Episode #369: The 2025 Blood Pressure Update

0:00 [SPEAKER_00]: Welcome back to the Barbell Medicine podcast where we bring modern medicine to strength conditioning and strength conditioning to modern medicine. [SPEAKER_00]: I'm your host, Dr. Jordan Faganbaum, and it's time to talk about blood pressure once again. [SPEAKER_00]: And why almost everything you knew is changing.

0:13 [SPEAKER_00]: Think of it, when was the last time a simple number could label you with a lifelong disease? [SPEAKER_00]: Now for decades medicine has used a single binary threshold for conditions like high blood pressure or hypertension. [SPEAKER_00]: But we now know that cardiovascular risk is a continuous spectrum, not a simple, on-off switch.

0:30 [SPEAKER_00]: And today we're diving into a new risk-based approach that's used to diagnose high blood pressure. [SPEAKER_00]: Finally, moving past those old-riched cut-offs. [SPEAKER_00]: We'll also break down the updated 2025 American College of Cardiology and American Heart Association guidelines that are pushing for a lower blood pressure goal for most adults based on the latest evidence.

0:49 [SPEAKER_00]: But that's not all. [SPEAKER_00]: We'll cover the condition that's often called the silent epidemic of hypertension, a condition called primary aldosteronism, and why new guidelines now suggest screening all individuals with high blood pressure for this common yet often misdiagnosis. [SPEAKER_00]: Plus, we'll look at the latest data on drug efficacy, how often you should be checking your home blood pressure if you're monitoring it on your own, and we'll even weigh in on the effectiveness of the new Apple Watch hypertension detection feature.

1:15 [SPEAKER_00]: ready to get the updated facts that could change how you practice and how you train. [SPEAKER_00]: Let's dive in. [SPEAKER_00]: But first, we have to introduce the second most handsome doctor in North America. [SPEAKER_00]: Dr. Austin Barackie, what's going on, dude? [SPEAKER_01]: Hey, excited.

1:27 [SPEAKER_01]: You know, this is an area that people have paid attention to for a long time, but man, the past few months, slash year or so of new publications and guidelines and research coming out. [SPEAKER_01]: It's just accumulated to a point where I was like, [SPEAKER_01]: do a kind of a comprehensive update, because some of the ways that I even practice and how I assess and manage patients has been directly impacted by a, by much of this in the past year.

1:51 [SPEAKER_00]: So yeah, looking forward to it. [SPEAKER_00]: As you set off air, blood pressure's life, and maybe this whole thing is more important than whether or not you put a couple kilos on the squat. [SPEAKER_00]: Maybe. [SPEAKER_00]: Maybe. [SPEAKER_00]: We'll see. [SPEAKER_00]: But we are the barbell medicine podcast, so maybe the next podcast is how to add two and a half kilos to your squad.

2:09 [SPEAKER_00]: No. [SPEAKER_00]: All right. [SPEAKER_00]: Well, let's just dive right into it because there is a lot of information to cover first. [SPEAKER_00]: Let's revisit this idea of how someone gets diagnosed with high blood pressure or even like high cholesterol. [SPEAKER_00]: You know, again, there's usually these cut points like, oh, if it's above this mark.

2:24 [SPEAKER_00]: You know, that means you have this condition, you get the diagnostic label, but Austin, you want to cover like how this normally happens in practice, how do people get a diagnosis of like high blood pressure? [SPEAKER_01]: Yeah, I mean, this dates back a long, long time to how we first figured out how to measure these things.

2:40 [SPEAKER_01]: If you go back to the original days of measuring blood cholesterol levels, for example, our best measurement at the time, our only real measurement was just drawing a total cholesterol level. [SPEAKER_01]: We didn't have any of these kind of sub-fractions, sub-tests, things like that. [SPEAKER_01]: And we just had very crude, correlational data.

2:56 [SPEAKER_01]: And so at the time, you know, you establish some somewhat arbitrary cutoff that attempts to divide those with a disease from those without it ends up being necessarily pretty crude and you end up refining that over time as you get better and better, you know, understanding of the disease, you end up [SPEAKER_01]: getting more accurate and reliable and precise testing.

3:18 [SPEAKER_01]: And you also get a better sense of this kind of risk, what we'll call stratification. [SPEAKER_01]: How precisely and accurately can we divide out those who are truly higher risk versus lower risk? [SPEAKER_01]: And is it really a binary like that higher versus lower risk? [SPEAKER_01]: Or is it a gradient, a spectrum of risk as we'll get to here?

3:36 [SPEAKER_01]: And then if it is a spectrum, how do you decide? [SPEAKER_01]: In whom you are going to recommend treatment or at least have that discussion with the patient because they're the person who ultimately, you know, is going to be the one who makes that decision whether to pursue treatment, what that treatment looks like and and how aggressive they want to be about it.

3:58 [SPEAKER_01]: And so the same applies with blood pressure where, you know, we originally got data and think it was like in the in the. [SPEAKER_01]: 50s or 60s, the first VA cooperative study was the one at the time that looked at blood pressure elevations and the risk of cardiovascular events like strokes.

4:14 [SPEAKER_01]: And at the time, you know, the study, if I recall off the top of my head, that one, they were looking at people who's like diastolic blood pressure was over 115, which is like one of the dreamly high. [SPEAKER_01]: And no surprise, those who had untreated blood pressures that high were at much higher risk of having things like strokes.

4:35 [SPEAKER_01]: And when they were treated with medication therapy at the time, and for the record, those are meds that we generally don't use anymore, those are very outdated. [SPEAKER_01]: drugs, but they were at least effective at lowering blood pressure. [SPEAKER_01]: There were massive impacts on their risk of stroke.

4:50 [SPEAKER_01]: And so, you know, if you think at that time, well, okay, at least we know based on these data that having a diastolic blood pressure below 115 is better than having a diastolic blood pressure above 115, diastolic being the bottom number. [SPEAKER_01]: Most people think of 115 is like, oh, cool, that's a good top number, but this is diastolic, right?

5:07 [SPEAKER_01]: So, [SPEAKER_01]: That's as crude as we were able to get at the time, recognizing that at that severe level of elevation, there is a significant potential benefit of lowering it. [SPEAKER_01]: And in the intervening decades, we have gotten better and better in better data and a better sense of where and how does this risk relationship kind of shake out?

5:29 [SPEAKER_01]: The conspiracy-minded folks among us will tend to think, well, back then, the cutoff for, say, total cholesterol was over 300 or 200 or whatever the case is, and they really just lowered these cutoffs because they want to sell you more drugs. [SPEAKER_01]: Or the blood pressure cutoff used to be, you know, a diet, just keep your diet stall like below in 15.

5:51 [SPEAKER_01]: And they're lowering it and tightening it just so they can sell you more drugs as if, you know, a large fraction of pharmaceutical revenue is coming from drugs that are pennies, you know, and ultimately generic at this point, which is not accurate, it's just not a not an accurate representation of this decision making process and the quality of data that we have at this point.

6:13 [SPEAKER_01]: to at least explain that risk relationship. [SPEAKER_01]: It is not that our understanding now that in general for blood lipids, lower for longer tends to be better with very high quality perspective, randomized control, you know, trial data and genetic data and things like that. [SPEAKER_01]: And to some extent, we see similar relationships with blood pressure down to a level that is much lower than those original studies that were looking at [SPEAKER_01]: Now we start to see that people's cardiovascular events measureably starts increasing as their blood pressures start to increase from somewhere in the range of like 1-10 to 1-15 systolic for the top number as it gets higher and higher from there we start to see people's risk measureably increase.

7:01 [SPEAKER_01]: Now it's not as great of an increase as people's cardiovascular [SPEAKER_01]: But it is measurable. [SPEAKER_01]: And so there are implications for that as far as what somebody how somebody ought to approach the question of how do I maximally mitigate my cardiovascular risk if that is something I want to do?

7:21 [SPEAKER_01]: And then from there we can decide, well, what are the potential trade offs of them? [SPEAKER_01]: Right? [SPEAKER_01]: So if I wanted to push somebody's blood pressure down that low, at least pharmaceuticaly, what trade offs are there that I need to be considering mainly in terms of side effects of therapy and things like that?

7:34 [SPEAKER_01]: But is there potential benefit? [SPEAKER_01]: based on this continuous spectrum of risk over the lifespan, it seems that getting it lower, not forever in debt, you like a lower and lower for blood pressure, but down to a certain level, we tend to see significant benefits. [SPEAKER_01]: So that's kind of been the evolution over the past.

7:49 [SPEAKER_01]: Let's call it 100 years of cardiovascular risk estimation with respect to cholesterol and blood pressure and shifting from setting cutoffs based on the best crude data we have at the time to this [SPEAKER_01]: a continuous variable understanding, not only continuous in terms of measurement but also across the entire lifespan.

8:08 [SPEAKER_00]: Yeah. [SPEAKER_00]: Yeah. [SPEAKER_00]: I've sort of felt this shift coming like little by little, you know, especially over the last, I want to call it 20, 25 years. [SPEAKER_00]: I mean, you think J and C seven, right, joint national, what was it coalition or committee committee. [SPEAKER_00]: Yeah, seven came out like 2003, right?

