The Peter Attia Drive - #258 - AMA #48： Blood pressure—how to measure, manage, and treat high blood pressure

00:00:00.000 hey everyone welcome to a sneak peek ask me anything or ama episode of the drive podcast

00:00:16.400 i'm your host peter atia at the end of this short episode i'll explain how you can access

00:00:20.840 the ama episodes in full along with a ton of other membership benefits we've created

00:00:25.460 or you can learn more now by going to peter atia md.com forward slash subscribe so without further

00:00:32.140 delay here's today's sneak peek of the ask me anything episode welcome to ask me anything

00:00:40.720 episode 48 i'm once again joined by an extensive in today's episode we will focus on one topic and

00:00:46.060 that topic is blood pressure if you listen to this podcast you have heard me talk quite a bit

00:00:50.980 about cardiovascular disease and usually when i'm doing so i'm doing so in the context of talking

00:00:56.340 about prevention vis-a-vis apo b and lipoprotein manipulation but you've probably also heard me

00:01:02.800 talk about blood pressure because high blood pressure along with high apo b and smoking

00:01:07.600 is one of the three leading causes of atherosclerosis what's perhaps most insidious is that many of you

00:01:14.320 listening to this don't actually realize you have high blood pressure and we therefore kind of begin

00:01:19.780 the discussion by talking about what high blood pressure is how common it is and how you go about

00:01:24.880 measuring it it turns out that the measurement you get in the doctor's office is probably not that

00:01:29.520 accurate for multiple reasons which i go into in this episode so what's most important for anybody who

00:01:34.420 really wants to get under the hood of their own blood pressure is that you get a cuff and you figure

00:01:38.000 out how to do this at home now this can be done with an automated cuff or a manual cuff and we'll talk

00:01:42.140 about both of those but it's really the way in which you go about doing this and the repeatability

00:01:47.100 of the measurements and the time you take to do it that determines whether or not you can make the

00:01:51.540 diagnosis of high blood pressure we then focus on what to do about it and this is where i think the

00:01:57.640 most important part of the discussion takes place how much does weight loss how much does exercise how

00:02:02.320 much does nutrition how much do any of these things tweak blood pressure and if they still fail to do so

00:02:08.360 what are the pharmacologic choices you have and how should you be thinking about them this is an

00:02:13.360 extremely important topic not only for cardiovascular disease but also for dementia and when you think

00:02:19.480 about the prevalence of those two conditions i think you'll understand why knowing your blood

00:02:23.920 pressure is simply a non-negotiable and if your blood pressure is elevated it has to be addressed

00:02:28.900 one last thing to note is that this is an audio only ama there's no video for it however the show notes

00:02:34.980 will include any figures and studies that i've discussed here and then some so without further delay i hope

00:02:41.420 you enjoy ama number 48 peter welcome to another ama how you doing very well thank you awesome you

00:02:53.660 know before we get started on this one some of the people who listened to one or two amas ago when we

00:02:59.300 were going over your dexter results we were talking and telling the story about reese's pieces and how

00:03:04.620 you had never heard of them and we did a call out to say hey if anyone else has never heard of them

00:03:10.100 please reach out and you will be pleased to know we probably had about 30 to 40 people who are in

00:03:16.700 the same boat as you and had no idea what reese's pieces are so you are not the only one

00:03:21.500 not the only one on this planet not the only one i mean again 30 to 40 compared to our listenership is not

00:03:29.840 a good percentage so you're definitely in the minority but yeah shout out to everyone who reached out and

00:03:35.920 the person who was the first to reach out we have something special going in the mail for them and

00:03:41.040 ironically they reached out to us before we even sent the email saying the podcast was live so

00:03:47.140 to say they are an active listener would be an understatement so shout out to that person they

00:03:52.720 know who they are today's ama is going to be on one subject but one important subject which is blood

00:04:00.420 pressure and all things blood pressure and people who have listened to the podcast will have heard

00:04:06.460 us talk about blood pressure before most recently the episode we released with you and ethan weiss

