Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 Without knowing any other history, consider carvedilol or nebivolol instead of norvasc. Looks like her HR could tolerate itAnother tool to help would be doing a impedance cardiography test (http://www.sonosite.com/products/bioz-dx/) on her to help direct therapy. There might be a provider local to you that has a BioZ that could run the test for you.rockyRakesh C. Patel, M.D.Arizona Sun Family Medicine, P.C. and Nexlev Health and Fitness633 E. Ray Road #101Gilbert, AZ 85296www.azsunfm.com and www.nexlev.com --- Subject: systolic hypertensionTo: "" < >Date: Monday, February 7, 2011, 11:13 AM Clinical advice please:I have an 85 y old female with long standing hypertension. Systolic BP is particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am worried about lowering her diastolic pressure too much. She is having periods of confusion and memory loss (not new since starting the ARB, but hard to sort it all out). Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes severe pedal edema)):Jan 27 195/87 78 4:15 pm Jan 27 171/75 74 7:32 pmJan 28 198/81 76 NoonJan 28 179/78 80 6:50 pmJan 29 182/89 69 6:45 amJan 29 173/73 78 2:45 pmJan 30 159/66 77 9:45 am Jan 31 167/74 87 8:15 amFeb 1 191/85 74 8:05 am Read about adding long acting isosorbide dinitrate to lower only systolic pressure, but I haven't used it for that indication before. Others have experience? What dose to start? Other ideas? SharonSharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 With a wide pulse pressure like that, I would want to make sure aortic stenosis wasn't playing a role in her worsening hypertension. If so, lowering her bp with multiple meds could cause syncope and possibly worse. Ben Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 Aortic stenosis or aortic regurgitation? With a wide pulse pressure like that, I would want to make sure aortic stenosis wasn't playing a role in her worsening hypertension. If so, lowering her bp with multiple meds could cause syncope and possibly worse. Ben -- Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 Either aortic stenosis or aortic regurgitation could cause a widened pulse pressure. I usually see aortic stenosis more commonly in my FP practice. But, as Graham points out, Aortic Regurgitation could cause a widened pulse pressure too. With aortic regurgitation the most common symptoms would be palpitations and dyspnea on exertion. With aortic regurgitation the murmur is diastolic and sometimes tough to hear. My textbook says that the murmur is usually a decrescendo murmur usually heard best at the third left interspace or the left lower sternal border. If you hear the murmur better along the right sternal border consider one of the forms of aortic regurgitation resulting from disease of the aortic root. An early diastolic murmur even in the presence of mitral stenosis and in the absence of other signs of aortic regurgitation-means aortic regurgitation until proven otherwise. Other cardiac findings include diastolic and systolic thrills, a hyperdynamic apex beat displaced downward and to the left. Most valuable single clinical sign of the severity of regurgitation is Hill's sign-a disproportionate elevation of blood pressure in the legs. Normally the systolic blood pressure is tender 20 mm higher in the legs and arms. In significant aortic regurgitation the leg pressure is over 20 and may be 50 or even 100 mm higher. Pressure difference correlates well with severity. Thanks for your question. Now I learned more about aortic regurgitation than I knew before. Ben With a wide pulse pressure like that, I would want to make sure aortic stenosis wasn't playing a role in her worsening hypertension. If so, lowering her bp with multiple meds could cause syncope and possibly worse. Ben -- Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 Either aortic stenosis or aortic regurgitation could cause a widened pulse pressure. I usually see aortic stenosis more commonly in my FP practice. Do you have a reference for the former? http://emedicine.medscape.com/article/150638-overview says that a systolic BP of 200 is unlikely with AS.cheers,-- Graham Chiuhttp://www.compkarori.co.nz:8090/ Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 But don’t forget that isolated systolic hypertension in the elderly is probably the most common problem. By definition, there is a widened pulse pressure. If she has hardening of the arteries these BP readings could be factitious. One educational piece I listened to recently suggested that if you suspect this, you could get wrist reading or finger readings are the smaller vessels are less likely to be as stiff as the larger vessels. Of course the only way to really measure it to do intra-arterial BP readings so one can really only suspect this. What dose of Hyzaar HCT? Diuretics are supposed to be extremely effective with ISH. Your diastolic isn’t that low so you have some room to play. Also think about why you are treating her. She is 85 and what will you gain with more aggressive treatment vs. what will you lose. Any stigmata of end stage disease? Kathy Saradarian, MD Branchville, NJ www.qualityfamilypractice.com Solo 4/03, Practicing since 9/90 Practice Partner 5/03 Low staffing From: [mailto: ] On Behalf Of Sharon McCoy Sent: Monday, February 07, 2011 1:14 PM To: Subject: systolic hypertension Clinical advice please: I have an 85 y old female with long standing hypertension. Systolic BP is particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am worried about lowering her diastolic pressure too much. She is having periods of confusion and memory loss (not new since starting the ARB, but hard to sort it all out). Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes severe pedal edema)): Jan 27 195/87 78 4:15 pm Jan 27 171/75 74 7:32 pm Jan 28 198/81 76 Noon Jan 28 179/78 80 6:50 pm Jan 29 182/89 69 6:45 am Jan 29 173/73 78 2:45 pm Jan 30 159/66 77 9:45 am Jan 31 167/74 87 8:15 am Feb 1 191/85 74 8:05 am Read about adding long acting isosorbide dinitrate to lower only systolic pressure, but I haven't used it for that indication before. Others have experience? What dose to start? Other ideas? Sharon Sharon McCoy MD Renaissance Family Medicine 10 McClintock Court; Irvine, CA 92617 PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com CyberDefender has scanned this email for potential threats. Version 2.0 / Build 4.03.29.01 Get free PC security at http://www.cyberdefender.