Hypertensive Woes - So many crises, so little time
The names of certain individuals have been changed to protect their identity
One of the things that the Covid pandemic has shown throughout the world is that when push comes to shove, generalists are what the public needs. Specialists are great but the backbone of the health system comes from the generalists who do just enough of everything to prevent it all from falling apart. This was interestingly a prediction that one of the most inspirational teachers in my life, the late Dr KC Gopalakrishnan sir hammered into my skull back when I was in final year.
Unfortunately the problem is that there is unfortunately no glamour in being a generalist. All young doctors prefer to be a specialist. The public prefers specialists. Family medicine doctors are not well trained. Emergency medicine is an underdeveloped field in Kerala. I do know outstanding GPs who are practicing good medicine but unfortunately you get the feeling that a lot of generalists feel underwhelmed by the trajectory their career has taken. A lack of passion will limit what you achieve in life.
There are plenty of conditions that are much better dealt with by primary care doctors than specialists. For example, 90-95% of patients with headache or giddiness or syncope are better managed at primary care level because these are most often benign complaints and do not need specialist management (until they do). You just need to have the interest and determination to understand the complexities of the evaluation and management. If you can manage these common complaints, you will do well in your career and certainly won't feel bored.
The Hypertension Conundrum
So it gives me great pain when I see primary care doctors completely mismanage something that should be their bread and butter - hypertension.
I was recently doing some research to develop some management protocols for one of my former employers when I was sent a management protocol for HTN by a friend which ironically increased my blood pressure quite nicely. I don't want to share it here because I'm not interested in shaming, but I'll just point out things that I had problems with
"If BP > 180/110, refer the patient immediately after initiating treatment. Repeat BP check after 2 min"
There are so many problems with this. First point I'd like to make before anything else is that treatment protocols are not gospel. They are mainly useful to maintain a minimum level of care and is in general more useful for more inexperienced doctors. But all of them have their limitations, even very well known ones. For example, the ACLS guidelines are great for a patient with chest pain but if you follow it blindly, you may end up harming a patient with a metabolic disorder like hyperkalemia.
The main problem I have with the above is that the whole thinking process is all wrong.. Your reflex when you see an elevated BP should be to ask - why is this patient's BP elevated? Because the vast majority of the time, the why is going to be much more important than how elevated the BP reading is. Your thought process when you see tachycardia is not - "OMG, I better start the metoprolol", it's going to be "OK, why is this guy tachycardic?" An elevated BP should be approached in the same manner.
The Pathogenesis
To understand this problem, we must go all the way back to medical college. Year after year our brains are hammered with "Normal is 120/80" and ">140/90 is bad". And then you finally pass final year, become an intern and start seeing patients. Suddenly you see patients with BP of 180s, 190s and you shit your pants. We all do. It doesn't seem normal which instantly triggers a reflex that we should do something about it.
Another thing that will make you do wrong things is the term "hypertensive urgency" - a poorly defined term with no real clinical use other than giving the false impression that it is appropriate to urgently reduce BP in these patients. It is only when you look up the literature and guidelines that you learn that hypertensive urgency requires you to urgently do nothing.
Hypertensive urgency is a mythical term that should be thrown out of textbooks. It's as badly named as other heroes like lupus anticoagulant (which makes you clot, not bleed).
And if you want to go even deeper, analytical approach to clinical problems is never taught in most medical colleges. What is most important for a doctor is not really what he knows but rather the way he thinks about clinical problems with that knowledge. This is why junior doctors shadow seniors - to get an idea of the reasoning process. You will struggle to get that from books.
So why is this a problem?
Go back to that original protocol.
"If BP > 180/110, refer the patient immediately after initiating treatment. Repeat BP check after 2 min"
The protocol really should be reframed in such a way that if BP > 180/110 - you should look for evidence of hypertensive emergency (acute end organ damage) which would need ICU care.