00:04:11.940 ethan coming back for the second time you both spoke a lot about blood pressure and as you said in that

00:04:18.020 one if you look at cardiovascular disease three main risk factors for cardiovascular disease are going

00:04:24.020 to be smoking which we don't necessarily talk a lot about because as you've said before we're kind

00:04:29.280 of the impression if you listen to this podcast and you still smoke you probably should know you

00:04:33.380 shouldn't so that's nothing really we need to say there the second is apob which clearly is a topic

00:04:39.860 that we cover a lot and has been covered and then the third is blood pressure and we kind of realized

00:04:45.140 we hadn't done as much of a deep dive on blood pressure and we get a lot of questions so we compiled all

00:04:51.140 those and in today's ama we're kind of really going to talk about a few different sections multiple

00:04:56.840 questions in each section which is what is high blood pressure low blood pressure why should someone

00:05:02.560 care you know what does it affect because it goes beyond just the risk of cardiovascular disease

00:05:08.080 as well as you know how do you know where you're at this is one where you know unlike apob you can't

00:05:13.880 give yourself an at-home blood test but you can check your blood pressure and you can understand how

00:05:19.980 it changes throughout the day what the different definitions mean and then we'll end with

00:05:24.800 really the main focus which is okay what can you do to control your blood pressure you know what

00:05:30.400 are the lifestyle factors that you can do to lower it how well do those work if you have to look to

00:05:36.380 use medications what are the most common drugs what do we know about them are there factors that

00:05:41.700 would make one quote unquote better than the other so that's really going to be our focus for this

00:05:47.520 ama and just given the importance of the topic and how many questions that we get on it and what we

00:05:52.960 compiled we figured we would just focus the entire thing on it so before we start rolling on it is

00:05:59.960 there anything else that you want to add to set the stage no i think that's a good way to land i think

00:06:05.100 presumably most people who listen to this podcast have had their blood pressure measured at least some

00:06:10.940 point in their life obviously when you go to a doctor's office even if you're going for anything

00:06:15.740 random they'll typically check it a lot of people will have at-home cuffs that they may be checking

00:06:20.660 so i think a lot of people have had their blood pressure measured but i think it might be helpful

00:06:26.160 to know like what does a blood pressure measurement actually mean like what is it actually doing and

00:06:31.620 measuring to understand that you have to sort of think about what the heart is doing so the heart is

00:06:37.700 pumping obviously that's what you feel if you put your hand on your chest and what you're feeling

00:06:43.780 pumping is kind of the pulsatile sensation of the pressure difference in the arteries as the heart

00:06:52.420 contracts so just remember there's two phases of the cardiac contraction the first is called systole

00:06:59.580 and systole is when the ventricles are contracting the ventricles are the larger chambers the left one

00:07:07.060 being the muscular one because it has to pump the blood against the systemic resistance of the whole

00:07:14.300 body and it's the one that's responsible for getting blood out to the body we're going to talk

00:07:18.620 about that pressure today so we're going to talk about the systemic circulation what we're not going

00:07:23.780 to talk about today is a different blood pressure which is pulmonary blood pressure it turns out that

00:07:28.980 when people hear like 120 over 80 is my blood pressure that is talking about the blood pressure in

00:07:35.060 their circulatory system of the periphery but if you wanted to know the blood pressure in your lungs

00:07:41.800 which is controlled by the right ventricle those would be pulmonary pressures and those would be

00:07:46.080 significantly lower again we won't talk about those just park that over the side so when your left

00:07:51.880 ventricle contracts you're in systole blood is leaving the heart through the aortic valve goes out the

00:07:59.340 aorta at the ascending part of the aorta and then it immediately just starts moving to the rest of the

00:08:04.220 body right so at the arch of the aorta it jumps off three little freeways if you will right so you have

00:08:10.760 the common carotid subclavian and nominate arteries and then it kind of goes over the arch comes down