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 saradarain says my thoughts exactly But better typed! But don’t forget that isolated systolic hypertension in the elderly is probably the most common problem. By definition, there is a widened pulse pressure. If she has hardening of the arteries these BP readings could be factitious. One educational piece I listened to recently suggested that if you suspect this, you could get wrist reading or finger readings are the smaller vessels are less likely to be as stiff as the larger vessels. Of course the only way to really measure it to do intra-arterial BP readings so one can really only suspect this. What dose of Hyzaar HCT? Diuretics are supposed to be extremely effective with ISH. Your diastolic isn’t that low so you have some room to play. Also think about why you are treating her. She is 85 and what will you gain with more aggressive treatment vs. what will you lose. Any stigmata of end stage disease? Kathy Saradarian, MD Branchville, NJ www.qualityfamilypractice.com Solo 4/03, Practicing since 9/90 Practice Partner 5/03 Low staffing From: [mailto: ] On Behalf Of Sharon McCoy Sent: Monday, February 07, 2011 1:14 PM To: Subject: systolic hypertension Clinical advice please: I have an 85 y old female with long standing hypertension. Systolic BP is particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am worried about lowering her diastolic pressure too much. She is having periods of confusion and memory loss (not new since starting the ARB, but hard to sort it all out). Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes severe pedal edema)): Jan 27 195/87 78 4:15 pm Jan 27 171/75 74 7:32 pm Jan 28 198/81 76 Noon Jan 28 179/78 80 6:50 pm Jan 29 182/89 69 6:45 am Jan 29 173/73 78 2:45 pm Jan 30 159/66 77 9:45 am Jan 31 167/74 87 8:15 am Feb 1 191/85 74 8:05 am Read about adding long acting isosorbide dinitrate to lower only systolic pressure, but I haven't used it for that indication before. Others have experience? What dose to start? Other ideas? Sharon Sharon McCoy MD Renaissance Family Medicine 10 McClintock Court; Irvine, CA 92617 PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com CyberDefender has scanned this email for potential threats. Version 2.0 / Build 4.03.29.01 Get free PC security at http://www.cyberdefender.com -- MD ph fax impcenter.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 yes indeed----I am with Kathy..... the best thing to do would be to fix this with a piece of duct tape-next time you take her blood pressure put a piece of duct tape on the screen where the blood pressure is written so you can ignore it. Seriously, I think I would do a short screen to rule out secondary causes of hypertension-I'm not sure I would check about any type of stenosis unless you are about to do something about it and then you can talk about things that are important to her..... you get the picture. Lou > > Clinical advice please: > > I have an 85 y old female with long standing hypertension. Systolic BP is > particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am > worried about lowering her diastolic pressure too much. She is having > periods of confusion and memory loss (not new since starting the ARB, but > hard to sort it all out). > > Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes > severe pedal edema)): > > Jan 27 195/87 78 4:15 pm > Jan 27 171/75 74 7:32 pm > Jan 28 198/81 76 Noon > Jan 28 179/78 80 6:50 pm > Jan 29 182/89 69 6:45 am > Jan 29 173/73 78 2:45 pm > Jan 30 159/66 77 9:45 am > Jan 31 167/74 87 8:15 am > Feb 1 191/85 74 8:05 am > > Read about adding long acting isosorbide dinitrate to lower only systolic > pressure, but I haven't used it for that indication before. Others have > experience? What dose to start? Other ideas? > > Sharon > Sharon McCoy MD > Renaissance Family Medicine > 10 McClintock Court; Irvine, CA 92617 > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > www.SharonMD.com > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 Agree. Most likely with all the calcium in her arteries it is the only way she can circulate blood around. Treat the patient not the blood pressure. Isosorbide helps, some of my patients are on it but, again, with non compliant arteries it may be difficult. from the Barrio yes indeed----I am with Kathy..... the best thing to do would be to fix this with a piece of duct tape-next time you take her blood pressure put a piece of duct tape on the screen where the blood pressure is written so you can ignore it. Seriously, I think I would do a short screen to rule out secondary causes of hypertension-I'm not sure I would check about any type of stenosis unless you are about to do something about it and then you can talk about things that are important to her..... you get the picture. Lou > > Clinical advice please: > > I have an 85 y old female with long standing hypertension. Systolic BP is > particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am > worried about lowering her diastolic pressure too much. She is having > periods of confusion and memory loss (not new since starting the ARB, but > hard to sort it all out). > > Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes > severe pedal edema)): > > Jan 27 195/87 78 4:15 pm > Jan 27 171/75 74 7:32 pm > Jan 28 198/81 76 Noon > Jan 28 179/78 80 6:50 pm > Jan 29 182/89 69 6:45 am > Jan 29 173/73 78 2:45 pm > Jan 30 159/66 77 9:45 am > Jan 31 167/74 87 8:15 am > Feb 1 191/85 74 8:05 am > > Read about adding long acting isosorbide dinitrate to lower only systolic > pressure, but I haven't used it for that indication before. Others have > experience? What dose to start? Other ideas? > > Sharon > Sharon McCoy MD > Renaissance Family Medicine > 10 McClintock Court; Irvine, CA 92617 > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > www.SharonMD.com > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 I don't know about the diastolic readings not being too low. I