husband who was very close to home, and he came and
called 911. (Dr. Salgo) At the end of the day you went
to the hospital and had a CT scan of your brain. What did they find? (Connie) A brain bleed. (Dr. Salgo) So you had a stroke? (Connie) Yes. A massive stroke. They did say they threw me in ICU for 5 days
and the blood was almost crossing the mid-line. They said if I went through the mid-line,
I’d be on a respirator and the question was for my husband whether they should operate
or not. My husband said no, let her go. (Dr. Salgo) Let you go? (Connie) Because she wouldn’t want to be a
vegetable. (Dr. Salgo) Okay, I want to leave that for
a little bit. But I do want to come back to this young woman
in tremendous physical condition. After weight lifting, now you are going to
go hiking and yet you have this big stroke. Is this one of the big complications of high
blood pressure? It is, isn’t it? (Dr. Mann) Stroke is the most common complication
of hypertension. It’s not all quite fitting together though. You are having someone who is in great shape,
mild hypertension, presumably, I don’t know if you checked your pressure at home and now
having a bleed at a young age. Even for someone with untreated hypertension,
it’s uncommon, especially with mild hypertension. I don’t know if there’s anything else involved
in combination with the blood pressure. (Dr. Harris) And that’s where you wonder a
little more about the family history, your father had his first heart attack at 35, I
wonder about his parents and brothers and sisters and so forth. (Connie) his sisters, he had 2 siblings die
of heart problems. One was electrical and one was a very young
child I don’t know. (Dr Harris) and what was the time course between
the time you stopped the beta blockers and the time you had the bleeding, what was the
time? (Connie) Probably about eight months to a
year. (Dr. Harris) Wow. (Dr. Mann) Was there any blood pressure reading
during those eight months? (Connie) I did take my blood pressure when
I was lifting weights. I don’t remember what it was, all I know is
that it was higher than 140 over 90. (Dr. Harris) So you’ve got to wonder, if
this is secondary hyper tension if there’s something else other than (Dr. Salgo) Sure, but let me ask a provocative
question. I know what our audience out there is asking. If she only had taken the beta blocker, she
wouldn’t have had the bleeding. What’s the answer to that? What do you think? (Dr. Mann) It would have reduced the risk. You don’t eliminate all strokes, you reduce
the risks. Even if you control all blood pressure perfectly,
if you have somebody who never had hypertension can they get a stroke? Of course they can, but with hypertension
the risk is much higher. You could have gotten the risk down to a normal
level, but there’s always a risk of stroke. (Dr. Salgo) something that Lisa said shocked
me, which made me think that maybe something else is going on with the additional risk
factor, but what Sam points out that seems really important. If there is on risk factor why add another
one to it? Let’s keep the blood pressure under control. Now Connie, you’re sitting here and you look
terrific, clearly this is going to have a happy ending, but I’d like everybody to sit
here just for a moment because it’s time for this week’s Myth or Medicine. (Narrator) Sodium or salt is an essential
mineral in the human body and has become a staple in the American diet. But one in every 3 adults has hyper tension
in the US. Limiting the amount of salt you eat will lower
your blood pressure. Therefore eating salt causes hypertension. Is this a myth or medicine? (Dr. John) Eating salt causes hypertension
– partially a myth, but mostly medicine. Hi, I’m John, professor of Medicine and
Cardiology at the University of Rochester Medical Center in Rochester, New York. Eating salt itself won’t cause people to
develop hypertension. Hypertension is a very complex genetic condition
where people’s blood pressure starts going up somewhere in their thirties or forties,
much like it did for other members in their family. Diets that are particularly high in sodium,
people who salt a lot of food, people who eat a lot of processed or canned food, often
get much more than six grams of sodium which is not good for their health. It can raise blood pressure and also increase
the overall risk of cardiovascular disease. So what I recommend to most people is to moderate
salt intake, which is probably the best thing to do if you’re concerned about having high
blood pressure. (Narrator) Chris from Ontario, New York asks
