MedStar Health Blog

On Nov. 13, 2017, two leading health groups, the American Heart Association (AHA) and the American College of Cardiology (ACC), jointly released new guidelines that group more individuals into the category of elevated or high blood pressure.

Normal blood pressure is still any reading less than 120 over 80, or less than 120 millimeters of mercury (mmHg) of systolic pressure and less than 80 mmHg of diastolic pressure. Under the new guidelines, blood pressure readings above that now are considered elevated or high. As the AHA/ACC note, 46 percent of U.S. adults now can be classified as having high blood pressure, up from 32 percent under the previous guidelines.

This issue isn’t one to be taken lightly. But it’s important to note that there aren’t suddenly millions of people who now have high blood pressure, or hypertension, that they didn’t have before. These new guidelines are meant to raise awareness of controlling blood pressure before it becomes a serious health risk.

What’s changed in the new blood pressure guidelines?

The new guidelines eliminate the old “prehypertension” category, which is when doctors would advise patients that their blood pressure was higher than normal but not quite enough to be classified as hypertension. The new guidelines start stage 1 and stage 2 high blood pressure at lower levels.

Here’s how the numbers break down:

• Elevated blood pressure: 120 to 129 mmHg systolic; less than 80 mmHg diastolic
• Stage 1 high blood pressure: 130 to 139 mmHg systolic; 80 to 89 mmHg diastolic
• Stage 2 high blood pressure: 140 or above mmHg systolic; 90 or above mmHg diastolic

It’s important to remember that this is not new information. We’ve known for many years that optimal blood pressure is less than 120 over 80, and that hasn’t changed. The new guidelines simply recognize that doctors and patients weren’t addressing the problem early enough. High blood pressure is a known risk factor for a number of dangerous conditions, including heart attacks, strokes and even Alzheimer’s disease, and the risk of diseases that are linked to high blood pressure doubles with a systolic pressure of 130 compared to 120. Lowering your systolic blood pressure just from 140 to 130 can mean a 15 to 20 percent reduction of your risk for heart disease.

What the new blood pressure guidelines don’t say

Despite the expected increase in hypertension diagnoses, the AHA/ACC’s new guidelines are clear about not advocating for a huge increase in the number of people who take medications to lower their blood pressure. If we’re too aggressive in prescribing medications, especially for people who haven’t hit the higher stages of blood pressure, we could risk overtreating their disease. Blood pressure medications can cause side effects, such as fatigue, headaches, nausea or dizziness. That last one is a particular problem among older people, who could be at risk for falling. Treating blood pressure with medications always involves balancing the medications’ benefits against their potential for harm. And in my opinion, for these people on the lower end of the spectrum, beta blockers, diuretics and other medications that reduce blood pressure can do more harm than good.

There are other medications we can use that are less harmful for patients who need just a little help controlling their blood pressure. And, of course, we’ll have to continue studying what types of drugs patients are receiving, so that we balance the benefits of treatment with the potential harm of overtreatment.

I believe the AHA/ACC’s new blood pressure guidelines should start blood pressure management conversations between patients and their healthcare providers. Being more aware of and aggressively managing lifestyle factors that contribute to high blood pressure, especially early on, is better for everyone involved.

Tips to get your blood pressure under control

I know there are people out there reading this and thinking, “Oh, great—another doctor talking to me about diet, exercise and losing weight.” And it’s true that these factors are critical in managing blood pressure. But what needs to change is how doctors talk to patients about these factors.

More than any other time in human history, we live in an era of self-empowered health care. For example, you don’t need a doctor to tell you you’re eating too much salt, which can cause blood pressure to rise. There are great apps out there, such as MyFitnessPal, that can tell you how much salt is in your diet. If you’re getting more than 2 or 2.5 grams of salt per day, you probably should eliminate high-sodium foods, including canned foods or fast food. Reducing your sodium intake to below these levels could lower your blood pressure four to seven points.