Then you need to look at any obvious cause for an elevated blood pressure? A patient with renal colic needs his/her pain managed, not their BP of 180. There are multiple factors controlling a patient's blood pressure. This can even be from acute anxiety which anyone who has worked in a casualty knows is extremely common. This is why it is always good to simply repeat the BP after a while (say 30 minutes). Repeating after 2 minutes is something I've not read in any standard literature.
"Clinical trials have shown that rest is effective at lowering blood pressure in patients with hypertensive urgency.23,24 One study initially treated 549 emergency department patients with a 30-minute rest period, after which time 32% of patients had responded (defined as a SBP <180 mm Hg and DBP <110 mm Hg, with at least a 20 mm Hg reduction in baseline SBP and/or a 10 mm Hg reduction in DBP).23 Another study randomized 138 patients with hypertensive urgency to either rest or active treatment with telmisartan. Blood pressures were checked every 30 minutes for four hours. The primary endpoint (reduction of MAP of 10%-35%) was similar in both groups (68.5% in the rest group and 69.1% in the telmisartan group)."
https://www.journalofhospitalmedicine.com/jhospmed/article/176615/hospital-medicine/acute-treatment-hypertensive-urgency
So there is evidence (which backs up what I see in day-to-day practice) that doing nothing is just as good and probably safer than doing something in hypertensive urgency,
Now you can see how people can get lead down the wrong path. They incorrectly try to do something and give an antihypertensive - this is usually a poor choice like furosemide (why this is popular, I'm not quite sure since it is not in any textbook or literature). But they also do the appropriate thing by making the patient rest which is pretty effective by itself to reduce BP in most asymptomatic patients. And the end result is that you have doctors thinking they have helped the patient when they actually haven't.
Look, you may get away with it in most patients but consider this. Treating has no benefit. So if you treat 100 patients and 2 of them get complications, the net effect is still harm over benefit. And believe me, there is a definite risk of overshoot hypotension if you go around reducing BPs acutely without thinking. I've seen a case where a certain Dr Joe decided to give iv lasix to a patient whose SBP was 160 and the patient was eventually diagnosed with bleeding oesophageal varices. Not good. Elderly patients can get giddiness because of these unnecessary interventions, fall and one can imagine all the complications that result from fractures in the elderly.
I also remember another incident with Dr Joe when he decided to start an elderly patient on IV fluids because she was feeling fatigued but also gave iv lasix at the same time because her BP was 180 and I was like "Dude, WTF?" Once you learn wrong concepts and practices, it can be difficult to unlearn them. And believe me, there are many Dr Joes running around.
What this does to the doctor-patient relationship
Most patients don't like being referred to a higher centre, especially if they are not symptomatic. Imagine if they travelled 35, 40 km only to find out they needed no acute treatment. It will decrease his/her trust and when the day comes that he/she really needs an urgent referral, they may not take things as seriously as they should.
The public also start developing this concept that BP needs to be reduced acutely every now and then. Once, I saw a patient who was asymptomatic but had BP in 200s. I looked over her old charts and found that this had happened at least 4 times before and all had the same result - acute reduction, observation and discharge with 0 advice on long term medications. This was madness. The only benefit to controlling BP in hypertensive urgency is longterm control. Reducing BP every now and then like this doesn't do shit. Needless to say, I had a very very hard time convincing the patient after her previous experiences.
Patients also begin wrongly assuming that certain symptoms to hypertension, even without checking their BP! I had a patient who presented with headache who told me he had already taken double dose of his antihypertensive. If you're wondering about the association between hypertension and headache, here is a prospective study with over 20,000 patients done in Norway.
"High systolic and diastolic pressures were associated with reduced risk of non-migrainous headache."
https://pubmed.ncbi.nlm.nih.gov/11909904/
As recently as last week, a junior of mine messaged me how he had tried to reduce a BP of 170/80 in an 85 year old patient presenting with vague symptoms. I politely informed him that whatever symptoms this patient had, it certainly wasn't due to that blood pressure. The normal for a 25 year old isn't necessarily what is expected in an 85 year old but this is not taught in textbooks.