8:26 [SPEAKER_00]: And they're like, look, if your blood pressure is greater than one, systolic blood pressure grade 115, there's, there's some risk, you know, but you don't know what [SPEAKER_00]: There's no like quantification of that, and we're not that refined yet, but I suspect 20 years from now, but look for every one millimeter of mercury that you are above this certain threshold.

8:46 [SPEAKER_00]: If you have these other risk factors or none of these other risk factors will be able to get more granular, right? [SPEAKER_00]: But it is, as you said, getting more and more refined. [SPEAKER_00]: But you've kind of felt this coming, you know, the way clinicians and researchers who are in the know start talking about blood pressure have been talking about blood pressure.

9:02 [SPEAKER_00]: Is it [SPEAKER_00]: look at its higher, that's generally worse, and if it's higher for longer, that's generally worse, that if it's for shorter period of time. [SPEAKER_00]: And so this, it kind of felt like this was the logical end that you were going to come towards or move towards where it's like, yeah, maybe just this cut point of 120 over 80.

9:19 [SPEAKER_00]: It is insufficient to describe not only treatment targets, but also like general advice for you know what most people's blood pressure should be and how we think about it as like a broader maybe risk score so that's a good segue into like this proposed shift towards diagnosing and treating elevated blood pressure and hypertension it's kind of this risk.

9:42 [SPEAKER_00]: based approach. [SPEAKER_00]: You want to talk people through these kind of this updated thinking using this new approach as far as like what are the new targets? [SPEAKER_00]: Maybe and then also like how do we arrive at this [SPEAKER_01]: Yeah, it's kind of coalescing into what I will call a little bit more of a coherent approach across the different cardiovascular risk factors, but at the same time, I'm going to point out some potential areas for critique here and and how individual clinicians or patients might opt for you know a different strategy based on their preferences use to borrow some terms from from elsewhere that we've talked about before those who are so called maximizers versus minimizers those who want to do everything possible.

10:25 [SPEAKER_01]: versus those who want to do the least possible to get the kind of a little bit more bang for the book perspective on this. [SPEAKER_01]: And so, again, shifting from a more binary, if you're above this number, if you get treated, if you're below this cut off, you don't get treated, recognizing that this is a gradient or a continuous type of approach.

10:42 [SPEAKER_01]: But there's also going to be differences based on people's other risk factors, right? [SPEAKER_01]: So somebody could have high blood pressure alone. [SPEAKER_01]: It could be mildly, moderately, severely elevated. [SPEAKER_01]: But no other, you know, concerning risk factor for heart disease, they could have [SPEAKER_01]: excellent metabolic health, blood sugar control, blood cholesterol levels, they might be otherwise lean, healthy active and just have a little bit of mildly elevated blood pressure.

11:07 [SPEAKER_01]: On the other hand, you can have somebody who has the same mildly elevated blood pressure, but it's also in the setting of maybe poorly controlled diabetes, some elevated blood cholesterol, they might smoke, they might have obesity, insulin resistance, fatty liver disease, [SPEAKER_01]: I'm painting a very different picture here, right?

11:21 [SPEAKER_01]: And then at the other end of the spectrum, you can have somebody with very high blood pressure, extremely elevated with no other risk factors in the same time, somebody with very high blood pressure and all the risk factors. [SPEAKER_01]: All of these are kind of different levels of risk.

11:32 [SPEAKER_01]: And so if you look back at cholesterol-based treatment guidelines, going back from those original days of, you know, the total cholesterol of over 200 is just just like definitively high. [SPEAKER_01]: And then refining it from there based on LDL or non-HDL, most recently, ABOB. [SPEAKER_01]: type metrics and then also recognizing that we don't just knee jerk treat everyone above a certain cut off in that situation, but rather the shift over the past 15-ish 20 years to using what are called various predictive equations to estimate somebody's risk of having a heart disease or cardiovascular type event.

12:08 [SPEAKER_01]: So there have been several iterations of these risk calculators, and we actually talked about the most recent iteration called the prevent calculator that came out last year. [SPEAKER_01]: And so the idea is that if we punch in people's cumulative set of established risk factors into these calculators, we can assess, well, what's their risk of having one of these things happen like a heart attack or a stroke in the next 10 years?

12:31 [SPEAKER_01]: And if somebody's risk is high, which is also somewhat arbitrarily set at about seven and a half percent or higher, then you are you have a more strong justification to treat this patient a little bit more aggressively perhaps using medications, but if it is less than that cut off, then maybe it's not super worthwhile and you can.

12:50 [SPEAKER_01]: you know reasonably continue to observe them. [SPEAKER_01]: At least that's how a lot of clinicians approach this in practice. [SPEAKER_01]: We get tons of questions on the forums and I get you know barbell medicine, you know consult inquiries from people who are maybe a little bit on the younger side and maybe they have some high blood cholesterol or some high blood pressure and they say well my doctor said that my tenure risk is not very high and so they weren't going to suggest doing you know anything at least medication-wise about it.

13:12 [SPEAKER_01]: What do you what do you suggest? [SPEAKER_01]: And so I end up having these conversations [SPEAKER_01]: That was, however, not the approach that was typically taken for the management of blood pressure until more recent guidelines have come out. [SPEAKER_01]: And as I said, had made it a little bit more of a coherent picture in the sense that they are now also advising treatment of blood pressure or not treating blood pressure based on this overall assessment of risk rather than just based on the blood pressure alone.

13:38 [SPEAKER_01]: So I can see a way in which this all makes sense of if we view blood pressure as a how high for how long, [SPEAKER_01]: All these other sorts of things, we can estimate somebody's overall risk and treat their cumulative risk rather than just treat the isolated variable blood pressure or cholesterol alone.

13:56 [SPEAKER_01]: I think that that is a reasonable way to go about it, assuming that the population that you are looking at in front of you and trying to make these decisions like the person, the patient, is well represented by the studies on which these calculators were derived and things like that. [SPEAKER_01]: So is it generalizable to that person?

14:14 [SPEAKER_01]: the issue or the critique that we have had historically is that, you know, these things like high blood pressure, high blood cholesterol, these other cardiovascular risk factors, they can emerge or be present in people who are much younger. [SPEAKER_01]: And the problem with that is that, you know, somebody who's in their 20s or early 30s, [SPEAKER_01]: We're not generally that concerned about their 10-year risk of having a heart disease type of enterist stroke.

14:40 [SPEAKER_01]: And so just basing our treatment recommendations on what's the risk in the next 10 years, it kind of gives them this 10-year window of unmitigated exposure if you don't do anything else about it. [SPEAKER_01]: And so they're 20-year, they're 30-year, they're 40-year risk if you want them to live.

14:55 [SPEAKER_01]: a long time without having a heart attack or stroke, you're not really doing a ton to modify that risk trajectory. [SPEAKER_01]: And so waiting until their risk gets high enough, well, there's a fair argument to be made that that's not a super-wise decision because you can't undo that exposure later on in life.

15:11 [SPEAKER_01]: And so there is an argument that you can make particularly for those that might resonate as what I'm quote-unquote maximizers who want to do as much as possible. [SPEAKER_01]: that potentially treating things a little bit more aggressively, potentially treating them a little bit earlier in life, if your goal is to maximally impact your lifelong risk of these sorts of complications, might be wiser than just deferring just because you're young, for example.

15:37 [SPEAKER_01]: And so that's kind of the big picture perspective on this shift from a binary treatment threshold for blood pressure to a more risk-based, which is now a little bit more inline, [SPEAKER_01]: with the risk-based treatment of blood cholesterol levels, both the pros of that approach, as well as some of the potential cons and critiques that we have encountered and that we are faced with when working with people and patients in day-to-day practice.

15:58 [SPEAKER_00]: Yeah. [SPEAKER_00]: To me, it just seems like maybe an expansion of how blood pressure is viewed. [SPEAKER_00]: Again, it's less of just a single number, looked at an isolation, [SPEAKER_00]: irrespective of the patient not not that I think that most physicians were practicing in that manner You know, but at some time you have to make clinical decisions right and you have limited time Unfortunately we go back to the problems with the system and so you're like well this patient in front of me You know we've got a in office measurement of 135 for their systolic blood pressure and you know just looking at them well They're young and you know active They're probably fine [SPEAKER_00]: something like that.

16:37 [SPEAKER_00]: That clinician has made a bunch of assumptions and probability-based assessments and I don't necessarily think I need to treat this person, but maybe this new information and additional guide for assessing a person's risk over overtime might actually change what's happening in the clinic.

16:57 [SPEAKER_01]: Yeah, one of the interesting things about that is, you know, when you're talking about somebody who's young, who might get kind of brushed off, that's a very common thing because in general, they're absolute risk in the near term for somebody who's young of these things is not terribly high.

17:10 [SPEAKER_01]: The interesting thing in, you know, [SPEAKER_01]: being in practice, having done primary care, or had working in the hospital setting, and knowing how a lot of other clinicians operate is, they might see a younger person with a little elevated blood pressure in clinic, and the next appointment might be somebody who is in their 80s, or even later.