You also can track your activity levels to see if you need to work in another trip to the gym per week or start an exercise plan if you aren’t physically active. Exercising for 30 minutes per day most days of the week can lower your blood pressure two to three points, and losing even 10 pounds of extra weight can lower blood pressure by three to five points.

I often talk to patients about medications that can increase blood pressure. Nonsteroidal anti-inflammatory drugs, or NSAIDs, are common culprits. NSAIDs have been clinically proven to increase blood pressure in people with normal and high blood pressure because they cause the kidneys to hold on to salt for too long. Not only can taking NSAIDs raise your blood pressure by two to three points, but they also can lower the effectiveness of any blood pressure medication your doctor may prescribe.

Another factor I encourage patients to control is sleep apnea, which has been linked to high blood pressure and a host of other cardiovascular problems. Doctors traditionally have ordered a sleep study if they believe a patient has sleep apnea, and we offer those in our Sleep Center. But you also may be a good candidate for a home sleep test.

Related reading: Putting Sleep Apnea to Bed

Lastly, I encourage everyone to measure their blood pressure on a regular basis, especially outside the doctor’s office. The stress of a doctor’s visit can cause people’s blood pressure to read abnormally high, and it might be lower when you measure it at your local pharmacy or at home. The AHA recommends cuffs used on the biceps (upper arm) for more reliable readings, and the association provides an easy-to-use calculator for understanding what those numbers mean. This is especially important for older adults, who are particularly at risk for high blood pressure and who have had higher target numbers under past guidelines.

Related reading: How to monitor your blood pressure at home

I’m cautiously optimistic about what the new AHA/ACC blood pressure guidelines can do to help. But just as the guidelines didn’t suddenly create millions of people with high blood pressure, they can’t suddenly create new doctors, nurses and other healthcare professionals to solve the problem. That means it’s up to everyone to take responsibility for their blood pressure and risk factors.

Know your blood pressure numbers. Talk to your doctor about how to lower those numbers if they’re high. Take ownership of the situation, because you can have a real and measurable effect on your future health.

Request an appointment with one of our cardiologists if you need help lowering your blood pressure.

For many people, a blister or ingrown toenail would be a minor nuisance, painful for a few days, but then it would heal and disappear. But for people with diabetes, common foot problems can become serious problems. In severe cases, they can result in amputation.

This is because diabetes can damage your nerves and blood vessels. Nerve damage can cause you to lose feeling in your feet. You might not even feel a blister or cut until it turns into a diabetic foot ulcer. In fact, people with diabetes have a 15 percent chance of developing this type of open wound in their lifetime. And if there’s damage to your blood vessels, your feet don’t get enough blood and oxygen, making it more difficult for a wound to heal.

Nearly one in 10 D.C. residents has been diagnosed with diabetes. But having diabetes doesn’t have to mean you’ll develop foot problems, too. With prevention, best practices and early treatment, we often can resolve the problem before it becomes more serious.

If you or a loved one has diabetes, learn how foot problems can develop, how you can prevent them, and how we treat them.

How diabetic foot problems develop

High or unstable blood sugar levels, the hallmark of diabetes, can cause the arteriesto change, which can choke off or damage nerves. This is known as diabetic neuropathy, and it initially feels like a tingling or pins-and-needles sensation, then burning, and finally numbness and lack of feeling in the foot.

Diabetic foot ulcers are usually the result of minor trauma, such as a blister or callus. They often appear under bony pressure areas, such as the heel or bottom of the foot. Normally, a person who develops one of these on their foot would feel pain and walk differently or wear different shoes to avoid putting additional pressure or friction on it. But if you have diabetic neuropathy, you won’t feel that pain. You’ll keep wearing the same shoes and walking on it just as you always do, leading it to turn into a more serious wound.