– I have hypertension. How often should I check my blood pressure? (Dr. John) The most accurate reading of blood
pressure is a well taken at home blood pressure. What we really want to treat in the office
is what your blood pressure is 99.99% of the time – which is not the reading that we see
in the doctor’s office. Once somebody is on a stable regimen of blood
pressure medication it’s probably not as important to take the blood pressure every
day. That is something that can prove an annoyance,
and it is something that is not as useful in the long run. But I still recommend taking the blood pressure
occasionally – maybe every week, or every two weeks just to make sure nothing is changing,
or moving slowly in the wrong direction. And that’s medicine. (Narrator) Not sure if it’s myth or medicine? Connect with us online, we will get to work
and get you a Second Opinion. (Dr. Salgo) And we’re back. We are here with Connie. About ten years ago or so you stopped taking
the blood pressure medicine you were on and you had a stroke. (Connie) Yes. (Dr. Salgo) The medicine made you feel bad,
and that’s why you stopped taking it? (Connie) Yes. (Dr. Salgo) Tell me a little bit about the
stroke. What happened, what was affected? (Connie) The whole left side. My brain was a right side bleed, it started
in my foot and worked its way up to my lips and face. (Dr. Salgo) You were paralyzed. (Connie) I was paralyzed, yes. (Dr. Salgo) Well, I am glad it’s gone. And did they tell you in the hospital how
high your blood pressure was? (Connie) No, they didn’t. (Dr. Salgo) The presumption is that it was
high, you were in the ICU. (Connie) Yes. (Dr. Salgo) OK, then I know you had a complication,
which was while you’re having a brain bleed, you had a clot form in your leg. (Connie) Yes, they didn’t move my legs around
at the time, so I developed a DVT. (Dr. Salgo) A deep vein thrombosis clot. So now they were faced with the complicated
problem between giving you an anti-coagulant to stop the clot in your leg, at the same
time they were worried about a bleed which is happening in your brain. (Connie) Yes. (Dr. Salgo) Then they had to get your blood
pressure under control. So how did they do that? (Connie) We went through different medications. They tested me a lot. I don’t know what drugs they gave me. But they gave me different types. (Dr. Salgo) All right now, when you’re doing
this there are about a zillion different drugs out there to treat high blood pressure, plus
or minus a kazillion, how do you start to work on this and get the right drug for the
right patient for the right problem? (Dr. Mann) What’s most important is that everybody’s
different. And the idea that you can take a guideline
and put everybody on the same medication doesn’t work. You have to figure out what’s the best medication
for that individual. And, in that circumstance, you might need
a different medication than you would under ordinary circumstances. So, which of the drug classes do you pick,
and you can divide it even though there are a gazillion medicines, there are about five
or six categories of medication. And, well, first of all, is salt and blood
volume a factor driving the hypertension? Some people tend to retain sodium and that’s
driving their hypertension. (Dr. Salgo) let me see if we can make this
very clear for our audience. Salt is what’s primarily driving the amount
of blood inside the blood vessel. It draws fluid in. And if there’s less salt, fluid leaves, so
you can imagine that if you fill your blood vessels up, then the tension inside them gets
higher. So salt should be, could be, in some people,
a variable. (Dr. Mann) Right. And, if so, then a drug like a diuretic or
calcium channel blocker like Norvasc can be very affective. Then that would be the way to go. And certainly, somebody whose heart rate is
slow, you don’t want to go with a beta blocker – perhaps that’s the cause. Then there are a few classes that target function,
or target mechanisms by the kidney. There’s what’s called the renal and endocrine
system. It’s a hormonal system by the kidneys that
helps control blood pressure, helps keep our pressure from falling too low, but in some
people it raises it too much. (Dr. Salgo) The kidneys make a chemical which
can squeeze your arteries and let them relax a little bit and you can attack the blood
pressure at the kidney level. (Dr. Mann) Right. The beta blockers do attack that, but they
have the side effect of slowing the heart rate and slowing people down. The ace inhibitors, the angiotensin also known
as [arbs], they tackle that system without the fatigue. And in somebody like you, that might have