00:08:16.680 and then it goes out to the rest of the body and this is happening really quickly even if your heart

00:08:20.340 is beating as slow as one beat per second or 60 beats per minute you know think about the rate at

00:08:26.160 which that happens i think everybody kind of understands that part so there's a pressure in the

00:08:30.440 artery that is experienced by literally the blood pushing against the walls of the artery during

00:08:38.000 that phase and that's obviously the bigger number but it's important to remember that there is a second

00:08:43.760 equally important phase of the heart which is the relaxation of the ventricle and that's how they

00:08:49.340 fill so that's called diastole so after the heart squeezes and blood leaves the heart the heart has to

00:08:56.460 relax to have blood come back into the ventricles through the atria by the way it's also important

00:09:04.040 to know that this is when the heart itself receives its blood supply so the heart receives its blood

00:09:09.600 supply during diastole whereas all the other organs are receiving their blood supply during systole and

00:09:16.040 even though the pressure in the arteries is lower during diastole which i think would be intuitive given

00:09:22.500 what i just described it's still more than zero there is still a tonic amount of pressure within

00:09:28.920 the artery wall so when you have your blood pressure checked and it spits out two numbers

00:09:33.480 let's just say it's 125 over 79 what that means is when your heart is doing the squeeze and there's a

00:09:42.540 greater force as blood is leaving the aorta the left ventricle via the aorta it's whatever number i said

00:09:48.760 i've already forgotten i think 124 millimeters of mercury is the pressure and when that ventricle

00:09:54.800 relaxes and begins to fill through the left atrium the pressure drops to whatever else i said i forget

00:10:02.420 i said 79 millimeters per mercury so millimeters of mercury is i'm not going to get into what those

00:10:07.800 numbers mean and how you do that but you know if anybody thinks back to like a chemistry class you can

00:10:11.880 have a manometer that basically determines pressure by how many millimeters it can raise mercury so the

00:10:18.320 higher that number the higher the pressure does it ever blow your mind when you think about what the

00:10:22.420 human body does on a daily basis that we don't even think about or see like as you were saying even if

00:10:28.220 it's 60 beats per minute which is one beat per second like it's just constantly doing it you've seen

00:10:33.900 bodies cut open from your time in surgery before so it's like you see that more but does it ever just

00:10:38.920 kind of blow your mind how we're able to function and we just don't even think about those little

00:10:43.220 things every day it still does and it's been i think back to my very first time in the anatomy lab

00:10:49.100 or my very very first time being in surgery and it's no less amazing to me today than it was then

00:10:54.980 i simply can't believe it the next question then naturally is what does it mean to have high blood

00:11:01.220 pressure because i think this is something that it seems like in the past five or ten years the

00:11:06.600 definitions may be changed and there's a few different types of definitions so i think it'd be helpful

00:11:11.360 to set the stage early of you know when we say high blood pressure what are the two numbers that

00:11:16.800 we're referring to so people can kind of as they look back at their own blood pressure results can

00:11:21.740 kind of know where they fit well as you said this has changed a little bit so prior to 2017 we had a

00:11:28.680 little bit more leeway in the system but the current updates which have been in place for about six years

00:11:34.080 and which were updated after the sprint trial in 2015 a trial that i'll explain in a moment

00:11:40.540 leave us where we are today where we are today is normal blood pressure is defined as having a

00:11:47.380 systolic blood pressure at or below 120 or technically below 120 millimeters of mercury over something less

00:11:56.020 than 80 millimeters of mercury so if blood pressure is both less systolicly than 120 and diastolicly 80

00:12:03.700 that's considered normal so 119 over 79 normal 121 over 79 technically not normal elevated is when

00:12:15.920 the systolic pressure is between 120 and 129 but the diastolic pressure remains less than 80 so we talk about

00:12:27.260 elevated blood pressure as a slight elevation in the systolic but not the diastolic pressure and then we get into

00:12:33.300 two stages of hypertension the first stage is when systolic blood pressure is 130 so we're between