Unfortunately, we often don’t see people with diabetic foot ulcers until the wound is advanced and an infection has begun to set in. They may not have felt the pain of the wound, but the infection is now making them sick, causing fever, chills and swelling or redness in the leg.

You may be able to avoid getting to this point by practicing some simple foot care techniques and seeing your doctor as soon as a problem develops.

How to keep your feet healthy when you have diabetes

We all have a tendency to ignore minor symptoms. No one wants to feel like they’re running to the doctor for something silly. But problems with your feet are never silly, especially if you have diabetes.

In a perfect scenario, diabetes patients will see a podiatrist once a year. During these exams, we’ll assess your blood flow and check for nerve damage. We’ll also evaluate your risk and develop a protection plan to prevent you from getting foot ulcers in the first place. Even if you’re not having problems, don’t skip that annual visit. I’d rather see you regularly and when you have a small wound than see you in the emergency room with a serious problem.

Request an appointment if you have diabetes and need an annual foot evaluation.

Along with an annual visit, follow these simple foot care tips:

• Inspect your feet every day. Check for cuts, sores, blisters, ingrown nails, redness or swelling. Use a mirror if you can’t see the bottom of your feet. Call your doctor if you find anything.
• Buy sensible shoes. Find shoes that fit your foot type and allow even distribution of foot pressure. Choose leather or canvas, which allows your feet to “breathe” better than plastic or other materials. Avoid pointed toes or high heels.
• Wear shoes and socks at all times, even in the house. This can help prevent injuries.
• Keep your skin moisturized. The soles of our feet contain more sweat glands per square centimeter than any other part of our body and excrete as much as half a pint of moisture each day. However, diabetics tend to sweat less in their feet, so they may experience more dry, cracking skin. This can be managed by applying moisturizer to your feet once or twice a day.
• Trim your toenails regularly. If you can’t reach your feet, ask a family member, friend or podiatrist to trim them for you.

How we treat diabetic foot problems

How we treat a diabetic foot depends on the severity of the wound. We also may recommend procedures to prevent further problems.

Treating minor foot ulcers

A minor foot ulcer, or one that is detected early, often can be taken care of with three simple steps:

• Debridement: This means we clean the wound and remove unhealthy tissue to allow healthy tissue to grow.
• Topical wound care: We’ll prescribe medication to keep the wound clean and stimulate healing.
• Offloading: This means we do something to take the pressure off the wound location, such as recommend crutches, a wheelchair, special shoes or a cast. It’s perhaps the most important step because once we take the pressure off, most wounds heal fairly quickly.

Limb salvage and amputation

Unfortunately, advanced diabetic foot ulcers can lead to below-knee amputation. We never want to see patients experience the loss of a body part. Through our limb salvage program, podiatric surgeons team up with plastic surgeons, vascular surgeons and experts in dermatology and infectious disease to save as much of the foot and leg as possible.

Read more: Saving limbs and improving lives: The Center for Limb Salvage

Our goal is always to prevent any type of amputation, but when necessary, we try to keep it as minimal as possible. By amputating only the toes or partial foot, you may be able to use a special shoe or insert to accommodate the loss. This is preferable to needing a prosthetic leg, which requires more work to stay active.

Preventive procedures

Along with treating diabetic foot conditions, there are other things we can do to prevent further problems. If you’ve had foot or vascular surgery to correct a problem, we’ll monitor you over the months and years after.

If we determine at some point down the road that there’s a new area of pressure developing, we may be able to correct it before it becomes a problem. Surgical examples include tendon lengthening or osteotomy, in which we cut or reshape a bone to relieve pressure.

We also may be able to avoid surgery with a non-invasive procedure. If, for example, you have hammertoe, in which the toe bends downward causing repeated ulcers on the tip of the toe, we could perform a percutaneous needle tenotomy. In this procedure, we use a needle to release part of the tendon from the bone.