17:30 [SPEAKER_01]: and the perspective that they take might be that the young person either probably find their, you know, quote unquote too young to put on a blood pressure medicine or to treat their blood pressure or their blood cholesterol, right? [SPEAKER_01]: Whereas they won't necessarily bat an eye at tweaking it in the older person because they, in absolute terms, the short shorter term risk in that older person is, yes, I agree.

17:50 [SPEAKER_01]: It is, it is much higher, right? [SPEAKER_01]: In my mind, that is a [SPEAKER_01]: is the person who's long-term risk if an addressed is going to accumulate and you can do something about that now. [SPEAKER_01]: The person who's in their 80s or 90s, they've already won the game. [SPEAKER_01]: They have gotten past the average life expectancy and the whole point of these preventative measures of treating blood pressure and blood cholesterol is so that you can get old and be healthy or at least not have suffered one of these events.

18:22 [SPEAKER_01]: Once you get to that point and you have maybe, indeed, not suffered one of these events. [SPEAKER_01]: Again, you've won the game, you don't have to necessarily be as ultra aggressive at that point if it's not within the person's goals. [SPEAKER_01]: And so I'm more often taken the opposite approach of this younger person.

18:38 [SPEAKER_01]: Those are clues early on in life that I ought to do something or at least address whether it be lifestyle related or even potentially these events to mitigate that long-term risk. [SPEAKER_01]: Whereas the much, much older person, I flip it and I'm like, man, this person's too old to be treated in their blood pressure.

18:51 [SPEAKER_01]: Yeah, carry on. [SPEAKER_01]: Yeah, because there's various risks that we'll get to later in being over aggressive with those patients, and that's actually what I end up seeing more often in the hospital. [SPEAKER_00]: Yeah, it, it, it kind of draws this analogy of what, how I think about like, strength training, prescription, and like my, [SPEAKER_00]: Spidey sense for how important it is for somebody's health like, you know, you see a 25 year old 30 year old or whatever who's maybe not exercising and they're they express some interest in it right and you're like, yeah, you should do everything train like a professional athlete go crazy go crazy, you know, and it's like.

19:23 [SPEAKER_00]: It's probably, you know, it is likely to improve their health up to some level, but the degree of benefit and their existing vulnerability for, like, sarcopenia, decreased muscular function or whatever is not likely to manifest for decades, whereas somebody in their, you know, 60s. [SPEAKER_00]: That is imperative to them that they start doing some sort of exercise right now You know, if they're not currently doing it.

19:46 [SPEAKER_00]: It's far more important for there immediate trajectory Than it is for the younger person. [SPEAKER_00]: Whereas it's kind of flipped backwards amongst most people who think about exercise They're like, yeah, you're in your 20s. [SPEAKER_00]: There's yeah, go crazy go off train like professional athlete We're as the way I look at it if you're in your 60s.

20:00 [SPEAKER_00]: I'm like you need to train like professional athlete because your life depends on it. [SPEAKER_00]: Yeah on some level [SPEAKER_01]: Yeah, I mean, your cumulative exposure to the iron, to the to the weights, uh, can can impact very, importantly, your your bone density, totally. [SPEAKER_01]: And beyond a certain point in life, particularly for postmenopausal women who are not, you know, on hormone therapy and things like that, it gets a steeper and steeper and steeper uphill battle to try to restore or mitigate bone losses, for example, if you haven't done that earlier in life.

20:26 [SPEAKER_01]: So it's a similar perspective, just interpreted a little bit differently in terms of this cumulative lifelong exposure to good things, [SPEAKER_00]: Yeah. [SPEAKER_00]: All right. [SPEAKER_00]: Well, let's talk about these new targets. [SPEAKER_00]: The 2025 ACC and AHA guidelines, those are acronyms for the American College of Cardiology and American Heart Association.

20:44 [SPEAKER_00]: These new guidelines were released and there are some updates to actual blood pressure targets as well as thresholds for treatment. [SPEAKER_00]: So just a few highlights here. [SPEAKER_00]: The new guidelines did reaffirm that for adults with confirmed elevated blood pressure or hypertension, [SPEAKER_00]: that the target should be an office blood pressure goal of less than 130.

21:05 [SPEAKER_00]: That's a top number, over 80 millimeters of mercury. [SPEAKER_00]: That's the bottom number of diastolic blood pressure. [SPEAKER_00]: And then there's an encouragement to further reduce systolic blood pressure again. [SPEAKER_00]: That's the top number to less than 120 millimeters of mercury for adults.

21:20 [SPEAKER_00]: To me, that seems like a relatively mild update, but it phrased more clearly because before there was some hemming in high and in [SPEAKER_00]: kind of hand waving like well look if it's an older person like you don't really need to get down that low or if a person has other comorbidities and maybe we have we're more liberal with their sort of blood pressure targets and now they're like probably shouldn't probably shouldn't do that.

21:43 [SPEAKER_00]: Does that is that your understanding of kind of this what I would call a mild update you know it was kind of out there but not phrased as clearly in previous guidelines. [SPEAKER_01]: I think it's making it more clear that to this threshold of less than getting it down to the systolic into the teens, for example, this concept of lower into that range is generally better.

22:03 [SPEAKER_01]: But it also is, I would say, a good idea or helpful because it kind of puts the [SPEAKER_01]: uh, the onus or part of the decision making on the clinician to uh, individualize that treatment approach based on the person in front of them of how aggressively uh, do I want to go about this and how am I going to get there?

22:20 [SPEAKER_01]: Because the how also matters, right? [SPEAKER_01]: So if you can get it down that low safely, then that's generally going to be beneficial for their heart disease risk. [SPEAKER_01]: But if you gave just a blanket recommendation of we want everybody's resting blood pressure in the office setting to be 115 over 70 there is going to be a fair amount of unintended harm from that sort of thing for a few reasons one we know that on average office blood pressure measurements tend to be.

22:47 [SPEAKER_01]: higher than people's actual resting blood pressure measurements when they're at home or going about their life. [SPEAKER_01]: And that's why several years back the U.S. [SPEAKER_01]: preventative services task force actually recommended that in order to confirm a diagnosis of high blood pressure that we actually try to get out of office blood pressure measurements if we can get high quality measures that not that we shouldn't exclusively rely on in office measures alone.

23:09 [SPEAKER_01]: And so we know that if you're in office says that tightly controlled that you're probably going to be even lower at home and for those who are maybe older who have some comorbidities who have like neuropathy or you know a neurological conditions or various other things. [SPEAKER_01]: Maybe they end up falling a little bit more often and having injuries like that from that which is something that I actually see on a pretty regular regular basis.

23:31 [SPEAKER_01]: So it does. [SPEAKER_01]: deliver this message of like in general lower is better if safe and you get to decide below that lower threshold, whether it is safe and how you want to actually get there with the person in front of you. [SPEAKER_00]: Yeah, yeah, they actually further comment on like treatment sort of thresholds where they say look if if you're an adult and you have a blood pressure measurement of greater than 140 over 90 and any adult, you know, probably a good idea to start an anti-hypertensive medication will actually talk about some updates to how you go about doing that what agents are selected.

24:04 [SPEAKER_00]: And then they further kind of refine this and say, well, look if it's not quite 140. [SPEAKER_00]: but it's greater than 130 over 80 and you have risk factors of heart disease based on this prevent calculator that we've linked in the show notes below. [SPEAKER_00]: If it's greater than 7.5% probably would benefit from an anti-hypertensive medication as well again further kind of refining these targets for for individuals and then further they say well look if it's less than or if it's greater than 130 but you don't have any these cardiovascular risk factors.

24:38 [SPEAKER_00]: But you could probably try lifestyle alone, especially if your risk is less than the seven and half percent kind of arbitrary cutoff. [SPEAKER_00]: However, if it may entain, if you can't get a hold on it, you can't get it to blow 130 over 80 in like three, six months, probably would also benefit from some medications.

24:58 [SPEAKER_00]: And again, this is, I don't know if this is like in response to a criticism [SPEAKER_00]: update, which was like 2017 American Heart Association guidelines where they're like, look, we're lower in the blood pressure targets. [SPEAKER_00]: And if you're a skeptic or critic, you're like, well, look, they're just trying to sell more anti-hypertensive drugs, which, hey, look, full marks, like, understandable how you could come to that position, although [SPEAKER_00]: If you read the whole document, they're like, no, we wanted to push lifestyle earlier to try to get a handle on this, but now that again, they've made it more clear, perhaps in response to criticism.

25:29 [SPEAKER_00]: I don't actually know what the committee, you know, how they kind of arrived at this clarification, but to me it seems reasonable. [SPEAKER_01]: Yeah, I agree and I like that they put this kind of caveat or at least the time point on there because what you sometimes see is if you follow a, you know, maybe a young person who's seen in a primary care clinic, they're not necessarily seen terribly frequently, especially if they don't have a ton of medical problems and so maybe they come in and they have a concerning, you know, maybe mildly moderately elevated blood pressure at one of their visits.

