Meds and Community Over Mindfulness for Most Hypertension

Ileana L. Piña, MD, MPH; Keith C. Ferdinand, MD


November 11, 2022

This transcript has been edited for clarity.

Ileana L. Piña, MD, MPH: Hello. I'm Ileana Piña, from Thomas Jefferson University, and this is my blog.

I'm thrilled to be at the American Heart Association Scientific Sessions. I am so honored to have my friend, Dr Keith Ferdinand, with me today to have a chat about blood pressure, which is one of his favorite subjects, and about what we need to do as a community to really address this issue.

It is not okay to remain with a high blood pressure that's not being treated. It is not okay to not get to target. It is not okay to not prescribe the medications that patients need. What an impact we could make on public health if we would do this.

Keith, I'll let you start by introducing yourself.

Keith C. Ferdinand, MD: I'm Keith Ferdinand. I'm a clinical cardiologist. I'm the Gerald S. Berenson Chair of Preventive Cardiology at Tulane University School of Medicine in my hometown of New Orleans, Louisiana,

Piña: That you love so much.

Ferdinand: I do.

Piña: I share that love of your wonderful city, with that wonderful food as well.

Ferdinand: Thank you.

Piña: There's a large amount of talk here about mindfulness for blood pressure. I know my patients tell me, "Well, my blood pressure shoots up when I'm upset with my family." I have another gentleman who has been having problems with unemployment and whether he could take disability, and his blood pressure has been out of whack because he's been dealing with that.

Tell us a little bit about this MB-BP trial.

Ferdinand: I chaired a late-breaker session, and there was some information that mindfulness — withdrawing from the daily stressors of life — may positively impact one's blood pressure. It can lower the blood pressure. Now remember, the study itself was in a selected group of patients, mainly self-identified White, and three fourths of them had college or postgraduate education.

I'm not going to make the case for our disadvantaged populations, including people who are really living on a fixed income, they live in a neighborhood with sirens and gunshots, that they're somehow going to withdraw from that and have peace and then have their blood pressures lowered.

All of us get the benefits of doing a little bit more to remove from the daily stress.

Piña: Also, the activity increased and diet improved. How do you handle that in your patients? You have a tough population.

Ferdinand: Down in New Orleans, we have many patients with resistant hypertension. It's more common in the South and it's more common among African Americans.

Of course, the mindfulness approach has the patient pay more attention to what we call therapeutic lifestyle changes, which are those things that can affect the blood pressure, including being physically inactive and eating too much sodium and not enough potassium. Here's one caution I have, Ileana. Our really difficult-to-treat patients need medications.

The 2017 high blood pressure guideline says most adults, and especially Black adults, need two or more medicines, so the medicines work. If we look at hypertension as the most powerful and prevalent risk factor across the population, if we're going to control it, most patients are going to need medicines. I'm certainly not against mindfulness. I think those therapeutic lifestyle changes are also important.

Piña: Yes, but they go together. I am very quick to prescribe medicines because I can't count that they're going to be doing the walking or the moving that I'm recommending or that they're going to have access to healthy foods.

Ferdinand: Here's my concern. I think that the therapeutic lifestyle changes are essential. That's the bedrock, but I don't want patients to get the unintended message that medications are bad, and you can get off of medicine or you can withdraw from medicines.

Piña: We have so many drugs available. If your patient is intolerant to one thing, there are other choices.

Ferdinand: There are 125 different blood pressure medicines. There's another late-breaker session for patients who have difficult-to-treat or resistant hypertension. There are even more medicines on the horizon, including renal denervation, which is a device that denervates the renal artery and helps decrease blood pressure.

Piña: There's no excuse to say there's no choice and to leave it the way it is.

Ferdinand: We've practiced long enough that we remember blood pressure medicines like reserpine, methyldopa, clonidine. They caused many side effects.

Piña: Do you remember Ser-Ap-Es?

Ferdinand: Oh, yes, a combination of all those terrible medicines. Some of the newer medicines, if you take them, you don't even feel anything. Angiotensin receptor blockers (ARBs), very low. ACE inhibitors, there may be a nuisance cough. Rarely, you can get 1 of 3000 African Americans or 1 of 1000 with angioedema.

Piña: I love the ARBs because of the low side-effect profile.

Ferdinand: The ARBs may not actually be as good for heart failure as the ACE inhibitors, but for blood pressure, the meta-analyses say they're just as good. They're like water, with placebo-like side effects.

The point being is that, yes — mindfulness, therapeutic lifestyle changes, physical activity, avoid sodium — but medications aren't bad. For the development of hypertension, once a person is middle aged and older, they need those medicines.

Piña: If you look at the SPRINT trial, it didn't really matter which drug. The doctors were told to choose an agent. They were given a list of choices, but they could do whatever they wanted.