Indeed, this is another major problem - false assumption that the BP is the cause of a symptom. If a 60 year old is presenting with vertigo, it is unlikely that it is due to a BP of 160. An assumption that this is the case will lead to two things - probable overtreatment of the BP and possibly missing a much more sinister diagnosis because of premature diagnostic closure.
At the end of the day, the reason this pisses me off so much is that it is the patients who are not getting the kind of care that they deserve.
The What If Syndrome
Now, not knowing the evidence behind common practices is only part of the problem here. Another one which is just as relevant is something that I'll call the "what if syndrome."
So some of you will be thinking, "What if I don't reduce the BP and the patient develops a stroke?"
Well if you go read some of the earlier links I gave, you'll see that studies have failed to show that acutely reducing BP in hypertensive urgency will prevent any short-term complications. All benefit is based on long-term BP control.
Unfortunately, many doctors are quick to blame another doc if something bad happens to their patient, even if it was for things well beyond their control. For example, even the best doctors working with the best facilities in the world admit they will miss about 1 in a 1000 MIs. It is not a possibility, it is an inevitability. Missing an obvious STEMI is bad but what about that middle aged patient with extremely vague symptoms and a normal ECG and troponin? Can anyone really be blamed if that patient has a bad outcome after being sent home?
So what about the so many doctors who work with much less than ideal facilities? We need to cut each other some slack. Diagnosis is not easy by any stretch of the imagination. Patients always surprise us. What is best for us and best for our patients is evidence based medicine. We must not become slaves to our fears. We need to learn to make brave decisions because that's what we are paid to do.
Conclusion
Basically what I've been rambling about is that protocols cannot be oversimplified to the level where it no longer has any evidence (literature/clinical experience) to support it. Protocols in order to be effective must be evidence based with adequate detail, only then can they be given any semblance of trust.
For more info on how to manage this condition, I highly recommend reading this -
https://emcrit.org/ibcc/hypertensive-emergency/
One of the things that the Covid pandemic has shown throughout the world is that when push comes to shove, generalists are what the public needs. Specialists are great but the backbone of the health system comes from the generalists who do just enough of everything to prevent it all from falling apart. This was interestingly a prediction that one of the most inspirational teachers in my life, the late Dr KC Gopalakrishnan sir hammered into my skull back when I was in final year.
Unfortunately the problem is that there is unfortunately no glamour in being a generalist. All young doctors prefer to be a specialist. The public prefers specialists. Family medicine doctors are not well trained. Emergency medicine is an underdeveloped field in Kerala. I do know outstanding GPs who are practicing good medicine but unfortunately you get the feeling that a lot of generalists feel underwhelmed by the trajectory their career has taken. A lack of passion will limit what you achieve in life.
There are plenty of conditions that are much better dealt with by primary care doctors than specialists. For example, 90-95% of patients with headache or giddiness or syncope are better managed at primary care level because these are most often benign complaints and do not need specialist management (until they do). You just need to have the interest and determination to understand the complexities of the evaluation and management. If you can manage these common complaints, you will do well in your career and certainly won't feel bored.
The Hypertension Conundrum
So it gives me great pain when I see primary care doctors completely mismanage something that should be their bread and butter - hypertension.
I was recently doing some research to develop some management protocols for one of my former employers when I was sent a management protocol for HTN by a friend which ironically increased my blood pressure quite nicely. I don't want to share it here because I'm not interested in shaming, but I'll just point out things that I had problems with
"If BP > 180/110, refer the patient immediately after initiating treatment. Repeat BP check after 2 min"
There are so many problems with this. First point I'd like to make before anything else is that treatment protocols are not gospel. They are mainly useful to maintain a minimum level of care and is in general more useful for more inexperienced doctors. But all of them have their limitations, even very well known ones. For example, the ACLS guidelines are great for a patient with chest pain but if you follow it blindly, you may end up harming a patient with a metabolic disorder like hyperkalemia.