26:01 [SPEAKER_01]: And maybe the doc says, yeah, let's just like, you know, do some lifestyle changes heavy air quotes around that whatever that counseling actually looks like for the person and then I'll see you in six months maybe and maybe that person doesn't actually come back for their six month appointment and then they come back a year later also maybe and a year later their blood pressure still elevated or maybe they're, you know, maybe they're 20s or 30s and they don't actually see a doctor every year and so then two years three years five years later they come back.

26:28 [SPEAKER_01]: That's years worth of exposure to unnecessarily elevated blood pressure that has not been kind of controlled and yes, in that short two three five year time period, their risk of a stroke is not going to be massively elevated, but that cumulative exposure across the lifespan is the thing that does drive long term risk and so this is a period of time.

26:47 [SPEAKER_01]: where we do have more opportunity, and so, you know, when I have these kind of conversations with folks, I give them often a couple of different options. [SPEAKER_01]: I often have a conversation about, here are some of the specific life stuff things that if we do them, here is the timeline on which I would actually expect to see blood pressure improvements.

27:04 [SPEAKER_01]: And so if somebody goes all out with all the behavior change stuff, maybe they reduce their alcohol intake, improve their sleep, [SPEAKER_01]: exercise, take a few inches off their waste measurement, adjust their diet to promote a healthier dietary pattern. [SPEAKER_01]: Their blood pressure is going to come down in a matter of, you know, days to weeks, I would expect to see that, right?

27:22 [SPEAKER_01]: It's not going to take six months to see that. [SPEAKER_01]: If somebody is going a little bit more gradually, maybe single behavior change at a time, it might take a little bit longer. [SPEAKER_01]: But I'm not going to say, hey, let's do these things and then I'll see you in a year for something like that.

27:34 [SPEAKER_01]: Or alternatively, what we could do is to spare you that exposure, we could start a super low dose of a medicine now. [SPEAKER_01]: And then if we end up seeing that your blood pressure is coming down well into the normal range or even starting to dip a little bit lower than that, then we can just come off the medicine later and we will have [SPEAKER_01]: You know, avoided this unnecessary exposure to elevated blood pressure.

27:52 [SPEAKER_01]: And so we work through that decision-making process kind of together and patients will opt for different things based on their preferences and things like that. [SPEAKER_00]: Yeah, that's that's actually a study I would like to see something large hundreds of thousands of patients where, you know, they they're like age match generally generally match for like demographics and another information.

28:13 [SPEAKER_00]: And then half of them get sort of early medication exposure. [SPEAKER_00]: Sure. [SPEAKER_00]: And the other are like, oh, we're going to let this ride for a few months while we initiate lifestyle stuff. [SPEAKER_00]: And then hopefully you come back and we get a measurement. [SPEAKER_00]: I would be curious.

28:26 [SPEAKER_00]: Like if you took that study, that, that, that, that, those groups. [SPEAKER_00]: And you followed them for 10 years, 20 years. [SPEAKER_00]: Is there a difference? [SPEAKER_00]: Because if you see a clear difference, you're like, well, shoot. [SPEAKER_00]: Maybe we shouldn't do this like.

28:38 [SPEAKER_00]: Early medication, if there's no real benefit, or if there is an apparent benefit, maybe you don't do this sort of like, let's do the lifestyle stuff first and kind of piecemeal it that way. [SPEAKER_01]: Yeah, I think that that's a, that would be a study that would be ideal to have. [SPEAKER_01]: I don't envision us getting something like that.

28:53 [SPEAKER_01]: And ultimately it's also gonna be a matter of degree. [SPEAKER_01]: And so I think that there would need to be, there would need to be some fancy statistical analysis that is above our heads to determine, basically, I guess if you think about blood pressure exposure [SPEAKER_01]: cumulative thing over the lifespan, how much or what is the kind of spectrum of risk reduction based on how much of that area under the curve lowering that you get.

29:18 [SPEAKER_01]: That was a very confusing way of explaining what I'm trying to say is like how much did you lower the person's blood pressure up front and for how long versus not doing that and then what was the impact on their risk say 10 years 20 years 30 years. [SPEAKER_01]: later, I don't envision we're going to get that study, but that would indeed be interesting to see.

29:37 [SPEAKER_00]: Yeah, hey, look, if you're researcher, just do that. [SPEAKER_00]: We don't need another creatine study. [SPEAKER_00]: We need this. [SPEAKER_00]: How about that? [SPEAKER_00]: All right. [SPEAKER_00]: We'll look after the break. [SPEAKER_00]: We'll be back to talk about new blood pressure screening guidelines.

29:48 [SPEAKER_00]: Apple watches hypertension detection feature and more. [SPEAKER_00]: All right, we're back here on the Barbell Medicine podcast. [SPEAKER_00]: We're talking about blood pressure once again, because there have been a lot of updates. [SPEAKER_00]: Recent guidelines have changed some new guidance on what to do for individuals with the, not only high blood pressure screening, and also, [SPEAKER_00]: how to treat individuals with elevated blood pressure.

30:10 [SPEAKER_00]: So let's get back to this screening discussion. [SPEAKER_00]: This was interesting. [SPEAKER_00]: Now it's interesting to me as just like if it's general physiology sort of nerd, I'm like, yeah, this is like way more prevalent than we thought. [SPEAKER_00]: The fact that it's been called like the silent epidemic of secondary hypertension, I did not know that.

30:27 [SPEAKER_00]: But it is interesting, so the new clinical practice guidelines from not only the endocrine society, but also, you know, there's some guidance in the AHA document. [SPEAKER_00]: The endocrine society, those ones that further, and they say, look, we suggest that all individuals with hypertension be screened for primary, all-dostronism by measuring a plasma [SPEAKER_00]: activity and determining the aldosterone to renin ratio, potassium should also be assessed not for screening itself, but to aid in the accurate interpretation of aldosterone.

31:04 [SPEAKER_00]: Now, look, if you haven't taken physiology in the last few years or these words are a little foreign to you, here's the overview here. [SPEAKER_00]: So one of the ways that the body controls blood pressure is by what's known as the renin angiotensin aldosterone system. [SPEAKER_00]: A renin is a hormone produced by [SPEAKER_00]: it is released in response to reduced blood pressure, which triggers the adrenal glands they sit on top of the kidneys.

31:29 [SPEAKER_00]: They produce this other hormone called aldosterone. [SPEAKER_00]: And aldosterone's job is to make the kidneys retain salt and water, which raises blood pressure and blood volume. [SPEAKER_00]: Now in primary aldosteronism, the adrenal glands overproduce aldosterone, but from some mechanism.

31:45 [SPEAKER_00]: This leads to sustained high blood pressure that doesn't tend to respond well to standard blood [SPEAKER_00]: It can also lead to low potassium levels, which we call hypokalemia. [SPEAKER_00]: So the new guidelines recommends meaning everyone with high blood pressure for primary aldosteronism, because it is so common, something like 14% of all individuals with hypertension in primary care setting have primary aldosteronism, which is actually higher in some specialty clinics.

32:15 [SPEAKER_00]: So this is something you've been doing for a few years. [SPEAKER_00]: that's that's interesting. [SPEAKER_00]: What like how what's the reason why you think this took a few years to come into like the new guidelines has been like collecting more data or just because things move slowly and medicine are like what's up?

32:34 [SPEAKER_01]: Yeah, a little bit of all the above as a kidney physiology nerd, this definitely caught my attention and yeah, so I first caught wind of this several years back by way of some endocrineologists who I follow and reading some of the papers that they were citing as this being definitely way more common than was recognized and.

32:55 [SPEAKER_01]: For, I know we have plenty of medical trainees, students, residents in the audience, even, obviously colleagues and things like that. [SPEAKER_01]: And we think back to how we get taught about this condition in medical school, about primary Eldosteronism, or also known as Con syndrome, where you have this benign adrenal tumor as the classic kind of teaching that is overproducing this hormone that leads to salt retention blood pressure elevation.

33:20 [SPEAKER_01]: The way we are taught about this condition is that you should start to suspect it when somebody meets criteria for what's called resistant type retention, meaning difficult to treat high blood pressure. [SPEAKER_01]: So in other words, somebody comes in with run of the mill high blood pressure, you don't actually think about this until much, much later in the process.

33:39 [SPEAKER_01]: and the criteria for resistant hypertension is for people to be on, maximal doses of at least three drugs and one of them has to be a diuretic drug. [SPEAKER_01]: And all of that takes a fair amount of time for a patient to get started on one drug and then another drug and a third drug and for the doses to get maximized.

33:59 [SPEAKER_01]: Or if they have the textbook features of very, very high blood pressure and low blood potassium levels which as with most kind of like textbook collections of findings doesn't actually happen in most patients so most patients with this condition don't have [SPEAKER_01]: that kind of characteristic finding of super high blood pressure and spontaneous low blood potassium levels.

34:21 [SPEAKER_01]: And so I think the issue was that too few people were thinking about this condition and it was not commensurate with how common it is that was under recognized. [SPEAKER_01]: I think if you tell most people that up to 14%, [SPEAKER_01]: people with high blood pressure in a primary care clinic might have a degree of this because it's just like high blood pressure itself.