did the calculations to figure out if she was getting enough cerebral flow. From an email to her a few weeks ago: Here is an equation to figure out the mean arterial pressure. Mean arterial pressure is important to make sure the brain gets enough blood flow: Attached is a graph of the MAP range for which the body can regulate the cerebral blood flow: 125-200 for people with hypertension 60-125 for people with normal blood pressure usually for example, at 198/87, 87 + 1/3 (198-87) = 87 + 1/3 (111) = 87+ 37 = 124 is the MAP 169/71 = 71 + 98/3 = 104 227/110 = 110 + 117/3 = 149 So, having the BP at 169/71 while normally would be much better than the 227/110, for someone with hypertension, may be borderline level to keep brain blood flow normal. Mainly, we just want to make sure we don't lower the blood pressure too quickly. Only reason to treat at this point is to prevent acute stroke really. I was trying to figure out when I need to worry about hypertension causing acute stroke. Certainly numbers listed in UTD are lower than hers are.... I have been ignoring to some degree for awhile while treating other stuff, but once she got to 220 ish a few times I got a little worried.Anyone know how to get finger or wrist readings? I have a wrist BP monitor I inherited from a patient, but it is not accurate at all. I guess I should try lower extremity readings for aortic regurg; I'll certainly go listen to her heart with AS or AR in mind..... She has had HTN since the late 1960's. Has also had headaches since she was 12 or 13. So, when she showed up to get an epidural for pain control (spinal stenosis, etc.), with headache and BP of 220/110 ish, they initially refused to do the epidural and contacted me, I guess thinking she was stroking out. Hyzaar dose was 100/25 mg, but she was usually on 12.5 HCTZ prior to trying the Hyzaar.Sharon McCoy MDRenaissance Family Medicine 10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com But don’t forget that isolated systolic hypertension in the elderly is probably the most common problem. By definition, there is a widened pulse pressure. If she has hardening of the arteries these BP readings could be factitious. One educational piece I listened to recently suggested that if you suspect this, you could get wrist reading or finger readings are the smaller vessels are less likely to be as stiff as the larger vessels. Of course the only way to really measure it to do intra-arterial BP readings so one can really only suspect this. What dose of Hyzaar HCT? Diuretics are supposed to be extremely effective with ISH. Your diastolic isn’t that low so you have some room to play. Also think about why you are treating her. She is 85 and what will you gain with more aggressive treatment vs. what will you lose. Any stigmata of end stage disease? Kathy Saradarian, MD Branchville, NJ www.qualityfamilypractice.com Solo 4/03, Practicing since 9/90 Practice Partner 5/03 Low staffing From: [mailto: ] On Behalf Of Sharon McCoy Sent: Monday, February 07, 2011 1:14 PM To: Subject: systolic hypertension Clinical advice please: I have an 85 y old female with long standing hypertension. Systolic BP is particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am worried about lowering her diastolic pressure too much. She is having periods of confusion and memory loss (not new since starting the ARB, but hard to sort it all out). Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes severe pedal edema)): Jan 27 195/87 78 4:15 pm Jan 27 171/75 74 7:32 pm Jan 28 198/81 76 Noon Jan 28 179/78 80 6:50 pm Jan 29 182/89 69 6:45 am Jan 29 173/73 78 2:45 pm Jan 30 159/66 77 9:45 am Jan 31 167/74 87 8:15 am Feb 1 191/85 74 8:05 am Read about adding long acting isosorbide dinitrate to lower only systolic pressure, but I haven't used it for that indication before. Others have experience? What dose to start? Other ideas? Sharon Sharon McCoy MD Renaissance Family Medicine 10 McClintock Court; Irvine, CA 92617 PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: www.SharonMD.com CyberDefender has scanned this email for potential threats. Version 2.0 / Build 4.03.29.01 Get free PC security at http://www.cyberdefender.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 she'll faint fall and break her hip on isosorbibide if you ask me. and THEN where you will be for haveing treated her systolics some of which were only 159 .Good exam- good history-- discuss the risks with her-- Consider as aspirin a day for stroke prevention might do you better.Send her home.( and were these home bps? Looked like it but also good t o rule out white coat syndorme?)Does she drink MAny little old ladies do. I plan to. Agree. Most likely with all the calcium in her arteries it is the only way she can circulate blood around. Treat the patient not the blood pressure. Isosorbide helps, some of my patients are on it but, again, with non compliant arteries it may be difficult. from the Barrio yes indeed----I am with Kathy..... the best thing to do would be to fix this with a piece of duct tape-next time you take her blood pressure put a piece of duct tape on the screen where the blood pressure is written so you can ignore it. Seriously, I think I would do a short screen to rule out secondary causes of hypertension-I'm not sure I would check about any type of stenosis unless you are about to do something about it and then you can talk about things that are important to her..... you get the picture. Lou > > Clinical advice please: > > I have an 85 y old female with long standing hypertension. Systolic BP is > particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am > worried about lowering her diastolic pressure too much. She is having > periods of confusion and memory loss (not new since starting the ARB, but > hard to sort it all out). > > Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes > severe pedal edema)): > > Jan 27 195/87 78 4:15 pm > Jan 27 171/75 74 7:32 pm > Jan 28 198/81 76 Noon > Jan 28 179/78 80 6:50 pm > Jan 29 182/89 69 6:45 am > Jan 29 173/73 78 2:45 pm > Jan 30 159/66 77 9:45 am > Jan 31 167/74 87 8:15 am > Feb 1 191/85 74 8:05 am > > Read about adding long acting isosorbide dinitrate to lower only systolic > pressure, but I haven't used it for that indication before. Others have > experience? What dose to start? Other ideas? > > Sharon > Sharon McCoy MD > Renaissance Family Medicine > 10 McClintock Court; Irvine, CA 92617 > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > www.SharonMD.com > -- MD ph fax impcenter.