The main problem I have with the above is that the whole thinking process is all wrong.. Your reflex when you see an elevated BP should be to ask - why is this patient's BP elevated? Because the vast majority of the time, the why is going to be much more important than how elevated the BP reading is. Your thought process when you see tachycardia is not - "OMG, I better start the metoprolol", it's going to be "OK, why is this guy tachycardic?" An elevated BP should be approached in the same manner.
The Pathogenesis
To understand this problem, we must go all the way back to medical college. Year after year our brains are hammered with "Normal is 120/80" and ">140/90 is bad". And then you finally pass final year, become an intern and start seeing patients. Suddenly you see patients with BP of 180s, 190s and you shit your pants. We all do. It doesn't seem normal which instantly triggers a reflex that we should do something about it.
Another thing that will make you do wrong things is the term "hypertensive urgency" - a poorly defined term with no real clinical use other than giving the false impression that it is appropriate to urgently reduce BP in these patients. It is only when you look up the literature and guidelines that you learn that hypertensive urgency requires you to urgently do nothing.
And if you want to go even deeper, analytical approach to clinical problems is never taught in most medical colleges. What is most important for a doctor is not really what he knows but rather the way he thinks about clinical problems with that knowledge. This is why junior doctors shadow seniors - to get an idea of the reasoning process. You will struggle to get that from books.
So why is this a problem?
Go back to that original protocol.
"If BP > 180/110, refer the patient immediately after initiating treatment. Repeat BP check after 2 min"
The protocol really should be reframed in such a way that if BP > 180/110 - you should look for evidence of hypertensive emergency (acute end organ damage) which would need ICU care.
Then you need to look at any obvious cause for an elevated blood pressure? A patient with renal colic needs his/her pain managed, not their BP of 180. There are multiple factors controlling a patient's blood pressure. This can even be from acute anxiety which anyone who has worked in a casualty knows is extremely common. This is why it is always good to simply repeat the BP after a while (say 30 minutes). Repeating after 2 minutes is something I've not read in any standard literature.
"Clinical trials have shown that rest is effective at lowering blood pressure in patients with hypertensive urgency.23,24 One study initially treated 549 emergency department patients with a 30-minute rest period, after which time 32% of patients had responded (defined as a SBP <180 mm Hg and DBP <110 mm Hg, with at least a 20 mm Hg reduction in baseline SBP and/or a 10 mm Hg reduction in DBP).23 Another study randomized 138 patients with hypertensive urgency to either rest or active treatment with telmisartan. Blood pressures were checked every 30 minutes for four hours. The primary endpoint (reduction of MAP of 10%-35%) was similar in both groups (68.5% in the rest group and 69.1% in the telmisartan group)."
https://www.journalofhospitalmedicine.com/jhospmed/article/176615/hospital-medicine/acute-treatment-hypertensive-urgency
So there is evidence (which backs up what I see in day-to-day practice) that doing nothing is just as good and probably safer than doing something in hypertensive urgency,
Now you can see how people can get lead down the wrong path. They incorrectly try to do something and give an antihypertensive - this is usually a poor choice like furosemide (why this is popular, I'm not quite sure since it is not in any textbook or literature). But they also do the appropriate thing by making the patient rest which is pretty effective by itself to reduce BP in most asymptomatic patients. And the end result is that you have doctors thinking they have helped the patient when they actually haven't.
Look, you may get away with it in most patients but consider this. Treating has no benefit. So if you treat 100 patients and 2 of them get complications, the net effect is still harm over benefit. And believe me, there is a definite risk of overshoot hypotension if you go around reducing BPs acutely without thinking. I've seen a case where a certain Dr Joe decided to give iv lasix to a patient whose SBP was 160 and the patient was eventually diagnosed with bleeding oesophageal varices. Not good. Elderly patients can get giddiness because of these unnecessary interventions, fall and one can imagine all the complications that result from fractures in the elderly.