34:40 [SPEAKER_01]: It's not a binary, you have it, you don't, but it's rather a spectrum. [SPEAKER_01]: So you don't have to have a blood pressure of 180 over 110 with a super low blood potassium level to have primary hyperaldo. [SPEAKER_01]: It's how much are you actually producing and what's the net impact.

34:53 [SPEAKER_01]: So you can't have it with much milder blood pressure [SPEAKER_01]: I think that any of the primary care docs who are listening to this right now, they have over a hundred patients in their primary care patient panel who have high blood pressure just because of how common it is right upwards of our think around 45 to 47% of adults in the US have high blood pressure right so if you take their primary care panel.

35:18 [SPEAKER_01]: You know that over 100 patients in their panel have high blood pressure, 14 of those have some degree of primary hyperaldosteronism. [SPEAKER_01]: I would suspect that anywhere from zero to like two of those might even be detected or suspected. [SPEAKER_01]: And even for those who are on multiple medicines, including a diuretic and things like that, it is often still insufficiently tested.

35:38 [SPEAKER_01]: Maybe because the person also has obesity or they have sleep apnea and people's like, think, oh, I have better explanations for why they might have this. [SPEAKER_01]: And so it's not actually tested. [SPEAKER_01]: So, I think that we think about it too late, not often enough that doesn't match the prevalence of this condition in practice.

35:54 [SPEAKER_01]: And again, what I keep coming back to is, if somebody needs to meet those criteria to be on all these medicines at high doses, that could take a year or longer for somebody to get on all of those things. [SPEAKER_01]: And we know that people with primary hyperaldostronism, even for a similar degree of blood pressure elevation, they have a higher risk of strokes and heart attacks and atrial fibrillation and heart failure and kidney disease.

36:16 [SPEAKER_01]: And this is in part thought to be just due to the direct toxic effects of eldostronism, uh, uh, eldosterone, the hormone in the body, right? [SPEAKER_01]: And so it's not equivalent to somebody else with the same degree of blood pressure control. [SPEAKER_01]: We keep coming back to this in different conversations, how you get their matters.

36:34 [SPEAKER_01]: So if your blood pressure gets up to a certain level because you're deadlifting, short term, not what I'm worried about. [SPEAKER_01]: If you have run in the middle high blood pressure and you get up to that level, okay, I'm concerned. [SPEAKER_01]: If you have primary hyperaldaustronism and you get up to that degree of blood pressure, I'm even more concerned because I know that even for a similar degree of blood pressure, you have a higher risk.

36:53 [SPEAKER_01]: of having all of these bad complications. [SPEAKER_01]: And then the other consideration here is that this is a much more straightforwardly treated condition because we have medicines that directly block al dostrom, called mineralicorta-quid receptor antagonists like spironalactone, a pleronone, et cetera, and some other ones that can have effects on this pathway.

37:15 [SPEAKER_01]: Or if somebody has that benign tumor in their adrenal gland, [SPEAKER_01]: They can undergo surgery, cut it out, and then they're cured of all high blood pressure, and they don't need to be on any medicines. [SPEAKER_01]: I've seen this miraculous effect happen in patients who do who are found to have those benign tumors, you cut it out and they're cured, right?

37:31 [SPEAKER_01]: I think a lot of patients would take that if you find it, but the only way you find it is if you think about it and you look, and that involves doing this straightforward blood test. [SPEAKER_01]: And so, yeah, ever since I learned about this a few years ago, I said, well, I'm going to start testing this in pretty much every one I diagnosed with high blood pressure in a primary care setting.

37:46 [SPEAKER_01]: I'm not doing it in my hospitalized patients because that's not the right place to be doing that in general for most patients. [SPEAKER_01]: Once in a rare while, I'll still do it, but not not often. [SPEAKER_01]: And so sure enough, you know, a couple of years down the line, now we're starting to see it incorporated into more clinical practice guidelines and so hopefully this gets disseminated both from the guidelines and from us talking about it here today.

38:07 [SPEAKER_00]: Yep, one correction, and I'm gonna quiz you here on the spot, which I know that you love, are you aware of the differences between reading and running? [SPEAKER_01]: Well, I almost corrected you because I know that no, for all of just we're going to get triggered that the correct pronunciation is reading.

38:25 [SPEAKER_00]: Yes, exactly. [SPEAKER_01]: Yes, it's often mispronounced, but I wasn't going to be that annoying. [SPEAKER_00]: No, no, yes. [SPEAKER_00]: So not only when I was doing my master's and anatomy and physiology, the professor was like, you know, I'm sure either I or another one of my classmates said renon, because you just see it.

38:41 [SPEAKER_00]: It's common. [SPEAKER_00]: Yeah, whatever. [SPEAKER_00]: You know, he goes, renons and cows. [SPEAKER_00]: It's a digestive enzyme, it curdles the milk, you know, whatever, and other roomant animals have it in their gastric juices. [SPEAKER_00]: Humans, we're talking about reenin. [SPEAKER_00]: When it comes to the reenin, and you've tense in all-dosterone system.

38:57 [SPEAKER_00]: So look, I forget his name, my professor, but if you happen to be listening to this, I'm so sorry. [SPEAKER_00]: You talk to me well, I'm just an idiot. [SPEAKER_00]: So I have no to tell you. [SPEAKER_00]: All right. [SPEAKER_00]: Well, no, that's a, that's a good summary. [SPEAKER_00]: Definitely practice changing.

39:12 [SPEAKER_00]: I would suspect for for many. [SPEAKER_00]: Yeah. [SPEAKER_00]: And yeah, so that's definitely important part of this update. [SPEAKER_00]: Speaking of updates, let's talk about some updated treatments here. [SPEAKER_00]: So traditionally treating individuals with elevated or high blood pressure meant starting, [SPEAKER_00]: on a single medication at a standard dose and then increasing that dose as needed to achieve the target blood pressure or blood pressure goal, occasionally adding additional medications as needed.

39:38 [SPEAKER_00]: However, new data has been flipping this on its head. [SPEAKER_00]: Uh, which, again, if you're a skeptic, you're like, of course, big farmers coming out with these new studies reactives more medications. [SPEAKER_00]: So Dr. Barack, you want to unpack this a little bit like, why is this becoming a thing and like, how does this actually change practice with respect to treating elevated blood pressure?

39:59 [SPEAKER_01]: Yeah, this reflects how I've been doing this for a while now and is also a little bit more coherent with a similar approach to how I turn to manage high blood cholesterol levels at least in patients who are not like ultra ultra high risk. [SPEAKER_01]: And one caveat here is that treating high blood pressure also first line, including in every clinical practice guideline that you read is gonna involve all of the lifestyle modifications that we talked about earlier, all the things that are in our guide on high blood pressure on the website that relates to things like improving the quality [SPEAKER_01]: getting sufficient physical activity addressing obesity, sleep, alcohol, things like that.

40:33 [SPEAKER_01]: So we have detailed information on that for people. [SPEAKER_01]: So it's not necessarily jumping straight to a blood pressure medicine unless you do need to jump to that based on the person's risk and that whole conversation that I discussed earlier. [SPEAKER_01]: And so, yeah, when I went through training, it was typically you just start one med, because that's simpler.

40:48 [SPEAKER_01]: And then you maximize, get up to the max dose. [SPEAKER_01]: And then if you still need more, then you can start a second one. [SPEAKER_01]: And the idea there was to keep things as simple as possible for patients. [SPEAKER_01]: We've talked about this a little bit again in the realm of lipid lowering and I'll re-address it here.

41:03 [SPEAKER_01]: But this topic was prompted by a new meta analysis that I believe was published in the Lancet of almost 500 randomized control trials. [SPEAKER_01]: So 484 RCTs over 100,000 patients in these trials. [SPEAKER_01]: And it was basically looking at what is the treatment effect based on different ways of using these blood pressure medicines.

41:23 [SPEAKER_01]: So I'll explain this slowly because it is really important to understand. [SPEAKER_01]: If I start you on a single medicine at the standard dose of that medicine, on average, I'm going to get about 8.7 millimeters of mercury lowering. [SPEAKER_01]: So that's, say, for your top number on that blood pressure, on average across the most common, like first line classes of blood pressure lowering medicines, [SPEAKER_01]: One drug standard dose about 8.7 percent, sorry, 8.7 millimeters of mercury lowering of your blood pressure.

41:52 [SPEAKER_01]: If I double that dose, take you from a standard dose up to twice that much. [SPEAKER_01]: On average, I'm going to only get an extra 1.5 millimeter mercury lowering of your blood pressure. [SPEAKER_01]: On top of the initial almost nine from the standard dose. [SPEAKER_01]: Those standard dose about nine, doubling that, [SPEAKER_01]: Now, what goes up as we tend to double triple quadruple doses is the incidence of side effects.

42:18 [SPEAKER_01]: Now, in general, these blood pressure medicines tend to be quite safe and don't tend to have severe side effects in most patients, even at higher doses. [SPEAKER_01]: But at higher doses, side effects are going to necessarily go up. [SPEAKER_01]: Whereas it seems that the effectiveness that I'm getting out of it is diminishing significantly.