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 Home from where?She is home and that's where I see her.Highest readings were at specialists's office so may be partially white coat but those listed were at home. I had her stop the Hyzaar HCT and restart the HCTZ because of concern of too low of diastolic contributing to periods of mental confusion. So now we are back up to systolics above those listed because those were on Hyzaar. Could start aspirin back up now that platelets are normal after splenectomy.Sometimes drinks 1/4 glass wine/day. Think that is fairly accurate.How high would systolic bp worry you? And any way to lower systolic without diastolic? What is important to her is outliving her husband as she manages the house and finances and supervises care for him (end stage Parkinsons). And of course grandkids and friends. Sharon Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 Is there any evidence to show that aspirin prevents stroke in elderly women?What are the risks of hemorrhagic stroke on aspirin?GI bleed? she'll faint fall and break her hip on isosorbibide if you ask me. and THEN where you will be for haveing treated her systolics some of which were only 159 .Good exam- good history-- discuss the risks with her-- Consider as aspirin a day for stroke prevention might do you better.Send her home.( and were these home bps? Looked like it but also good t o rule out white coat syndorme?)Does she drink MAny little old ladies do. I plan to. Agree. Most likely with all the calcium in her arteries it is the only way she can circulate blood around. Treat the patient not the blood pressure. Isosorbide helps, some of my patients are on it but, again, with non compliant arteries it may be difficult. from the Barrio yes indeed----I am with Kathy..... the best thing to do would be to fix this with a piece of duct tape-next time you take her blood pressure put a piece of duct tape on the screen where the blood pressure is written so you can ignore it. Seriously, I think I would do a short screen to rule out secondary causes of hypertension-I'm not sure I would check about any type of stenosis unless you are about to do something about it and then you can talk about things that are important to her..... you get the picture. Lou > > Clinical advice please: > > I have an 85 y old female with long standing hypertension. Systolic BP is > particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am > worried about lowering her diastolic pressure too much. She is having > periods of confusion and memory loss (not new since starting the ARB, but > hard to sort it all out). > > Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes > severe pedal edema)): > > Jan 27 195/87 78 4:15 pm > Jan 27 171/75 74 7:32 pm > Jan 28 198/81 76 Noon > Jan 28 179/78 80 6:50 pm > Jan 29 182/89 69 6:45 am > Jan 29 173/73 78 2:45 pm > Jan 30 159/66 77 9:45 am > Jan 31 167/74 87 8:15 am > Feb 1 191/85 74 8:05 am > > Read about adding long acting isosorbide dinitrate to lower only systolic > pressure, but I haven't used it for that indication before. Others have > experience? What dose to start? Other ideas? > > Sharon > Sharon McCoy MD > Renaissance Family Medicine > 10 McClintock Court; Irvine, CA 92617 > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > www.SharonMD.com > -- MD ph fax impcenter.org -- Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 ok so she's home ALot of the trouble is as folks say-- can you believe that this is a true bp number--given the problem of stiff arteries In fact the longer I practice the less I think that we accurately measure bp at all( weight, white coat stuff, alcohol, Ijust ran out of my meds etc etc) Not easy Some of the studies about systolic hypertension in the elderly had folks who were at mean ages of 70 or 72 This woman has lived much longer than that Obviously she sounds vital and may have years ahead of her. But she is older than many of these 'Studies " talk about As the country ages this stuff is unknown terrtory though we daily tread it Apparently she has a complex PMH we do not know all the details of, also MAny folks use chlorthalidone The ALLHAT study is the one that is talked about alot and changes diuretic from hctz which is relatively mild to chlorthaidone ---you run the risk of orthostasis but this might be better here. You can use isosorbbide to allegedly impact the systolic not the diastolis and while I have never done it ever done it I have alot of patietns like this-mine never will take any pills so I just fret and worry. If she want s to treat then pick a low dose on short acting isosorbide til you see what long acting dose is then safe to use. but if she is at home and not in pain and can get 159 moer times than not--not 220/110 when someone is about to put in needle into a special part of the body for pain she is suffering with, then better to leave 159 systolic alone Yes the experts say 140-- to do that you may add three- 4 drugs They also say that about 72 yr olds. The long acting calcium channel and the diuretic and the arb perhpas. Resisitant hypertension is oftern treated also with spironolactone per UTD. I have alot of this stuff and it is always hard Let us knowNot simple Home from where?She is home and that's where I see her.Highest readings were at specialists's office so may be partially white coat but those listed were at home. I had her stop the Hyzaar HCT and restart the HCTZ because of concern of too low of diastolic contributing to periods of mental confusion. So now we are back up to systolics above those listed because those were on Hyzaar. Could start aspirin back up now that platelets are normal after splenectomy.Sometimes drinks 1/4 glass wine/day. Think that is fairly accurate.How high would systolic bp worry you? And any way to lower systolic without diastolic? What is important to her is outliving her husband as she manages the house and finances and supervises care for him (end stage Parkinsons). And of course grandkids and friends. Sharon -- MD ph fax impcenter.