been the way to go. And beta blockers occasionally are the right
drug, for somebody who’s hyper and their heart is racing, it helps slow them down. It’s very good and it lowers their blood pressure. Otherwise, a beta blocker would not be the
first drug to go to in somebody being newly treated for hypertension. (Dr. Salgo) Let me point out that you are
in the hospital, with a very complicated medical history at this point, but Lisa, you’ve seen
people in your office that walk in with nothing else going on other than it looks like their
blood pressure is too high. Do you go through that same algorithm picking
the right drugs? (Dr. Harris) Pretty much. The question that popped up in my mind was,
was this the first time he had noticed an elevated blood pressure with her annual physical? Because I wouldn’t rush to start someone on
a medication with one blood pressure reading. You certainly need to repeat it and see what
subsequent readings are. (Dr. Salgo) Where does diet and exercise fit
in here? I always hear you should try diet and exercise
first. (Dr. Harris) It depends on what the level
was. If this is someone who had one isolated reading,
then we could certainly advise about diet and exercise she was already doing pretty
much everything she could do. I can’t really see where we could maximize
her diet and exercise in her lifestyle any more than she had. But absolutely we have to go through the treatment
algorithm. What is the patient’s lifestyle? Is there, do they need a medication that’s
once a day, twice a day, three times a day? What’s the side-effect profile? Before we can figure out what medication to
prescribe. (Dr. Salgo) Now Connie, what drugs are you
on right now? (Connie) I’m on Lotrel 5-10, I alternate between
5-10 and 2.5-10. And, which is an ace inhibitor and a calcium
blocker. And, they keep my blood pressure under control
at all times. If I miss a pill it goes right back up within
24 hours. (Dr. Salgo) Wow, and what kind of follow-up
are you getting from your docs now? (Connie) Actually my doctor wants to take
me off the blood pressure medication or reduce it, and I refuse to do that. (Dr. Salgo) But the important thing is you’re
still talking to your doctor. You’re not stopping the drugs on your own
are you? (Connie) I am. No, I would never stop the drug, it’s my life-line
(laughs). (Dr. Salgo) And you’re talking to your doc,
you’re having conversations all the time? (Connie) Yes. (Dr. Salgo) So this is just an isolated decision
on your part. (Connie) No, no. (Dr. Mann) Yes, that’s an important point. I try to reduce medicine as much as possible,
get people off medicine if possible. You have a history of stroke, I don’t know
how low your blood pressure is, but I think you’re the kind of patient I would say, you
know you’re doing well, feeling well, the medicine is not bothering you. With that history, I would agree with you,
I would stay on the medicine. (Connie) My blood pressure is about 120 over
75. I take it maybe once a month just to check
whether it be morning or evenings, or after I train. (Dr. Harris) I would agree, I would not, certainly
at that level. I think if you were having low blood pressure
and dizzy spells, and feeling more fatigue, then we could really talk about possibly reducing
the dose. But you’re controlled at that level. (Dr. Salgo) You’re still Connie, you told
me you still climbed a volcano. (Connie) Yes, yes [holy akhlah]. And I climbed Machu Picchu four times when
I was there. I couldn’t get enough of it. (Dr. Salgo) OK, how’d your blood pressure
do when you did that? (Connie) Actually at Machu Picchu, I did do
the quinoa leaves, the tea that they give you. And I also had an altitude drug, and it worked
perfect, my blood pressure was normal. I was very much amazed at it. (Dr. Mann) And you know an important point
there is that, you said when you miss a pill your blood pressure goes up within a day,
but the other thing is when you’re taking medication regularly over months and years,
high blood pressure effects the arteries. It causes stiffening and thickening to the
arteries. When you have a controlled blood pressure,
that stiffening improves, so that your arteries are actually healthier and your pressure probably
will not go up as high as it did before, unless you stay off the medicine for a while. (Dr. Salgo) Now Connie, we’ve got these two
experts here, we’ve got about a minute, minute and a half left for your Second Opinion. What do you want to ask them? (Connie) Well, I have a question. With a brain bleed, should I take baby aspirin,