42:37 [SPEAKER_01]: What if I start you on two medicines up front? [SPEAKER_01]: And both of them are at the standard doses. [SPEAKER_01]: I'm going to get per this data at these data, 14.9 millimeters of mercury lowering. [SPEAKER_01]: So about 15, what if I double both medicines? [SPEAKER_01]: So now you're taking two medicines that double the standard dose, then I'm only going to get 2.5 points additional.

42:59 [SPEAKER_01]: So you see a similar pattern here that that additional lowering is significantly mitigated as we crank up the doses and again side effect risks tend to go up. [SPEAKER_01]: What if instead I put you on three different medicines at a quarter of the standard dose? [SPEAKER_01]: So, on one hand you're like, oh my gosh, can you believe it?

43:17 [SPEAKER_01]: They're putting me on three drugs. [SPEAKER_01]: Well, they're on a fraction of the standard dose. [SPEAKER_01]: So you're getting a width of three different medicines. [SPEAKER_01]: I'm already getting 11 millimeters of mercury on less than standard dosing, meaning that side effect risks are even lower.

43:31 [SPEAKER_01]: but I'm getting more effectiveness than one drug at the standard dose. [SPEAKER_01]: And the reason why is different people's blood pressure can be elevated for different reasons. [SPEAKER_01]: And when we use different treatment methods, different medicines, different lifestyle things, we're essentially attacking the problem of the ultimate high blood pressure from multiple different angles.

43:52 [SPEAKER_01]: So some people's blood pressure might be driven a little bit more by their obesity than by their alcohol use. [SPEAKER_01]: If I address their obesity, then that might have a bigger impact. [SPEAKER_01]: If I get them to lower their alcohol use, it might have a little bit lesser impact.

44:05 [SPEAKER_01]: Somebody else might be the opposite pattern. [SPEAKER_01]: And so by addressing both of those things, [SPEAKER_01]: I can have the biggest impact on people's blood pressure. [SPEAKER_01]: This is a similar phenomenon. [SPEAKER_01]: Some might be due to sodium retention. [SPEAKER_01]: Some might be due to vascular constriction.

44:19 [SPEAKER_01]: Some might be due to other factors. [SPEAKER_01]: And so using different medicines that work differently can tend to give us bigger bang for our buck such that we can use even lower doses that might be standard. [SPEAKER_01]: And we see this most significantly at a quadruple [SPEAKER_01]: therapy, so four different drugs, but at a quarter of the dose, tiny, tiny little doses can get on average 22.5mm of mercury lowering, which is substantial.

44:44 [SPEAKER_01]: really substantial, right? [SPEAKER_01]: And by using quarter doses, the risk of side effects is trivial at that level, compared with using one drug at double the standard dose or two drugs at double the standard dose where that risk of side effects is necessarily going to be a bit higher.

44:57 [SPEAKER_01]: So that's the general pattern. [SPEAKER_01]: I've had plenty of patients with difficult to control blood pressure who I've had this conversation with. [SPEAKER_01]: and we've ended up opting based on their preferences, whether they said I only want to take one pill, in which case I might still there are certain combination single pill products that have two medicines in one pill, and so for them, the act of taking one pill is actually still delivering two medicines, and I might be able to get away with a little bit lower dosing.

45:22 [SPEAKER_01]: Whereas others say, I don't really care, I'm willing to take as many pills as you want, but I want to avoid any side effect possible in which case I'm willing to give them multiple. [SPEAKER_01]: And then we go with, you know, ultra low doses and see a more significant impact that way. [SPEAKER_00]: Yeah, no, that's a great summary.

45:37 [SPEAKER_00]: To me, it kind of, let me get you take on this. [SPEAKER_00]: All right, so we know like with exercise, and it's effect on blood pressure, that when you look at folks with blood pressure levels, greater than 140 millimeters of mercury systolic, that endurance exercise alone on average lowers that blood pressure by about eight millimeters of mercury, and resistance training on its own, tends to lower systolic blood pressure by about eight millimeters of mercury, but when you combine them, [SPEAKER_00]: Yeah, it's like 14 millimeters of mercury, which look, it's not purely additive, so there's some overlap like similar mechanisms, but I hadn't really put too much thought into this before.

46:16 [SPEAKER_00]: I wonder if they do attack resting blood pressure via different mechanisms, like maybe resistance training, primarily focuses on like the elastin component of your arterial system, [SPEAKER_00]: and then the cardiovascular fitness is more of like a, you know, vaso constriction elsewhere, or something, or salt balance, I don't know, something.

46:35 [SPEAKER_00]: I'm just making stuff up at this point. [SPEAKER_00]: But yeah, it wouldn't surprise me if they were like different mechanisms by which resting blood pressure was lowered, but when you combine the two, you get a bigger effect than either an isolation. [SPEAKER_00]: So kind of a similar thing here, maybe.

46:47 [SPEAKER_01]: Yeah, totally. [SPEAKER_01]: That's how I think about all these different lifestyle interventions. [SPEAKER_01]: And for anyone who's interested in, you know, that was it. [SPEAKER_01]: That was kind of a detailed explanation. [SPEAKER_01]: Interestingly, somebody put together a cool website based on this Lancet meta analysis.

47:00 [SPEAKER_01]: They call it the blood pressure treatment efficacy calculator and you just go to BP model.org. [SPEAKER_01]: BPmodel.org and you just hit start and you can put in some numbers and based on the data from that minute analysis, it can accent essentially predict for you what would be on average the expected treatment effect of any combination of these different treatments.

47:22 [SPEAKER_00]: What would be the expected treatment effect of replacing table salt with sodium bromide? [SPEAKER_01]: uh, neuropsychiatric uh, devastation, just yeah, bromism. [SPEAKER_00]: All right, fair enough. [SPEAKER_00]: All right. [SPEAKER_00]: Uh, okay, so there's also been updates to monitoring, specifically with self-monitored blood pressure so taking blood pressure at home.

47:42 [SPEAKER_00]: The purpose of this like self-monitored blood pressure should be to check for, quote, true changes. [SPEAKER_00]: in resting blood pressure, that ultimately is used to guide either medication adjustments, the initiation of medications, so on and so forth, so if you frequently monitor your blood pressure at home, you know, you want to make sure that if it changes detected that it's a significant change, it's real, it's not an artifact or hallucination, and that it correctly informs decision making.

48:12 [SPEAKER_00]: So, you know, [SPEAKER_00]: There's been some update here based on new evidence that's come out. [SPEAKER_00]: Dr. Brocket, you want to summarize some of this new data and how this shakes out with respect to clinical practice. [SPEAKER_01]: Yeah, I came across this paper recently and it also impacted how I think about this a little bit and to paint a broader picture here.

48:32 [SPEAKER_01]: There. [SPEAKER_01]: are a lot of things that can be tested. [SPEAKER_01]: We've talked about this a lot before. [SPEAKER_01]: You can test all sorts of blood tests, you can test physiologic parameters like blood pressure, you can test blood sugar, and so you can go absolutely wild with this stuff, right?

48:47 [SPEAKER_01]: The extreme example would be getting like a full set of blood tests done every day, right? [SPEAKER_01]: There would be a lot of noise in that data, right? [SPEAKER_01]: Your white blood cell count is going up and down hourly throughout the day. [SPEAKER_01]: Your testosterone level going up in the morning, down into the afternoon, bottoms out in the evening and up and down again, your cortisol going up and down.

49:06 [SPEAKER_01]: Your other. [SPEAKER_01]: hormones, your gratin, your B-WAN, your potassium, all these things are changing all the time. [SPEAKER_01]: And so the question is, what degree of data frequency do we need to make decisions that actually impact people's risk? [SPEAKER_01]: Because I think it is tempting, especially for those who are more either just maximizers who want to do everything.

49:27 [SPEAKER_01]: But also people with medical conditions, it can get to be burdensome to be a patient. [SPEAKER_01]: There is a phenomenon in the world of diabetes called diabetes distress, where you just are overwhelmed with the sheer burden of all the things that you need to do to manage your condition.

49:43 [SPEAKER_01]: And I see this a lot. [SPEAKER_01]: I see patients who maybe, you know, if you're on insulin, that's necessarily a little bit of a higher risk medicine. [SPEAKER_01]: And so that often needs blood sugar [SPEAKER_01]: But I also see patients with diabetes who are not on insulin who are checking their blood sugar all the time and wanting to change all sorts of things that they do based on checking these things.

50:04 [SPEAKER_01]: we've talked about this before, the extreme example being people who don't have diabetes using continuous glucose monitors. [SPEAKER_01]: And they send a number and they're like, whoa, yes. [SPEAKER_01]: And making constant decisions about it. [SPEAKER_01]: And if look, if that is your jam, go for it.

50:19 [SPEAKER_01]: But it is probably not necessary to achieve the health outcome that we're looking for. [SPEAKER_01]: And it can lead to a lot of distress or, you know, anxiety, it can lead to a lot of unnecessary attention to things that could be [SPEAKER_01]: going about your life, maybe forming healthier relationships or doing something else with that time.

