Treating High Blood Pressure

Blood pressure quality measures piss me off.  I just got a report about what portion of my patients’ blood pressures are at treatment goal and my numbers are lower than they should be.

Know why?

I have a lot of patients who have what is known as white coat hypertension.  That means that their blood pressure is higher at the doctor’s office than it is at home.  My own husband has mild white coat hypertension.

I strongly encourage my patients whose blood pressure is high in my office to monitor their blood pressure at home.  I need to know what their blood pressure is when they are not at the office.  They can monitor at different times of the day but the most important time to check is first thing in the morning.

What should blood pressure be?  The current recommendations are that patients less than 60 years old should be treated for blood pressures higher than 140/90, and if they are over 60 years old they should be treated if the blood pressure is over 150/90.  However, if a patient has diabetes they should be treated if the blood pressure is over 140/90 regardless of how old they are.

I have no trouble with these recommendations and I definitely practice this way.  I will keep working with my patients to get their blood pressure down until they are at goal.  The number one risk factor for stroke and a huge risk factor for heart attacks is uncontrolled high blood pressure.

My problem with the quality measures that the government requires of doctors is that they only take into account what a patient’s blood pressure is when they are at the doctor’s office.  So if my patient has white coat hypertension and tells me their blood pressure first thing in the morning at home is 125/70 (and they have a good reliable home blood pressure meter) it doesn’t really matter to me what it is when they are in the office.

If I treat white coat hypertension with the goal of meeting treatment goals AT THE OFFICE, the patient will be hypotensive (have low blood pressure) at home.  They will be dizzy and not feel well.  They may faint.  They will not tolerate exercise well.  Male patients will be more likely to have erectile dysfunction.

We know that, in the short term, low blood pressure is more dangerous than high blood pressure.  If I am not careful about making sure I right-size my treatment, I will hurt my patient.  I will take a patient who feels well and make them sick when it’s not needed.

On my first day of medical school I took an oath to do no harm.  To avoid both overtreatment and “therapeutic nihilism.”  To focus on prevention as well as treatment of disease.  And above all, to remember that I am treating a person, not a set of vital signs.

If you are my patient and I’m treating you for high blood pressure, please monitor your blood pressure at home.  Use a good-quality monitor (I bought an Omron meter for my hubby and me to use) and bring your log with you when you come to see me.  If I don’t have home blood pressure readings, the only info I have to use to manage your blood pressure is what I see at the office.  This is usually accurate, but may not be for certain patients.

We’re partners, both working to help you be as healthy as possible.  Watch your diet, make sure you’re getting enough magnesium (and supplement if you need to), control your stress and work on your physical fitness.

Treating high blood pressure, like all the rest of medicine, is more than just prescribing and taking pills.  There’s as much art as science involved, and we need to be mindful of the whole person existing everywhere, not just a set of vital signs obtained in the doctor’s office.  Done right, controlling blood pressure will reduce the risk of heart attack and stroke without causing side effects.

And that is much more important to me than a set of quality measures that judge how well I do my job.  How can looking at what percent of my patients have normal blood pressure at the time they’re in my office be a good measure of how well I care for them?

It isn’t.  So I don’t care.  What kind of doctor do YOU want?

QUESTION:  Do you monitor your blood pressure at home?  Is your blood pressure higher at the doctor’s office than it is at home?


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