I also remember another incident with Dr Joe when he decided to start an elderly patient on IV fluids because she was feeling fatigued but also gave iv lasix at the same time because her BP was 180 and I was like "Dude, WTF?" Once you learn wrong concepts and practices, it can be difficult to unlearn them. And believe me, there are many Dr Joes running around.
What this does to the doctor-patient relationship
Most patients don't like being referred to a higher centre, especially if they are not symptomatic. Imagine if they travelled 35, 40 km only to find out they needed no acute treatment. It will decrease his/her trust and when the day comes that he/she really needs an urgent referral, they may not take things as seriously as they should.
The public also start developing this concept that BP needs to be reduced acutely every now and then. Once, I saw a patient who was asymptomatic but had BP in 200s. I looked over her old charts and found that this had happened at least 4 times before and all had the same result - acute reduction, observation and discharge with 0 advice on long term medications. This was madness. The only benefit to controlling BP in hypertensive urgency is longterm control. Reducing BP every now and then like this doesn't do shit. Needless to say, I had a very very hard time convincing the patient after her previous experiences.
Patients also begin wrongly assuming that certain symptoms to hypertension, even without checking their BP! I had a patient who presented with headache who told me he had already taken double dose of his antihypertensive. If you're wondering about the association between hypertension and headache, here is a prospective study with over 20,000 patients done in Norway.
"High systolic and diastolic pressures were associated with reduced risk of non-migrainous headache."
https://pubmed.ncbi.nlm.nih.gov/11909904/
As recently as last week, a junior of mine messaged me how he had tried to reduce a BP of 170/80 in an 85 year old patient presenting with vague symptoms. I politely informed him that whatever symptoms this patient had, it certainly wasn't due to that blood pressure. The normal for a 25 year old isn't necessarily what is expected in an 85 year old but this is not taught in textbooks.
Indeed, this is another major problem - false assumption that the BP is the cause of a symptom. If a 60 year old is presenting with vertigo, it is unlikely that it is due to a BP of 160. An assumption that this is the case will lead to two things - probable overtreatment of the BP and possibly missing a much more sinister diagnosis because of premature diagnostic closure.
At the end of the day, the reason this pisses me off so much is that it is the patients who are not getting the kind of care that they deserve.
The What If Syndrome
Now, not knowing the evidence behind common practices is only part of the problem here. Another one which is just as relevant is something that I'll call the "what if syndrome."
So some of you will be thinking, "What if I don't reduce the BP and the patient develops a stroke?"
Well if you go read some of the earlier links I gave, you'll see that studies have failed to show that acutely reducing BP in hypertensive urgency will prevent any short-term complications. All benefit is based on long-term BP control.
Unfortunately, many doctors are quick to blame another doc if something bad happens to their patient, even if it was for things well beyond their control. For example, even the best doctors working with the best facilities in the world admit they will miss about 1 in a 1000 MIs. It is not a possibility, it is an inevitability. Missing an obvious STEMI is bad but what about that middle aged patient with extremely vague symptoms and a normal ECG and troponin? Can anyone really be blamed if that patient has a bad outcome after being sent home?
So what about the so many doctors who work with much less than ideal facilities? We need to cut each other some slack. Diagnosis is not easy by any stretch of the imagination. Patients always surprise us. What is best for us and best for our patients is evidence based medicine. We must not become slaves to our fears. We need to learn to make brave decisions because that's what we are paid to do.
Conclusion
Basically what I've been rambling about is that protocols cannot be oversimplified to the level where it no longer has any evidence (literature/clinical experience) to support it. Protocols in order to be effective must be evidence based with adequate detail, only then can they be given any semblance of trust.
For more info on how to manage this condition, I highly recommend reading this -
Comments
Post a Comment