50:37 [SPEAKER_01]: And so there are people for whom I recommend, hey, we should probably check this less. [SPEAKER_01]: We don't need to be checking your blood sugar all the time. [SPEAKER_01]: And the same applies with blood pressure. [SPEAKER_01]: I think this also is in part because people think [SPEAKER_01]: that blood pressure delivers its risk on shorter time periods than it really does.

50:55 [SPEAKER_01]: So some people think my blood pressure is a little higher today. [SPEAKER_01]: I might am I at higher risk of having a stroke today? [SPEAKER_01]: Oh, and it's a little lower tomorrow or it's higher during this time of the day, lower during this time of the day. [SPEAKER_01]: And as we've talked about, this is a cumulative lifelong thing.

51:10 [SPEAKER_01]: So the risk of high blood pressure that I worry about, [SPEAKER_01]: is high blood pressure that is present over the course of years to decades, right? [SPEAKER_01]: It's not that your blood pressure went up this morning and was normal tomorrow morning and was low the day after that. [SPEAKER_01]: I'm, you know, I'll have to interpret that in a broader context because it would be a poor idea for me to be overly reactive and to change what we're doing based on every single data point.

51:35 [SPEAKER_01]: I sometimes see patients who are instructed to take their blood pressure and then only take their blood pressure medicine if their blood pressure is above a certain cut off and I'm like that and how this works that is in advisable for for a lot of reasons and generally is a is a poor idea so.

51:52 [SPEAKER_01]: the idea, you know, we talk, we've been talking this whole episode so far about how important blood pressure is, how it's, you know, it's the leading modifiable risk factor for heart disease, you know, cardiovascular disease complications and premature death. [SPEAKER_01]: And so you might come away from all all of our conversations so far.

52:06 [SPEAKER_01]: It's like, oh my gosh, I need to be so worried about my blood pressure. [SPEAKER_01]: I should be checking it every day or multiple times a day, more is better. [SPEAKER_01]: And it's like, maybe, maybe not, right? [SPEAKER_01]: It is very important as a health-related parameter, [SPEAKER_01]: Right, the analog of a continuous glucose monitor would be for you to just be like living your life with an arterial line or a, you know, a constant blood pressure monitoring device, which will get to it a little bit with this apple watch and what the potential upsides and downsides of something like that would be, especially if you are paying such close attention to it.

52:41 [SPEAKER_01]: that you feel compelled to act on every deviation, right? [SPEAKER_01]: So if it goes up a little bit, what do you do? [SPEAKER_01]: If it goes down a little bit, what do you do? [SPEAKER_01]: That's not really a way to live life. [SPEAKER_01]: And so what these data that were published recently, ultimately showed us just to distill a whole lot of detail down, is that [SPEAKER_01]: A lot of the time, if you're checking stuff really frequently, much of what you are catching is noise, and if you space things out a little bit further, you are less likely to get caught up in all of that noise.

53:10 [SPEAKER_01]: And so you want to know what is the optimal kind of re-testing interval that you should use in order to reflect a true increase or decrease or stability in your blood pressure. [SPEAKER_01]: And so what they found was that at a six-month retesting interval, if somebody's blood pressure was elevated at that time, it only had a 25% chance of reflecting a true sustained increase in their blood pressure.

53:36 [SPEAKER_01]: At 12 months later, an elevated reading had a 65% probability of reflecting a true sustained blood pressure elevation, meaning that there was a third chance that was essentially a false positive reading. [SPEAKER_01]: There are a couple different ways that you could take this. [SPEAKER_01]: the first and what I want to make clear is you don't need to be monitoring your blood pressure like every day, right, or even every week.

53:59 [SPEAKER_01]: It might be useful early in the process if we're making a ton of active changes to things, but you should not be living your life constantly measuring all of these parameters. [SPEAKER_01]: The other thing is that in my approach to this, in my practice, when I'm having somebody do ideally high quality home blood pressure measurements using a validated device and correct technique, I'm not usually making decisions based on a single reading.

54:23 [SPEAKER_01]: What some other data has found that we cited in our guide to high blood pressure is that by doing three days of readings AM and PM morning and evening and averaging those, that's good enough and also I'll do that and then it's going to be a while before I do that again At which point I might make some modifications to the treatment plan, but we're not doing this every day or multiple times a day indefinitely and ideally as you get better control, whether through lifestyle medicine's both, we can space this out more and more and more and you can live your life and not have to be [SPEAKER_01]: paranoid about checking this all the time, which is similar to my approach to other things, be it blood cholesterol levels, be it blood sugar levels, things like that.

55:01 [SPEAKER_00]: Yeah, I mean, this is also true of other maybe physiological parameters we see in the training space. [SPEAKER_00]: I think about like body weight or like muscular strength. [SPEAKER_00]: Imagine if like every morning, without fail, you step on a scale. [SPEAKER_00]: Which I'm not saying that's a bad thing to do.

55:13 [SPEAKER_00]: But like, oh, look, if you weigh above this amount, you don't eat. [SPEAKER_00]: Yeah, you just don't eat. [SPEAKER_00]: But you weigh below this, you get to eat, you know, or we're going to take some measure of strength. [SPEAKER_00]: every single day. [SPEAKER_00]: And until it drops below a certain level, that's when you get to train.

55:30 [SPEAKER_00]: But if it's above a certain level, you don't need to exercise. [SPEAKER_00]: You're good to go. [SPEAKER_00]: It's just that these short-term changes are mostly artifacts of like this normal human variability and like an Ebb and flow back and forth. [SPEAKER_00]: And so you want to make sure that whatever management decisions you're making.

55:47 [SPEAKER_00]: In this case, blood pressure, in other cases, body weight, strength, programming, blood cholesterol levels that you're capturing a real change. [SPEAKER_00]: And one that needs to be acted upon. [SPEAKER_00]: You can use averages over longer periods of time. [SPEAKER_00]: So if you do the more frequent measuring that's okay, but micro managing it on a day-to-day basis for most of these variables is probably not the move.

56:10 [SPEAKER_00]: Is that fair to say? [SPEAKER_01]: Yeah, I think that, you know, as somebody myself who has never been somebody who's willing to like way track or measure macros in my own life, I do my own like autoregulatory strategy tends to be relatively frequent body weights, however, I recognize that there is a range of just noise in that number and I'm not acting differently based on those every single day.

56:34 [SPEAKER_01]: But rather it is there to kind of detect trends and impact things that way. [SPEAKER_01]: And so if over the course of days to weeks, I was noticing that things were going down and down and down or up and up and up compared with where I wanted to be then over time that would impact kind of behavior on average.

56:50 [SPEAKER_01]: But this is not something where it's like, oh, my weight is up 0.5 kilos today. [SPEAKER_01]: I'm going to adjust my daily intake down by this much or up. [SPEAKER_01]: And then at the same time, if the number was way different than the day before, then I'm going to say, oh, that's probably a false positive something's wrong with the scale.

57:06 [SPEAKER_01]: So it's almost recognizing that there's a range of plausible outcomes day to day of noise. [SPEAKER_01]: And outside of that, it's more likely fake than it is real. [SPEAKER_01]: And I'm not really acting or doing anything differently until I see a sustained trend outside of where I want to be, that prompts action.

57:20 [SPEAKER_01]: And so that would be a similar approach here. [SPEAKER_00]: Yeah, a quick question is just to see if you got this in the in the in the dome on average. [SPEAKER_00]: What is the heaviest human body weight and a given week for most individuals? [SPEAKER_00]: What day? [SPEAKER_00]: Sunday morning.

57:41 [SPEAKER_00]: Yeah, exactly. [SPEAKER_00]: Sunday's in Mondays and the Eastern on Fridays. [SPEAKER_00]: Yeah, the range is typically on the order of a few pounds or so about one to two percent of someone's wait, but this can vary by season holidays and more. [SPEAKER_00]: But yeah, there's like a general rhythm and some of that's due to dietary pattern changes, but yeah, things can change significantly as far as like what the scale is able to pick up.

58:01 [SPEAKER_00]: But yeah, I thought that's interesting. [SPEAKER_00]: Okay, let's get into the final, and perhaps maybe most impactful update that people, yeah, yeah, might be coming across might be hearing about Apple just came out with this new hypertension detection feature for the Apple watch. [SPEAKER_00]: Now, as you mentioned early, nearly half of adults in the United States have a diagnosis of elevated blood pressure or hypertension.

58:28 [SPEAKER_00]: There's another proportion of individuals who do currently have elevated blood pressure or hypertension who have not yet been diagnosed. [SPEAKER_00]: And so I don't care to speculate on how many folks are out there, but it's a lot of millions of people. [SPEAKER_00]: And even those who do have high blood pressure, they might not be adequately managed.

58:46 [SPEAKER_00]: So this watch, then this tool, theoretically could be beneficial if it's accurate. [SPEAKER_00]: Meaning, is it actually picking up people with elevated blood pressure or hypertension, not giving you a bunch of false positives? [SPEAKER_00]: So you reviewed this data, we linked to Apple's supplied PDF that has a bunch of their findings.

