When it comes to blood pressure targets, one size does not fit all…

March 13th, 2018

The Lown Institute Vignette Competition challenges medical students and trainees to shine a light on everyday overuse and underuse – common practices that either give patients unnecessary tests and procedures, or that fail to give patients necessary care. Sharing stories of the downstream consequences of overuse can be a powerful counterbalance to the ‘more is better’ culture and can help clinicians recognize and avoid overuse. 

This year, we received vignette submissions from students and trainees all over the country (and internationally!) on topics from avoiding polypharmacy to inappropriate stenting to navigating clinical guidelines. We’ll be highlighting the two competition winners and publishing some of the top vignettes on our blog.

We’re publishing the top vignettes on our website. Learn more about the competition and read all the vignettes here.

This week we have an interview with Dr. Deepa Ramadurai, a second-year internal medicine resident at the University of Colorado Medical School. She is the lead author of one of the winning vignettes titled, What should the target blood pressure be? Dr. David Tanaka, Associate Professor of Internal Medicine at UC, was a co-author.

You can read the winning vignette on our website, and read our interview with Dr. Ramadurai below!

Lown Institute: Tell me about the case that inspired the vignette.

Dr. Deepa Ramadurai: This patient transferred care to me as his primary care doctor in my first year of residency, so I know him very well. He had a history of hypertension, type 2 diabetes, and chronic kidney disease. But despite being 81 years old and having all these conditions, he was high-functioning and health-literate.

He came to the primary care clinic with light-headedness and fatigue, symptoms that were affecting his ability to enjoy activities he loved like caring for his grandchildren and golfing. 

Did you originally think the symptoms were effects of a medication?

When he told me his symptoms, one of the first things I thought of was that it was a side effect of hypertension drugs. It turns out that his anti-hypertensives had been increased a few months before to try and lower his blood pressure. When we gradually tapered and eventually discontinued two of these medications, his symptoms went away. 

There have been several changes in the guidelines for blood pressure over the past few years. As a young doctor, how do you navigate these changes, and the politics around them?

It’s not easy. Our attendings tell us, you always have to be critically thinking. You have to review literature when it comes out but don’t take anything as gospel. It’s easy to be swayed by the first thing you hear, but we have to look deeper. 

Most of these studies that inform guidelines don’t recruit participants that are representative of the population we care for, such as elderly patients and patients with diabetes. The most recent target, released by the ACA/AHA last year, recommends a more aggressive target for all patients, even though we don’t have strong evidence showing this benefits certain patients that are at higher risk for side effects.

So we have to take that information and take into account what happened in the past, think about what’s best for patients. If our patients are having side effects from medications, are we causing more harm than good?

This case is a success story in deprescribing, but we know there are often many challenges to deprescribing. Do you have any words of advice in facing these obstacles?

Yes, there are a lot of challenges making medication decisions with patients. I think the most important thing is informing patients of the risks and benefits of drugs and allowing them to take charge of their care. We may know details about the drugs, but patients already know what they consider a good quality of life and what’s their tolerance for risk.

These factors won’t be the same for every patient. We have to understand where they’re coming from – some patients may know others who had a bad experience with a certain drug, or they have family members who died from heart disease and want to take every precaution. Individualized care means we have to take side effects and quality of life into account, as well as the risk for cardiovascular events.