Diabetes care doesn’t stop at controlling blood sugar. If you or a loved one has diabetes, get in the habit of practicing proper foot care, scheduling regular check-ups and seeking early treatment for problems to prevent serious diabetic foot complications, including amputation.

Most people are unfamiliar with the term “palliative care” and often confuse it with hospice. Palliative care and hospice services work with people who are dying. However, palliative care can be provided at any point during treatment of a serious illness.

Palliative care uses a holistic approach to ease suffering and promote quality of life for people with serious and chronic illnesses, such as heart disease, kidney disease and cancer. This can include addressing symptoms such as pain, nausea, lack of appetite or shortness of breath. Palliative care teams also help patients and loved ones process feelings associated with being ill, such as sadness, anger, frustration and worry. Another important part of the work involves making sure patients and families understand the nature and state of their illness, so they can make informed choices about care.

Our team at MedStar Washington Hospital Center includes doctors, nurse practitioners, pharmacists, a chaplain and social workers like me.

Palliative care is a relatively young field of medicine and we are still getting the message out about what we do. So we understand when providers, patients and families don’t know how we can help or are hesitant to consult us because they think we only work with patients who are dying. I’ve compiled a list of three common misconceptions about palliative care in the hopes that it will clear up misgivings people have about seeking our assistance and clarify how we help patients at all stages of serious illness.

1. Are you here because my loved one is dying?

This is a question we sometimes get when we meet with patients’ families. Sometimes patients refuse our services because they feel to do so means that they must be dying. When they do so, they may miss opportunities to receive valuable support.

An important aspect of what we do is to educate patients and families alike about how palliative care can help. We talk about the similarities and differences between hospice (end-of-life only) and palliative care (end-of-life and in conjunction with treatment).

Our team addresses physical, emotional and daily living concerns, as well as supports patients and families as they cope with medical issues. A serious illness can influence your physical and emotional wellbeing. Medical treatment may or may not cure your disease, and it can cause painful or uncomfortable side effects. Being in the hospital away from loved ones can be stressful and frightening.

Through symptom management, we help manage pain and other side effects of treatment and illness. Through counseling and listening, we help patients and loved ones consider care and treatment recommendations from their doctors and how that fits with their life goals.

2. You want to talk my loved one out of treatment.

Our work does not involve talking patients out of a particular course of treatment. It may involve raising questions about whether the treatment is likely to help in the way the patient hopes, and whether there might be other types of care that would be more beneficial.

Palliative care providers also help patients and loved ones translate confusing medical terminology into information they understand. This allows them to make informed decisions about their care. We recognize that facing serious illness can be stressful, and when people are stressed, it’s hard for them to absorb what they hear from doctors about their conditions. We sit with patients and loved ones, answer their questions and make sure everyone is on the same page.

Using language that patients and loved ones understand is important to our work. We do our best to avoid medical jargon, and we use reflective listening to ensure that patients and families have understood the information being presented. For example, we might ask, “What have you heard from the doctors?” Or, “What is your understanding of what’s just been said?”

In addition, we are inclined to use terms such as “death” and “dying,” rather than “transitioning” or “too sick to recover,” in an effort to make sure that patients and families are clear about the medical reality of an illness or condition.

3. You’re here to “withdraw care” because my doctor has given up on me.

We understand that it can be very hard for patients and loved ones to hear that their condition or illness is not curable and will continue to worsen despite medical intervention. These are some of the most frightening moments for a patient or family, and make them feel that the doctors have “given up.”

As palliative care clinicians, we are sensitive to these reactions. We tell patients and families that we never stop providing care, but when a cure is not possible, we may shift to a plan of care that is focused on making patients feel as good as possible for the remainder of their lives.

Growing our palliative care program

Our palliative care team was established in 2015, and has been growing steadily since. As of mid-2017, we consult with about 140 patients and families each month. We first partnered with the advanced heart failure program, where we saw patients who were at the beginning, middle or end of treatment. That collaboration has helped us construct a solid foundation for our expansion throughout the hospital.