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 No, not easy. I try to handle some of the easy ones myself:). Always in pain, although that is slightly better.Does anyone 85 have a simple medical history? Maybe a few. Some of the readings on only HCTZ (12.5) and Norvasc (and not right before injections or right after they refused to do injections):181/131 192/87 200/89 192/77 170/73 I don't know how to get truly accurate readings. Graham, I'll try to answer your aspirin and women questions from the literature, although I know that may be hard. And increasing risk of bleed when systolic pressure is 200 is an exciting proposition. Thanks for keeping us thinking. This is what I generally use, but then that is not specific to women in their 80's.: Table 1. Estimates of Benefits and Harms of Asprin Therapy Given for 5 Years to 1,000 Individuals with Various Levels of Baseline Risk for Coronary Heart Disease* -------------------------------------------------------------------------------- Baseline risk for coronary heart disease over 5 years: 1% Total mortality: No effectCHD events**: 1-4 avoided Hemorrhagic strokes***: 0-2 causedMajor gastrointestinal bleeding events****: 2-4 caused Baseline risk for coronary heart disease over 5 years: 3% Total mortality: No effectCHD events**: 4-12 avoided Hemorrhagic strokes***: 0-2 causedMajor gastrointestinal bleeding events****: 2-4 caused Baseline risk for coronary heart disease over 5 years: 5% Total mortality: No effectCHD events**: 6-20 avoided Hemorrhagic strokes***: 0-2 causedMajor gastrointestinal bleeding events****: 2-4 caused Sharon Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 No, not easy. I try to handle some of the easy ones myself:). Always in pain, although that is slightly better.Does anyone 85 have a simple medical history? Maybe a few. Some of the readings on only HCTZ (12.5) and Norvasc (and not right before injections or right after they refused to do injections):181/131 192/87 200/89 192/77 170/73 I don't know how to get truly accurate readings. Graham, I'll try to answer your aspirin and women questions from the literature, although I know that may be hard. And increasing risk of bleed when systolic pressure is 200 is an exciting proposition. Thanks for keeping us thinking. This is what I generally use, but then that is not specific to women in their 80's.: Table 1. Estimates of Benefits and Harms of Asprin Therapy Given for 5 Years to 1,000 Individuals with Various Levels of Baseline Risk for Coronary Heart Disease* -------------------------------------------------------------------------------- Baseline risk for coronary heart disease over 5 years: 1% Total mortality: No effectCHD events**: 1-4 avoided Hemorrhagic strokes***: 0-2 causedMajor gastrointestinal bleeding events****: 2-4 caused Baseline risk for coronary heart disease over 5 years: 3% Total mortality: No effectCHD events**: 4-12 avoided Hemorrhagic strokes***: 0-2 causedMajor gastrointestinal bleeding events****: 2-4 caused Baseline risk for coronary heart disease over 5 years: 5% Total mortality: No effectCHD events**: 6-20 avoided Hemorrhagic strokes***: 0-2 causedMajor gastrointestinal bleeding events****: 2-4 caused Sharon Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 good question I f her bp is really up aspirin maybe more of a riskThere probably is not evidence for every move you could make so it is informed consent and judgment in uncharted territory..Back to the duct tape. Is there any evidence to show that aspirin prevents stroke in elderly women?What are the risks of hemorrhagic stroke on aspirin?GI bleed? she'll faint fall and break her hip on isosorbibide if you ask me. and THEN where you will be for haveing treated her systolics some of which were only 159 .Good exam- good history-- discuss the risks with her-- Consider as aspirin a day for stroke prevention might do you better.Send her home.( and were these home bps? Looked like it but also good t o rule out white coat syndorme?)Does she drink MAny little old ladies do. I plan to. Agree. Most likely with all the calcium in her arteries it is the only way she can circulate blood around. Treat the patient not the blood pressure. Isosorbide helps, some of my patients are on it but, again, with non compliant arteries it may be difficult. from the Barrio yes indeed----I am with Kathy..... the best thing to do would be to fix this with a piece of duct tape-next time you take her blood pressure put a piece of duct tape on the screen where the blood pressure is written so you can ignore it. Seriously, I think I would do a short screen to rule out secondary causes of hypertension-I'm not sure I would check about any type of stenosis unless you are about to do something about it and then you can talk about things that are important to her..... you get the picture. Lou > > Clinical advice please: > > I have an 85 y old female with long standing hypertension. Systolic BP is > particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am > worried about lowering her diastolic pressure too much. She is having > periods of confusion and memory loss (not new since starting the ARB, but > hard to sort it all out). > > Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes > severe pedal edema)): > > Jan 27 195/87 78 4:15 pm > Jan 27 171/75 74 7:32 pm > Jan 28 198/81 76 Noon > Jan 28 179/78 80 6:50 pm > Jan 29 182/89 69 6:45 am > Jan 29 173/73 78 2:45 pm > Jan 30 159/66 77 9:45 am > Jan 31 167/74 87 8:15 am > Feb 1 191/85 74 8:05 am > > Read about adding long acting isosorbide dinitrate to lower only systolic > pressure, but I haven't used it for that indication before. Others have > experience? What dose to start? Other ideas? > > Sharon > Sharon McCoy MD > Renaissance Family Medicine > 10 McClintock Court; Irvine, CA 92617 > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > www.SharonMD.com > -- MD ph fax impcenter.org -- Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR. -- MD ph fax impcenter.org Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 What's her renal function? If low, a loop diuretic such as torsemide