as to watch out for clots and prevent that from happening? (Dr. Mann) That’s a tough question. (Dr. Harris) That’s a tough one, yeah. (Dr. Mann) Especially with your family history
of coronary disease. What I would do is, maybe get a test such
as a coronary artery calcium score, to see if you’re at high risk for coronary disease. If you are, I would take the aspirin, and
if you’re not then maybe avoid the aspirin. (Dr. Harris) So in other words, we’re doing
a risk assessment – a risk benefit assessment. So we know that baby aspirin reduces the risk
for cardiac events, however, since you had a bleed, you’re at higher risk. So, the question is how much risk do you have
for a heart attack to make a determination. That’s what a calcium score will do. (Dr. Salgo) But, you have it in your family,
a very strong heart attack. This isn’t an easy question. (Dr. Harris) No, it’s not…it’s not. (Dr. Salgo) So there is no definitive answer. Anything else you want to ask? (Connie) Yes, one other thing. I exercise a lot, sometimes I might get a
pulled muscle. How much ibuprofen, that raises your blood
pressure, that is contradictive to the medication I’m taking. (Dr. Harris) So, you’ll jump in on that one. Periodic ibuprofen is fine, when we talk about
ibuprofen raising blood pressure, we’re talking about people taking multiple doses over long
periods of time. So, pulling a muscle and taking a couple of
doses of ibuprofen should not be problematic, but you should check your blood pressure while
you’re taking it. (Dr. Salgo) Except, ibuprofen is a NSAID,
just like aspirin. Doesn’t that circle you back to the aspirin
question? (Dr. Harris) Except that, you know, if you
were my patient it would be you can take a couple of days of ibuprofen, ice, rest, elevate,
you know the RICE things, and come in, check your blood pressure at home and we’ll monitor
this very closely. I wouldn’t say go take 800 milligrams of ibuprofen
for three days and come back and see me in two weeks. (Dr. Salgo) (laughs) All right. (Connie) I do take 800 mg’s and it raised
my blood pressure. (Dr. Salgo) Well, there you are. Thank you so much for joining us. Connie, stay right here, thank you two as
well, because it’s time for this week’s Second Opinion Five. (music) ( Dr. Chad teeters) Hello I’m Dr. Chad Teeters,
and I’d like to review five things to do if you have hypertension. The first is to watch your diet. We all know we need to be watching our calorie
and our fat intake, but if you have hypertension, you should also be watching your sodium intake. Keep in mind things we eat regularly such
as sandwich meat or cans of soup, each have about a gram of sodium a piece. If you add cheese to that sandwich, or if
you eat in a restaurant, you likely double the amount of sodium that you’re getting. The next thing to do is to exercise regularly. All of us should be exercising at least 30
minutes a day five to six days per week. You want to go at a pace where you can’t sing
or hum your favorite tune, but you can still speak in complete sentences. You don’t have to do all 30 minutes at the
same time, but you need to be making sure you’re getting that 30 minutes in each day. The third thing to do to keep your hypertension
under control is to take your medications. Study show that Americans miss more frequently
than not about one dose of medications per week or more. If your doctor has prescribed a medication
for you to control your blood pressure, you need to be taking it. The fourth thing to keep in mind is to tell
your doctor about any side effects to medications that you may be having. Admittedly, anti-hypertension drugs can cause
side effects, but if you need to be on those medications you need to be taking them regularly
and you certainly want to discuss with your doctor before you stop any medications. The final thing to keep in mind is that you
likely need to see your doctor about twice a year if you have hypertension. In the early stages when you’re getting your
blood pressure under control, you may need to be seen as frequently as every one to two
weeks, until the blood pressure comes down. And that is your Second Opinion Five. (music) (Dr. Salgo) Thank you so much for watching
Second Opinion. We hope you continue this conversation on
our website where you can comment on this show, send us your show ideas, you can share
your health story with us, and maybe we’ll invite you to join us on the show. The web address is secondopinion dash tv dot
org. I’m Dr. Peter Salgo. I’ll see you next time for another Second

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