59:06 [SPEAKER_00]: What's your take on how good of a job does the Apple watch actually do at identifying folks with LDA blood pressure? [SPEAKER_01]: Um, I would say it's medium. [SPEAKER_01]: And there's a lot of caveats to this. [SPEAKER_01]: I'm, I'm actually, I haven't fully made up my mind on this, but we'll just present the data and maybe we'll come to some degree of consensus here.

59:28 [SPEAKER_01]: So yeah, Apple released a PDF that included their data on this that, um, [SPEAKER_01]: reported overall sensitivity, meaning, you know, what proportion of people is it correctly, you know, catching with this condition is overall about 41% of people, meaning that as a screening tool on its own, not awesome, meaning it is missing a lot of people.

59:52 [SPEAKER_01]: So an ideal screening tool would have very, very high sensitivity. [SPEAKER_01]: It would be very sensitive to detect those with high blood pressure at the risk of catching a lot of false positives. [SPEAKER_01]: And so then typically in most, you know, traditional screening practices in medicine, we use an initial high sensitivity tool that catches everyone with it plus a bunch of false positives.

1:00:14 [SPEAKER_01]: And then in the subsequent step of evaluation, we use a test that is much more specific and that more specific test will then tell us it'll weed out those who are false positives and leave us with the population who truly have the condition. [SPEAKER_01]: Based on various variables to include the overall prevalence of this condition in the population, as well as how sensitive this test is, and the other parameter of how specific it is where correctly rules out those who don't have high blood pressure, we can get a sense of how well this test performs.

1:00:47 [SPEAKER_01]: So I mentioned that overall sensitivity is about 41%. [SPEAKER_01]: So about 60 out of every 100 people who have high blood pressure are not. [SPEAKER_01]: Sorry, of all comers who are wearing the watch are not being caught now among those who have higher and higher blood pressure. [SPEAKER_01]: So those was staged to hypertension.

1:01:03 [SPEAKER_01]: That's the highest kind of cut off the sensitivities better, which you would expect to find so 53 almost 54% sensitivity in that population. [SPEAKER_01]: So the higher people's blood pressure gets the better. [SPEAKER_01]: This test gets it detecting it, which is not terribly surprising.

1:01:19 [SPEAKER_00]: Yeah, but also not great either. [SPEAKER_00]: You're like, yes, this is the highest cohort of my highest blood pressure measurement. [SPEAKER_00]: You would expect that sensitivity if the detection software, or whatever was very, very good. [SPEAKER_00]: You would expect that number to be in the 90s.

1:01:32 [SPEAKER_00]: Yeah, no, it's like if you set the BMI cut off right now, the cut point we have for 30 for OB cities 30 right and unfortunately we miss about half of folks who are carrying too much body fat with with that cut point is just not low enough to capture individuals who are carrying too much body fat, but don't have a BMI level high enough.

1:01:50 [SPEAKER_00]: So you would set it to like 22. [SPEAKER_00]: Well, now the sensitivity is 100%. [SPEAKER_00]: but the amount of false positives that you're getting are substantially increase. [SPEAKER_00]: It makes for a better, quote, screening tool, but then a bunch of folks are like, what do you say, do you imagine the internet?

1:02:03 [SPEAKER_00]: What do you, you're, you're, you're saying that I'm obese. [SPEAKER_00]: It's like, well, no, we're just trying to improve the sensitivity of this test, but this, this specificity would be, be lower. [SPEAKER_01]: Yeah, so, I mean, for this, this test, [SPEAKER_01]: the sensitivity of it is not off.

1:02:17 [SPEAKER_01]: We're missing a bunch of people, but what's the other side of that coin is that what will call the specificity correctly ruling out those who don't have high blood pressure is much better. [SPEAKER_01]: And you can see that from Apple's perspective, if they took a lot of doctors advice to heart and said, we want to limit false positives to reduce unnecessary worry, which is what they describe in their paper.

1:02:36 [SPEAKER_01]: Then this is a way to do that if you don't have a quote unquote gold standard test that has really really good sensitivity and really really high specificity because those that combination is rare in diagnostic medicine. [SPEAKER_01]: And so if they opted for something with a you know more specificity then you're not getting a freak as many people out because you're not going to have as many false positives.

1:02:56 [SPEAKER_01]: But that comes at the risk of more false negatives people who are not caught with this. [SPEAKER_01]: Ultimately, this trend of wearables is a complex space. [SPEAKER_01]: The Apple watches have long had the ability now to detect things like atrial fibrillation. [SPEAKER_01]: And that's a abnormal heart rhythm that can lead to consequences.

1:03:15 [SPEAKER_01]: But it has left a lot of doctors in a bind. [SPEAKER_01]: With what do I do with this information? [SPEAKER_01]: When an Apple watch tells me that this patient has had atrial fibrillation, [SPEAKER_01]: because all of the evidence that we have on how to treat atrial fibrillation comes from an era when we diagnosed atrial fibrillation differently.

1:03:32 [SPEAKER_01]: And so they're just different populations of people who come in, for example, with symptoms of their heart racing, beating out of their chest with atrial fibrillation. [SPEAKER_01]: That's a fundamentally different person than somebody who says, oh, my Apple Watch told me I had like 15 seconds of a fib and I didn't feel anything, right?

1:03:47 [SPEAKER_01]: So we don't have good evidence on that population [SPEAKER_01]: And so I think similarly, if we're going to have a new tool like this, ideally it is a bit better in terms of its accuracy, but also what do we do with this and where we'd have to probably confirm and validate those findings using more traditional blood pressure measurement methods because that's the evidence base on which our treatment kind of recommendations come from.

1:04:11 [SPEAKER_01]: And so to give people an idea, because we gave a lot of bio-statistical numbers, which even makes medical trainees and other physicians eyes glaze over, given that about half the population has high blood pressure, to put these numbers into some real-life values. [SPEAKER_01]: If we test a put Apple watches on 100 people, 20 of them will test positive and have high blood pressure.

1:04:41 [SPEAKER_01]: 27 people with high blood pressure will be missed and 44 out of the 100 will be true negatives meaning they don't have high blood pressure and it will not you know advise them that they have high blood pressure so 20 correctly diagnosed with it 44 correctly diagnosed without it nine false positives and 27 false negatives so do with that what you will in terms of deciding do you like this tool the apple watch for blood pressure detection or not [SPEAKER_01]: As a clinician, it's not going to be my favorite thing, and regardless, if I have a patient who tells me that my apple watched is telling me that I have high blood pressure.

1:05:15 [SPEAKER_01]: I've never had a high blood pressure measurement before. [SPEAKER_01]: I've never been told I had high retention. [SPEAKER_01]: We're going to go through some additional steps to confirm it. [SPEAKER_01]: I'm not going to jump to immediate treatment based on apple watch data alone. [SPEAKER_01]: If this ends up getting more people who have high blood pressure and didn't know it diagnosed and treated, then maybe this ends up being in that benefit.

1:05:33 [SPEAKER_01]: But it is insufficient on its own for this. [SPEAKER_01]: In other words, people should still be, I think, checking their web pressure on the recommended intervals in other ways in case they are among that 27 out of 100, who might get missed if all they're relying on is just, at my watch, will tell me if it's a problem.

1:05:49 [SPEAKER_00]: Yeah, I think the best use case I see for this, which is maybe a little interesting from like a social dynamics perspective, it's like if you happen to have an Apple watch, but you for whatever reason don't have a primary care physician, you don't interface with your primary care physician and it does happen to detect that you have elevated blood pressure.

1:06:09 [SPEAKER_00]: That's probably a net benefit if it triggers a behavior to go see a doctor for an assessment. [SPEAKER_00]: I don't know that this replaces regular blood pressure screening. [SPEAKER_00]: Nor should it, but I don't think it's aimed towards that. [SPEAKER_00]: It's more like a, if you happen to be between your intervals of regular scene of physician, especially maybe if you're younger, you don't routinely interface with a physician, maybe that's the best use case here, but otherwise I don't think it replaces either self-monitoring the more validated methods or in office measurement with your [SPEAKER_00]: All right.

1:06:45 [SPEAKER_00]: Well, look, I can't say that this is going to be our last blood pressure podcast, because that seems unlikely. [SPEAKER_00]: As stuff continues to change, we'll continue to update you. [SPEAKER_00]: That's one of the things we like to do here at Barbell Medicine, but we appreciate your attention to listening to our podcast.

1:07:03 [SPEAKER_00]: But before you guys go anywhere, please leave us a five-star rating and a review. [SPEAKER_00]: It really helps drive traffic to our podcast so we can keep bringing you all latest nuance and health. [SPEAKER_00]: In fitness, [SPEAKER_00]: From everyone here at Barbell Medicine, special shout out to Dr. Also Barakie for joining us.

1:07:15 [SPEAKER_00]: I'm Dr. Jordan Fagamam. [SPEAKER_00]: We'll catch you next week and every week right here on the Barbell Medicine podcast.