00:12:42.880 130 and 139 or diastolic blood pressure is between 80 and 89 so does that make sense because you'll

00:12:49.820 notice there's a bit of a gap in there right so you could be 120 over 83 and now you're at stage one

00:12:57.100 even though your systolic is normal and then stage two hypertension is when either systolic exceeds 140

00:13:04.940 or diastolic exceeds 90 so again in summary normal blood pressure is less than 120 and less than 80

00:13:14.180 elevated is 120 to 129 over less than 80 stage one hypertension is 130 to 139 or 80 to 89 stage two is

00:13:26.420 greater than 140 or greater than 90 okay so where do these numbers come from because these aren't just

00:13:32.420 arbitrary right these are sort of based on something important and that something important is called

00:13:37.040 the sprint trial this is a trial i think it was published in 2015 it was like i think it was like

00:13:41.940 about a year or two before these guidelines were shifted and the purpose of this trial was really to

00:13:47.380 ask the question what is the benefit of for lack of a better word aggressive blood pressure control

00:13:54.120 so the study looked at just under 10 000 people who had a systolic blood pressure of 130 or greater

00:14:03.020 who were also at advanced cardiovascular risk but who did not have type 2 diabetes and the reason

00:14:08.220 for that patient selection is you wanted a group of people who were at high enough risk for ascbd that

00:14:13.320 you could start to see events in a relatively confined period of time you have to remember this is always the

00:14:18.700 goal of clinical trials even when you're doing large double-blinded trials you want to be able to have

00:14:24.540 enough events in the trial that you don't have to run the trial for 10 years so you've got a high risk

00:14:29.820 population though it's worth noting they don't have type 2 diabetes and they have to have a systolic blood

00:14:35.600 pressure over 130 so they were randomized into two groups the first group which we'll call the intensive

00:14:44.200 treatment was treated to a systolic blood pressure of less than 120 and the standard treatment were

00:14:52.780 treated to a blood pressure of less than 140 makes sense so one group is kind of being treated to not

00:15:00.100 be over 140 the other group was really being pushed down to 120 so at coming in the average blood pressure

00:15:06.320 of all comers was about 140 over 78 now ethan and i talked about this a little bit but just in case folks

00:15:13.020 didn't hear that podcast or just in case people need a little bit of a refresher is this study did a

00:15:18.500 pretty rigorous job of assessing blood pressure so they used an office visit where blood pressure was

00:15:26.200 measured three times using the following protocol so the patient would sit down for five minutes doing

00:15:33.420 nothing not talking not not doing anything their back is supported their legs aren't crossed after five

00:15:39.700 minutes blood pressure was taken with an automated cuff this was sized properly and used in perfect correct way

00:15:47.100 which we'll talk about in a little while later in this podcast they would take that reading five minutes later

00:15:51.900 they would repeat that and five minutes later they would repeat that so the blood pressure for that visit

00:15:59.020 was deemed as the average of all three of those readings this is a lengthy procedure right it took 15 minutes to get

00:16:06.960 those three readings and to determine their blood pressure but that number served as your blood pressure

00:16:12.440 so if you were on day one you were 137 over 81 and you had that reading well if you were in the

00:16:21.380 business as usual group or the placebo group or not the placebo group but the standard treatment group

00:16:25.840 they would make no adjustment to your medication if you were already on medication if you were not on

00:16:30.020 medication they wouldn't add medication but if you were on the intensive group they would treat you

00:16:35.080 so at one year after one year of this the average systolic blood pressure in the intervention group

00:16:42.580 the high intensity group was 121.4 millimeters of mercury in the standard group it was 136.2

00:16:49.480 this intervention was stopped early i forget how long they wanted to run this study for i think

00:16:56.000 they were looking to do this for five years i could be mistaken on that but regardless at just a little

00:17:01.200 over three years in median follow-up the study was halted and this is not uncommon in hard outcome

00:17:08.160 studies we see this quite often where the benefits in one of the arms is so much greater that it becomes