may be more effective than a thiazide. ok so she's home ALot of the trouble is as folks say-- can you believe that this is a true bp number--given the problem of stiff arteries In fact the longer I practice the less I think that we accurately measure bp at all( weight, white coat stuff, alcohol, Ijust ran out of my meds etc etc) Not easy Some of the studies about systolic hypertension in the elderly had folks who were at mean ages of 70 or 72 This woman has lived much longer than that Obviously she sounds vital and may have years ahead of her. But she is older than many of these 'Studies" talk about As the country ages this stuff is unknown terrtory though we daily tread it Apparently she has a complex PMH we do not know all the details of, also MAny folks use chlorthalidone The ALLHAT study is the one that is talked about alot and changes diuretic from hctz which is relatively mild to chlorthaidone ---you run the risk of orthostasis but this might be better here. You can use isosorbbide to allegedly impact the systolic not the diastolis and while I have never done it ever done it I have alot of patietns like this-mine never will take any pills so I just fret and worry. If she want s to treat then pick a low dose on short acting isosorbide til you see what long acting dose is then safe to use. but if she is at home and not in pain and can get 159 moer times than not--not 220/110 when someone is about to put in needle into a special part of the body for pain she is suffering with, then better to leave 159 systolic alone Yes the experts say 140-- to do that you may add three- 4 drugs They also say that about 72 yr olds. The long acting calcium channel and the diuretic and the arb perhpas. Resisitant hypertension is oftern treated also with spironolactone per UTD. I have alot of this stuff and it is always hard Let us know Not simple Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 From: UTDOL: Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease Impact of age — The six large scale randomized trials of aspirin in primary prevention include over 90,000 subjects from age 40 to 89, but their average 10-year risk of a first CHD event is less than 5 percent. Further randomized evidence is accumulating in several large scale randomized trials, in particular ARRIVE and ASPREE which target patients at moderate to high risk with an average risk of a first CHD event of 10 to 19 percent. Since risk of a first CHD event increases with age in men and women, these trials will include a greater preponderance of older subjects. Such data should form a rational basis for guidelines for primary prevention in moderate to high-risk men and women. Impact of gender — The totality of randomized evidence suggests no differences in response toaspirin between men and women. A 2009 meta-analysis of the results from 22 trials of primary and secondary prevention, included about 135,000 patients, and showed no difference in the response to aspirin between men and women [42]. A 2002 meta-analysis of the trials of secondary prevention came to a similar conclusion [10]. In the WHS aspirin showed a significant benefit on risk of a first stroke but not a first MI [51]. Since 90 percent of the subjects were under 65 the predominant occlusive vascular event in such women is stroke, not MI. In the 10 percent of women aged 65 and over who accrued 30 percent of the endpoints, MI was far more common and aspirin reduced the risk of a first MI to the same degree as in the previous trials of primary prevention predominantly in men. This hypothesis of possible gender differences had been formulated from a 2006 gender specific meta-analysis of randomized trials restricted to aspirin in the primary prevention of cardiovascular disease suggested a gender difference [54]. In this meta-analysis of over 51,000 women, about 80 percent of women were from the Womens Health Study (WHS) discussed above. Aspirin was associated with a significant 12 percent reduction in the combined cardiovascular outcome of nonfatal MI, nonfatal stroke, and cardiovascular mortality (odds ratio 0.88; 95% CI 0.79-0.99), attributable principally to a significant 33 percent MI reduction in men and 17 percent stroke reduction in women. Until more compelling evidence is available, we believe that the use of aspirin for primary prevention should be based on individual clinical judgments about absolute risks of a first CHD event rather than being gender specific [54]. Calculated as best as I can, 10 year risk for stroke is >20%, so according to tables going up to age 79, we could prevent 34 ischemic strokes and cause 18 major GI bleeds using aspirin for 10 years in 1000 women of that risk category. I don't know of a way to calculate risks for hemorrhagic strokes. Better get out on my house calls now.... Sharon Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 Here's a pre-digested recommendation http://www.uspreventiveservicestaskforce.org/uspstf09/aspirincvd/aspcvdrs.htm The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. Grade: I statement. From: UTDOL: Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease Impact of age — The six large scale randomized trials of aspirin in primary prevention include over 90,000 subjects from age 40 to 89, but their average 10-year risk of a first CHD event is less than 5 percent. Further randomized evidence is accumulating in several large scale randomized trials, in particular ARRIVE and ASPREE which target patients at moderate to high risk with an average risk of a first CHD event of 10 to 19 percent. Since risk of a first CHD event increases with age in men and women, these trials will include a greater preponderance of older subjects. Such data should form a rational basis for guidelines for primary prevention in moderate to high-risk men and women. Impact of gender — The totality of randomized evidence suggests no differences in response toaspirin between men and women. A 2009 meta-analysis of the results from 22 trials of primary and secondary prevention, included about 135,000 patients, and showed no difference in the response to aspirin between men and women [42]. A 2002 meta-analysis of the trials of secondary prevention came to a