Recent Guideline Changes Warrant More Education
Heart disease is the number one killer of both men and women in the United States. Nashville Medical News reached out to several area cardiologists and asked them to weigh in on recent guidelines revisions for cholesterol (see page 1) and blood pressure.
A Better Understanding
Walter Clair, MD, MPH, executive medical director of the Vanderbilt Heart and Vascular Institute and president of the Greater Nashville American Heart Association, said guidelines changes reflect a deeper clinical understanding.
"There are philosophical overlays to both issues," Clair said. "In cardiology, we try to offer our best understanding of the evidence, but providers get frustrated about guidelines because in the process of developing them, we identify areas for which we don't have recommendations. We're also identifying avenues for future areas of research."
In rolling out new guidelines, Clair said organizations like the American Heart Association and American College of Cardiology attempt to simplify presentation of clinical findings for the public in order to create awareness of guidelines prior to seeing the doctor.
"We were happy to have guideline updates over two consecutive years on both hypertension and cholesterol, because it's notable in both cases that we recognize the foundation of lifestyle changes is necessary along with medication," Clair said. "All of these lifestyle factors cross over and are risk factors for stroke and heart disease, and both guidelines emphasized we need to think about lifestyle issues from a preventative point of view and as our first line of treatment."
New BP Guidelines
Stricter blood pressure guidelines issued at the end of 2017 mean half of Americans are now classified as hypertensive.
Blood pressure categories in the new guideline are:
- Normal: Less than 120/80 mm Hg;
- Elevated: Systolic between 120-129 and diastolic less than 80;
- Stage 1: Systolic between 130-139 or diastolic between 80-89;
- Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
- Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
However, guidelines emphasize the large percentage of Americans now classified as "elevated" don't necessarily need medication - and those who do start may not need them for life. The goal, Clair said, should be to get blood pressure in a healthy range through lifestyle changes and, if necessary, medication. New guidelines emphasize the importance of regular monitoring, and Clair urges providers to refuse to accept excuses.
"We can't give patients a pass on white coat hypertension," he said. "We have to document that it's low in other settings, because patients aren't being clear about the fact that they're not actually checking it at other times, so they don't really know if it's white coat hypertension or not."
Thomas Johnston, MD
Thomas Johnston, MD, cardiologist at Centennial Heart - Nashville, said the most important thing the new guidelines brought to the forefront was the importance of monitoring blood pressure at home, in addition to the office. "They really emphasized the importance of accurate blood pressure measurements - and went through the process of how to get an accurate reading in the office and how to teach patients to do it at home," Johnston said.
Prior to pharmacological treatment, providers should be certain that pressures are consistently high across multiple readings at home and in the office. "This emphasized how important non-pharmacologic interventions are, not just low salt diets but those rich in potassium. We're learning that small changes can lower pressure 10 to 12 mm of mercury, which is more than what a lot of medications can do. No other disease is as greatly impacted by lifestyle changes and exercise as heart disease."
For otherwise healthy patients with borderline blood pressure, Johnston urges providers to double check cuff size and to schedule a follow-up in one month. Ask patients to purchase a quality home cuff and make sure they know how to use it. He also encourages providers to educate staff about the American Heart Association's Target: BP initiative, which encourages a team approach to blood pressure management.
"The most important thing is not making light of elevated blood pressure in the office, because the worst thing to happen is that it isn't acted on," he said. "The new guidelines do make it more difficult to get patients where they need to be, but we do need to be more aggressive in keeping numbers in the normal range while minimizing side effects to reduce the number of strokes and heart attacks."
Revised Cholesterol Guidelines
Cholesterol guidelines also call for more stringent monitoring, and new statin studies are calling for increased usage of the drug, which has been shown to improve outcomes in a broader spectrum of patients.
Stacy Davis, MD
"The benefits of statins far outweigh the risk, but patients hear conflicting information on TV and become fearful," said cardiologist Stacy Davis, MD, of Saint Thomas Heart. "In reality, statins have had more impact on reducing cardiac mortality than most medications we use."
The problem, she said, is that patients often stop medication after experiencing side effects like muscle aches, when they simply needed a lower dose or a different statin. "Not all statins are the same, and if you're intolerant of one, you may well tolerate another," she noted. She added she also urges patients to adopt aggressive dietary and exercise changes.
The updated guidelines specify physicians should run labs on patients four to 12 weeks after starting statin therapy. Davis said she checks labs six weeks after initiating statin therapy, after changes in statin dosing, and then annually.
New guidelines also stress the danger of drug interactions since certain medications, including antibiotics, can boost the side effects of statins, leading patients to ditch their prescription altogether. Davis said she urges providers to have a discussion with patients explaining potential side effects but keeping it in context of lowered cardiac risk.
"The new guidelines do a really important job of specifying documented coronary artery disease risk factors, and they're broadening statin use to include those with risk enhancing factors for coronary artery disease," she said. Those enhancing risk factors for patients range from chronic kidney disease and inflammatory disorders to premature menopause or a history of preeclampsia. The South Asian population also has been classified as a high-risk ethnic group.
"Primary care providers, OBs, cardiologists and nephrologists all need to realize that if we can prevent coronary artery disease, we'll be doing a good job of preventing mortality as well as morbidity," Davis stated.
Clair said today's patients are more educated about heart disease and increasingly aware of risk factors, which helps providers take a more preventative stance in addressing cardiovascular disease. "They're now coming to us saying, 'What about this?'" he said.
Claire continued, "I also believe providers are becoming less complacent about borderline numbers and realizing they've got to push those lower. So many of our providers are becoming part of larger systems of care, which are pushing for improved population statistics, as well. As physicians, we're getting appropriate pressure externally to help us do these things."