00:17:16.040 unethical to continue the study and that was the case here so the primary outcome which was a composite

00:17:22.940 outcome of reduction in cardiovascular mortality was significant it was about a 25 relative reduction so

00:17:33.240 the hazard ratio is 0.075 and the absolute risk difference was about 0.54 over the course of one year

00:17:44.780 that's actually pretty significant by the way it doesn't sound like a lot right 25 reduction a little

00:17:50.280 over half a percent absolute risk reduction but you have to remember that's a single year reduction in

00:17:55.640 risk that's quite significant when you consider that blood pressure just like lipids are compounding

00:18:01.560 risk factors at the three-year mark the total event rate was i believe in an unadjusted way i want to

00:18:11.720 say 1.6 percent lower in the intensive group and again this was for this primary outcome so which is

00:18:20.780 a composite outcome it was kind of a mace-like output so it was myocardial infarction non-myocardial

00:18:26.240 infarction acute coronary syndrome stroke acute heart failure and cardiovascular death what i found pretty

00:18:31.980 interesting about this study was that it also saw a benefit in all-cause mortality i would not have

00:18:39.260 necessarily expected this so i don't think it's that surprising that they saw a benefit in the

00:18:44.200 primary composite outcome which really all pertained to heart attacks and strokes it's maybe a little

00:18:49.400 surprising how big the benefit was in such a short period of time but what i think really caught people

00:18:54.460 off guard in a pleasant way was that all-cause mortality was also reduced 27 percent and it was like a

00:19:03.160 one point two percent absolute risk reduction this is pretty interesting it's not that you wouldn't

00:19:10.240 expect the death rate to be improved from a cardiovascular disease standpoint which it was

00:19:15.680 right it was a 2x reduction in cardiovascular disease death specifically but it's that you would

00:19:22.420 see also a reduction in all sorts of other types of death and this was seen in you know not surprisingly

00:19:28.780 perhaps kidney disease amazingly accidental death suicide homicide was significantly less so again

00:19:36.220 it's possible that maybe a larger study that wouldn't pan out maybe a hundred thousand people

00:19:41.020 you wouldn't have seen that but nevertheless this was about as dispositive a study as you're going to see

00:19:47.060 demonstrating the efficacy of aggressive blood pressure lowering and again the takeaway is even over a

00:19:53.380 relatively short period of time aggressive blood pressure management to a systolic pressure less than 120

00:19:59.060 compared to standard of care which we used to think was you know kind of 130 to 140 is tolerable left very

00:20:05.160 little ambiguity about the importance of that kind of recommendation to double click on something you said

00:20:10.380 because i think it is important and we've talked a little bit about it when you've talked about

00:20:14.680 statin therapy before which is the percentage that we saw in this trial over the one two and three

00:20:23.160 year mark you kind of mentioned that that can compound over a lifetime and so if you saw that

00:20:29.200 much of a difference in a short period of time it only gives you more confidence because the reality

00:20:35.160 is if someone goes with high blood pressure for most of their life untreated you're not looking at only

00:20:40.180 three years you could be looking at from 35 to 75 you could be looking at 40 years and obviously you can't

00:20:46.240 run a 40 year trial and i know you've talked about this before with statins when i can't remember which

00:20:52.100 study came out and i remember you saying the stock went down because people thought the result would

00:20:59.080 have been even more positive but you were kind of talking about if you look at how short that period was

00:21:04.020 and how long people live with high apob or high blood pressure even though this was a short period it still

00:21:11.060 gives you even more confidence that this is something that people should take seriously even at a young age

00:21:16.940 even if it's not going to kill them in a year yeah compounding is insanely powerful when it comes to

00:21:22.160 this type of biology whether it be smoking apob or blood pressure when we're dealing with endothelial

00:21:29.320 exposure again let's just take a step back and talk about why these things pose such a risk

00:21:33.620 ascvd cerebrovascular disease you know you can think of them as blood vessel diseases and elevated blood