Ferdinand: If you look at SPRINT, there's a regression line, starting high going down low, and it's a linear, direct relationship between lowering blood pressure and decreasing cardiovascular events, including the love of your life, heart failure. Ischemic disease, of course, can cause heart failure. In all the clinical trials, it stands out. If you look across the whole population, especially if you include HFpEF, hypertension is a major cause of heart failure.

Piña: When I want patients to take their medicines, I say — this is one thing that, for years, I've been saying — if you lower your blood pressure, your heart failure chances are less. I can tell you that the actual data show this. It's not just us saying it. Now we have the data to back that up.

Tell me a little bit about chlorthalidone. There have been some interesting conversations.

Ferdinand: There are some mixed messages. My friend from the VA came up with the study that suggested that there was no benefit of chlorthalidone vs hydrochlorothiazide. Here's how the study was designed. They attempted to match the dose of the chlorthalidone to the dose of hydrochlorothiazide. It was 25 mg hydrochlorothiazide vs 12.5 mg chlorthalidone, but in the ALLHAT trial and most of the studies that have really shown that bang for your buck, it's 25 mg chlorthalidone. I'm not going to suggest that a small dose of chlorthalidone is inherently better than 25 mg hydrochlorothiazide.

Piña: That's not the message we want to convey.

Ferdinand: The dose of chlorthalidone used in ALLHAT and other trials was 25 mg.

Piña: That's what I use in the clinic. I have a tough case right now where I've tried several drugs and she comes in with a sudden increase in blood pressure. I just added chlorthalidone.

Ferdinand: It has a longer half-life; it can last for days. It tends to maintain its effect even with moderate CKD; GFR is in the 40 mL/min/1.73 m2 range. For those patients who take hydrochlorothiazide, they probably won't get any more hypokalemia, and if they do — you like RAS agents — that RAS agent will blunt some of that hypokalemia.

Piña: That's what I did. I put her on a RAS inhibitor and added chlorthalidone.

I want to end with the community work that's been done not only in your neck of the woods but also in other places in this country.

Ferdinand: Lisa Cooper from Johns Hopkins has a study in which they use community health workers with step therapy, training patients how to manage their blood pressure. We've been doing community outreach with the Healthy Heart Community Prevention Project in New Orleans for decades. I think that's the way we really have to manage these chronic conditions, and I'll tell you why: the magic 15-minute doctor visit — especially doctors. Nurse practitioners and PAs take a little bit more time. Maybe they care more.

Piña: We heart failure doctors take a little more time.

Ferdinand: Yes, you do. With that 15-minute visit that some primary care doctors are now being mandated to stick to, it's hard to control a chronic condition with a patient coming in every 3-4 months. Out-of-the-office self-measured blood pressure, community interventions, community health workers, and community support, I think, is the way we need to manage this chronic disease.

Again, I go back especially to those patients who have disadvantage, who live in the social determinants of health where you work, live, play, and pray. When things are tough, they need the community to nest around them and help them understand shared decision-making, adherence to sodium, therapeutic lifestyle, and take your doggone medicines.

Piña: I need to give a shout-out to the Philadelphia community group because they're actually going into the community and teaching the community about blood pressure, not only saying to take your medicines, but here's what blood pressure actually does to your heart and to your circulatory system.

Ferdinand: We do that in New Orleans. We had an 8-week program with seniors in one of the community centers in which we went in. We taught them about diabetes specifically, and not only what is diabetes, but also how to utilize the medications, how to talk to your doctor, how to ask those tough questions, and about exercise.

Piña: The conversations go both ways.

Ferdinand: Everything. I think that's the way to go to empower the patient. We now have nomenclature where we call it shared decision-making. It's not us saying "thou shalt do." It's, what do we want to do together?

Piña: We call it a team. My patients are always amazed when I say they're part of my team.

Ferdinand: Absolutely.

Piña: As usual, thank you for your dedication to that population for the years that you've done this. I've been watching you all these years and you always impress me.

Ferdinand: Thank you for this opportunity. I always love talking to you. Hopefully we can inspire some people to inspire some others.

Piña: To do the right thing. I'm so glad you were able to join me today.

You've heard it from the best. Let's get that blood pressure down. Let's get these patients where they should be within that margin of not only safety, but also extensive benefits down the line.

This is Ileana, signing off from the American Heart Association Meeting. Have a great day.

Ileana L. Piña, MD, MPH, is a heart failure and cardiac transplantation expert. She serves as an advisor/consultant to the FDA's Center for Devices and Radiological Health and has been a volunteer for the American Heart Association since 1982. Originally from Havana, Cuba, she is passionate about enrolling more women and minorities in clinical trials. She also enjoys cooking and taking spin classes.

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