similar conclusion [10]. In the WHS aspirin showed a significant benefit on risk of a first stroke but not a first MI [51]. Since 90 percent of the subjects were under 65 the predominant occlusive vascular event in such women is stroke, not MI. In the 10 percent of women aged 65 and over who accrued 30 percent of the endpoints, MI was far more common and aspirin reduced the risk of a first MI to the same degree as in the previous trials of primary prevention predominantly in men. This hypothesis of possible gender differences had been formulated from a 2006 gender specific meta-analysis of randomized trials restricted to aspirin in the primary prevention of cardiovascular disease suggested a gender difference [54]. In this meta-analysis of over 51,000 women, about 80 percent of women were from the Womens Health Study (WHS) discussed above. Aspirin was associated with a significant 12 percent reduction in the combined cardiovascular outcome of nonfatal MI, nonfatal stroke, and cardiovascular mortality (odds ratio 0.88; 95% CI 0.79-0.99), attributable principally to a significant 33 percent MI reduction in men and 17 percent stroke reduction in women. Until more compelling evidence is available, we believe that the use of aspirin for primary prevention should be based on individual clinical judgments about absolute risks of a first CHD event rather than being gender specific [54]. Calculated as best as I can, 10 year risk for stroke is >20%, so according to tables going up to age 79, we could prevent 34 ischemic strokes and cause 18 major GI bleeds using aspirin for 10 years in 1000 women of that risk category. I don't know of a way to calculate risks for hemorrhagic strokes. Better get out on my house calls now.... Sharon -- Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2011 Report Share Posted February 7, 2011 Here's a pre-digested recommendation http://www.uspreventiveservicestaskforce.org/uspstf09/aspirincvd/aspcvdrs.htm The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. Grade: I statement. From: UTDOL: Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease Impact of age — The six large scale randomized trials of aspirin in primary prevention include over 90,000 subjects from age 40 to 89, but their average 10-year risk of a first CHD event is less than 5 percent. Further randomized evidence is accumulating in several large scale randomized trials, in particular ARRIVE and ASPREE which target patients at moderate to high risk with an average risk of a first CHD event of 10 to 19 percent. Since risk of a first CHD event increases with age in men and women, these trials will include a greater preponderance of older subjects. Such data should form a rational basis for guidelines for primary prevention in moderate to high-risk men and women. Impact of gender — The totality of randomized evidence suggests no differences in response toaspirin between men and women. A 2009 meta-analysis of the results from 22 trials of primary and secondary prevention, included about 135,000 patients, and showed no difference in the response to aspirin between men and women [42]. A 2002 meta-analysis of the trials of secondary prevention came to a similar conclusion [10]. In the WHS aspirin showed a significant benefit on risk of a first stroke but not a first MI [51]. Since 90 percent of the subjects were under 65 the predominant occlusive vascular event in such women is stroke, not MI. In the 10 percent of women aged 65 and over who accrued 30 percent of the endpoints, MI was far more common and aspirin reduced the risk of a first MI to the same degree as in the previous trials of primary prevention predominantly in men. This hypothesis of possible gender differences had been formulated from a 2006 gender specific meta-analysis of randomized trials restricted to aspirin in the primary prevention of cardiovascular disease suggested a gender difference [54]. In this meta-analysis of over 51,000 women, about 80 percent of women were from the Womens Health Study (WHS) discussed above. Aspirin was associated with a significant 12 percent reduction in the combined cardiovascular outcome of nonfatal MI, nonfatal stroke, and cardiovascular mortality (odds ratio 0.88; 95% CI 0.79-0.99), attributable principally to a significant 33 percent MI reduction in men and 17 percent stroke reduction in women. Until more compelling evidence is available, we believe that the use of aspirin for primary prevention should be based on individual clinical judgments about absolute risks of a first CHD event rather than being gender specific [54]. Calculated as best as I can, 10 year risk for stroke is >20%, so according to tables going up to age 79, we could prevent 34 ischemic strokes and cause 18 major GI bleeds using aspirin for 10 years in 1000 women of that risk category. I don't know of a way to calculate risks for hemorrhagic strokes. Better get out on my house calls now.... Sharon -- Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 8, 2011 Report Share Posted February 8, 2011 Reference for Graham,Best, BenJ Hum Hypertens. 1996 Feb;10(2):65-7.Systolic hypertension in critical aortic stenosis and the effect of valve replacement.Ie E, Mook W, Shapiro AP.Department of Medicine, Shadyside Hospital, Pittsburgh, PA, USA.AbstractAll cases of aortic valve replacement (AVR) for critical aortic stenosis (AS) in a 3 year period were reviewed and 43 cases were included in the study. Twenty patients had systolic hypertension preoperatively by sphygmomanometry and/or by measurement of central aortic pressure during cardiac catheterization. These patients also had a significantly higher mean left ventricular (LV) peak pressure than their normotensive counterparts. Following AVR all 43 patients were normotensive. This study suggests that not only can an elevated blood pressure (BP) be found in the presence of AS, but that AS itself can cause hypertension, in which case AVR can result in normalization of BP. We suggest that the systolic hypertension is due to a partial transmission of the higher LV peak pressure across the aortic valve, despite the stenotic valve acting as a pressure barrier. This effect may be more pronounced the tighter the stenosis.PMID: 8867557 [PubMed - indexed for MEDLINE] Either aortic stenosis or aortic regurgitation could cause a widened pulse pressure. I usually see aortic stenosis more commonly in my FP practice. Do you have a reference for the former? http://emedicine.medscape.com/article/150638-overview says that a systolic BP of 200 is unlikely with AS.cheers,-- Graham Chiuhttp://www.compkarori.co.nz:8090/ Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 8, 2011 Report Share Posted February 8, 2011 Reference for Graham,Best, BenJ Hum Hypertens. 