00:21:41.040 pressure hypertension is a mechanical disruption to the endothelium smoking is a chemical disruption

00:21:47.560 to the endothelium and of course apob is the concentration of the lipoprotein that itself

00:21:54.500 goes through that disrupted endothelium and then causes the pathologic sequence of events that we're

00:21:59.660 very familiar with so it's not surprising that these are all area under the curve problems when talking

00:22:06.680 about normal blood pressure elevated blood pressure high blood pressure in the past when we've talked

00:22:11.880 about hba1c you've kind of mentioned before you know like pre-diabetes is about 5.7 percent i think

00:22:19.300 diabetes is about 6.5 percent and you've said like hey if you're at 6.4 percent and so you're not

00:22:25.980 technically at having the diabetes level does that mean like you should celebrate it's like no the

00:22:31.100 difference between those is so small that you want to take care of it earlier and so you've always kind

00:22:35.760 of talked about one that's kind of why you don't like the a1c metric and you look at other things

00:22:40.720 but two you always kind of want lower is better when it comes to blood pressure if someone has let's

00:22:47.860 say 119 over 78 so they're in the normal category but there may be kind of creeping to the elevated

00:22:55.800 category if that was your patient would you be worried about that or are you happy with any blood

00:23:01.700 pressure in the normal category thank you for listening to today's sneak peek ama episode of

00:23:07.520 the drive if you're interested in hearing the complete version of this ama you'll want to become

00:23:12.120 a member we created the membership program to bring you more in-depth exclusive content without relying

00:23:18.100 on paid ads membership benefits are many and beyond the complete episodes of the ama each month they

00:23:24.620 include the following ridiculously comprehensive podcast show notes that detail every topic paper

00:23:30.660 person and thing we discuss on each episode of the drive access to our private podcast feed the

00:23:37.140 qualies which were a super short podcast typically less than five minutes released every tuesday

00:23:42.420 through friday which highlight the best questions topics and tactics discussed on previous episodes of

00:23:47.680 the drive this is particularly important for those of you who haven't heard all of the back episodes

00:23:53.340 becomes a great way to go back and filter and decide which ones you want to listen to in detail

00:23:57.980 really steep discount codes for products i use and believe in but for which i don't get paid to

00:24:03.380 endorse and benefits that we continue to add over time if you want to learn more and access these

00:24:09.060 member-only benefits head over to peter atia md.com forward slash subscribe lastly if you're already a

00:24:16.520 member but you're hearing this it means you haven't downloaded our member-only podcast feed where you can get

00:24:21.240 the full access to the ama and you don't have to listen to this you can download that at peter

00:24:26.640 atia md.com forward slash members you can find me on twitter instagram and facebook all with the id

00:24:34.580 peter atia md you can also leave us a review on apple podcast or whatever podcast player you listen on

00:24:41.320 this podcast is for general informational purposes only and does not constitute the practice of medicine

00:24:46.820 nursing or other professional health care services including the giving of medical advice

00:24:52.140 no doctor patient relationship is formed the use of this information and the materials linked to this

00:24:57.880 podcast is at the user's own risk the content on this podcast is not intended to be a substitute for

00:25:04.300 professional medical advice diagnosis or treatment users should not disregard or delay in obtaining

00:25:11.340 medical advice from any medical condition they have and they should seek the assistance of their

00:25:16.480 healthcare professionals for any such conditions finally i take conflicts of interest very seriously

00:25:22.680 for all of my disclosures and the companies i invest in or advise please visit peter atia md.com

00:25:29.940 forward slash about where i keep an up-to-date and active list of such companies

00:25:46.480 um

00:26:03.720 you

00:26:04.040 you

00:26:04.440 you

00:26:04.980 you

00:26:05.440 you

The Peter Attia Drive - June 12, 2023

#258 - AMA #48： Blood pressure—how to measure, manage, and treat high blood pressure

Episode Stats

Length

Words per Minute

Word Count

Sentence Count

Summary

Transcript