We now work with cancer teams and hospitalists, and we’ve also branched into the intensive care units. These providers care for large volumes of patients, many of whom are seriously ill or injured. We help them collaborate with the family members to discuss and navigate care plans together.

As more providers learn about our services, the demand continues to grow. Despite this, we’re seeing fewer than five percent of the people who come into the hospital. That means there are many more people who could benefit from our services, and it strengthens our resolve to continue growing as a program. In addition, because our team will never be able to meet the need, an important part of our work involves educating other providers about how to integrate palliative care into their own practices. And as we grow, our mission remains constant: to help people with serious and chronic illnesses feel as good as possible for as long as possible.

For years, patients with angina (chest pain) caused by blockages in the arteries have been treated with medications. When medications alone aren’t enough, cardiologists have turned to stents—small mesh or plastic tubes inserted into an artery to keep it open. However, a study published in The Lancet suggests that stents are not superior in alleviating chest pain when compared to drugs, which has patients and doctors alike questioning whether stents have a role in treatment plans for ongoing chest pain.

It’s troubling that this study is receiving so much press, because the main takeaway is not new: For most patients, medical treatment will respond to some degree of chest pain relief, but the best drugs in the world will not open the blockages. Stents do.

Stents aren’t the best treatment for everyone. This is a commonly known fact—as with any condition, there is no catch-all treatment for angina, which is caused by fatty plaque buildup that narrows the arteries and blocks blood flow (stenosis or atherosclerosis). But for someone with a severely blocked artery, a stent can stop their chest pain faster and lower the risk of reducing blood supply to the heart muscle.

Though the study may cause some people to question the need for stenting, I don’t foresee it making waves in cardiology due to a few concerning elements.

Concerns with the stents study

Three key issues about this study jumped out at me:

• The participant pool: With just 200 patients, the data pool is too small for the findings to be considered statistically significant.
• The timeline: Data were collected over six weeks, which is too short a window to draw solid conclusions in terms of risk reduction.
• Baseline: Patients at baseline were not that sick at baseline. Patients at the beginning of the study had a good exercise capacity, so it was not that hard to treat them with medications to improve their symptoms.

A better study, published in 2007, was the COURAGE study. It compared PCI, or percutaneous coronary intervention (angioplasty with stenting) to optimal medical therapy. The study was conducted over nearly five years with more than 2,200 patients and provided long-term, statistically relevant information. The study found that treatment with stents did not reduce the risk of death or heart attacks at five years, and medication alone was about as effective as medication plus PCI for the initial treatment of stable coronary artery disease. This does not mean PCI doesn’t work. Stents do reduce chest pain and are usually prescribed at MedStar Heart & Vascular Institute for patients who do not respond initially to medical therapy or when medication alone isn’t enough to control the disease symptoms.

Who is a good candidate for stents?

Many cardiologists, myself included, prescribe medication alone before recommending stents for patients who have moderately blocked arteries, minimal chest pain and a low risk for a heart attack in the near future. Some patients can safely choose between medication alone and medication plus a stent, depending on their symptoms and how blocked the artery has become. Often, these patients will opt for the stent.

But an artery that is 80 percent or more blocked is like a ticking time bomb in terms of heart attack risk. When a patient’s artery is that blocked, I don’t feel comfortable risking their life on medication that might not be effective on its own. In those cases, I’ll recommend a stent to reduce their risk of a cardiac event. We need to remember that drugs do not open the blockage and drugs may have side effects.

While not everyone needs or should have a stent, the study in The Lancet does not indicate that the therapy is ineffective. Rather, it illustrates the need for doctors and patients to work together to determine the most effective therapy for their unique condition instead of applying generalized standards to everyone’s care. If you have a stent and are concerned, or if you’re thinking about getting one, call 703-552-4036  for an appointment with one of our MedStar Heart & Vascular Institute cardiologists.