1996 Feb;10(2):65-7.Systolic hypertension in critical aortic stenosis and the effect of valve replacement.Ie E, Mook W, Shapiro AP.Department of Medicine, Shadyside Hospital, Pittsburgh, PA, USA.AbstractAll cases of aortic valve replacement (AVR) for critical aortic stenosis (AS) in a 3 year period were reviewed and 43 cases were included in the study. Twenty patients had systolic hypertension preoperatively by sphygmomanometry and/or by measurement of central aortic pressure during cardiac catheterization. These patients also had a significantly higher mean left ventricular (LV) peak pressure than their normotensive counterparts. Following AVR all 43 patients were normotensive. This study suggests that not only can an elevated blood pressure (BP) be found in the presence of AS, but that AS itself can cause hypertension, in which case AVR can result in normalization of BP. We suggest that the systolic hypertension is due to a partial transmission of the higher LV peak pressure across the aortic valve, despite the stenotic valve acting as a pressure barrier. This effect may be more pronounced the tighter the stenosis.PMID: 8867557 [PubMed - indexed for MEDLINE] Either aortic stenosis or aortic regurgitation could cause a widened pulse pressure. I usually see aortic stenosis more commonly in my FP practice. Do you have a reference for the former? http://emedicine.medscape.com/article/150638-overview says that a systolic BP of 200 is unlikely with AS.cheers,-- Graham Chiuhttp://www.compkarori.co.nz:8090/ Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 8, 2011 Report Share Posted February 8, 2011 Hi BenI don't deny that AS can be associated with hypertension .. I've seen it too.But a widened pulse pressure is classically described with AR and not AS. Your reference doesn't address this. In fact, AS is supposed to have a narrowed pulse pressure, and in severe cases, pulsus parvus et tardus Cheers, Reference for Graham,Best, Ben J Hum Hypertens. 1996 Feb;10(2):65-7. Systolic hypertension in critical aortic stenosis and the effect of valve replacement. Ie E, Mook W, Shapiro AP. Department of Medicine, Shadyside Hospital, Pittsburgh, PA, USA. Abstract All cases of aortic valve replacement (AVR) for critical aortic stenosis (AS) in a 3 year period were reviewed and 43 cases were included in the study. Twenty patients had systolic hypertension preoperatively by sphygmomanometry and/or by measurement of central aortic pressure during cardiac catheterization. These patients also had a significantly higher mean left ventricular (LV) peak pressure than their normotensive counterparts. Following AVR all 43 patients were normotensive. This study suggests that not only can an elevated blood pressure (BP) be found in the presence of AS, but that AS itself can cause hypertension, in which case AVR can result in normalization of BP. We suggest that the systolic hypertension is due to a partial transmission of the higher LV peak pressure across the aortic valve, despite the stenotic valve acting as a pressure barrier. This effect may be more pronounced the tighter the stenosis. PMID: 8867557 [PubMed - indexed for MEDLINE] Either aortic stenosis or aortic regurgitation could cause a widened pulse pressure. I usually see aortic stenosis more commonly in my FP practice. Do you have a reference for the former? http://emedicine.medscape.com/article/150638-overview says that a systolic BP of 200 is unlikely with AS.cheers,-- Graham Chiuhttp://www.compkarori.co.nz:8090/ Synapse - the use from anywhere EMR. -- Graham Chiuhttp://www.compkarori.co.nz:8090/Synapse - the use from anywhere EMR. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 10, 2011 Report Share Posted February 10, 2011 Some additional thoughts, ignoring her age. I know, but play along for academic purposes. I'd get an echo to r/o valve dz. Consider spironolactone and a spot renin/aldosterone level. Look into one of the new renin blockers as a possibility. OSA can cause a sympathetic overdrive leading to hypertension that's hard to control. Treating the OSA can make a big difference. Renal artery stenosis? Personally, I'm of the school that old ladies with SBP 140-150 is ok if they are symptomatic with lower BPs and may fall down go boom. SBP in the 180-200 range scares me regardless of age. I usually look for a secondary cause like OSA, renal artery stenosis, hyperaldosteronism, valvular abnormality. Then again, I'm an internist with lots of pens and we usually like to order tests. > > Clinical advice please: > > I have an 85 y old female with long standing hypertension. Systolic BP is > particularly elevated now. I added an ARB to HCTZ and Norvasc, but I am > worried about lowering her diastolic pressure too much. She is having > periods of confusion and memory loss (not new since starting the ARB, but > hard to sort it all out). > > Here are some readings on the Hyzaar HCT (and Norvasc 2.5 (more causes > severe pedal edema)): > > Jan 27 195/87 78 4:15 pm > Jan 27 171/75 74 7:32 pm > Jan 28 198/81 76 Noon > Jan 28 179/78 80 6:50 pm > Jan 29 182/89 69 6:45 am > Jan 29 173/73 78 2:45 pm > Jan 30 159/66 77 9:45 am > Jan 31 167/74 87 8:15 am > Feb 1 191/85 74 8:05 am > > Read about adding long acting isosorbide dinitrate to lower only systolic > pressure, but I haven't used it for that indication before. Others have > experience? What dose to start? Other ideas? > > Sharon > Sharon McCoy MD > Renaissance Family Medicine > 10 McClintock Court; Irvine, CA 92617 > PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax: > www.SharonMD.com > Quote Link to comment Share on other sites More sharing options...
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