Cleveland_Clinic_Host: Hypertension affects one in four Americans and current national data estimate that approximately 72 million Americans have elevated blood pressure. Poorly controlled hypertension is a major cause of cardiovascular and kidney disease.
Clinical studies show that good control of blood pressure provides the most significant protection from cardiac and kidney disease. Studies show that a significant proportion of Americans with hypertension are unaware that they have it, so few patients receive treatment for hypertension. Furthermore, only a third (33%) of patients who are receiving treatment are controlled to recommended blood pressure goal.
The Center for Blood Pressure Disorders Program at Cleveland Clinic is internationally acclaimed, having been at the forefront of basic and clinical research and advances in hypertension management for more than 70 years. Our research scientists had identified some of the chemicals that lead to hypertension and successfully performed the initial clinical trials with medications that are now used in standard hypertension management.
The Center for Blood Pressure Disorders successfully runs one of the largest clinical programs for hypertension in the United States and treats difficult-to-control hypertension in patients referred from all over the U.S., Europe and Asia.
The Center for Blood Pressure Disorders is a comprehensive hypertension management program staffed by physicians who are internationally recognized experts in hypertension. Our team at the center includes nephrologists, internists, dedicated physician assistants and experienced clinical nurse practitioners with a focus on providing quality patient care for the optimal control of blood pressure in patients with hypertension.
Cleveland_Clinic_Host: Dr. Mohammed Rafey was appointed to the Department of Nephrology & Hypertension in 2007. Dr. Rafey earned his medical degree from Bangalore University Medical College in Bangalore, India. He completed an internal medicine internship and residency at North General Hospital in New York. He was also a hypertension fellow and a nephrology fellow at Mount Sinai Hospital in New York. He is board certified in Internal Medicine as well as Nephrology and is designated at a Hypertension Specialist by American Society of Hypertension.
He was awarded Masters in Clinical Research by New York University in 2007. He is a member of several professional societies, including the American Medical Association, American Society of Hypertension, American College of Physicians, American Society of Internal Medicine, American Society of Nephrology and the National Kidney Foundation. Dr. Rafey has published several papers and abstracts on topics related to kidney disease, and hypertension.
Cleveland_Clinic_Host: For additional information about Cleveland Clinic Glickman Urological and Kidney Institute and the Center for Blood Pressure Disorders, please visit us on our website clevelandclinic.org/ nephrology or call us locally 216.444.6771; toll free 800.223.2273 ext. 4-6771.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Mohammed Rafey, MD. We are thrilled to have Dr. Rafey here today for this chat. Let’s begin with some general questions about high blood pressure and how it affects your kidneys.
play422: What is your opinion on blood pressure that varies from systolic 190 to 140 throughout the day? It is higher mid-afternoon & in the morning.
Speaker_-_Dr__Mohammed_Rafey: Most of the time fluctuations are due to inadequate blood pressure medications. In some cases these fluctuations may be a result of secondary cause that could lead to hypertension where certain chemicals that maintain blood pressure in normal range are produced in an unregulated fashion, causing sudden elevation in blood pressure.
It is important that you be evaluated by someone who specializes in hypertension to thoroughly evaluate your condition. They will then be able to place you on proper therapy.
clanker: When I take my blood pressure at home, it’s fine. When I’m in the doctor’s office, it’s always higher. Is this normal?
Speaker_-_Dr__Mohammed_Rafey: You probably have a condition that is referred to as "White Coat Hypertension". This is seen in as many as 15% of the general population.
In your case, if you have hypertension and you are taking medications, please make sure that your physician is aware of your home blood pressure readings.
If you do not have hypertension, please be aware that the cut-off point for normal home blood pressure readings is an average of <135/85 mmHg. If your average home blood pressure readings are above this number, then you probably do have hypertension and need to be treated.
silverandgold: How many times a day should I check my blood pressure?
Speaker_-_Dr__Mohammed_Rafey: Based on the recent home blood pressure guidelines published in May 2008 by American Heart Association, American Hypertension Society and others, you should check your blood pressure twice a day for one week prior to visiting your physician. Overall, taking an average of 14 blood pressure readings appears to accurately reflect a normal blood pressure.
These guidelines recommend that the physicians should follow the average of these 14 readings instead of relying on office readings. These guidelines were published simultaneously in several journals last year.
The following is the summary of these guidelines on accurate measurement of blood pressure.
Technique of measuring blood pressure:
- You should not have indulged within the 30 minutes preceding the measurement in activities such as smoking, drinking coffee, or exercising.
- Please sit quietly and rest for 5 minutes in a chair with back rest, with the arm supported on a flat surface, such that the upper arm is supported at the level of the heart.
- It may be easiest to measure BP in the non-dominant arm.
- At least 2 and preferably 3 readings should be taken at 1 time. Please and the value for each reading written down in a diary.
- The interval between readings can be as little as 1 minute.
- Readings should routinely be taken first thing in the morning (preferably before you take medications) and at night before you go to bed (preferably before you take medications)
- The frequency of readings will be determined by your physician.
- Please do not measure blood pressure at times, such as when you think you are under stress or the BP is high.
- Please note that the variability of blood pressure readings is high and that individual high or low readings have little significance.
- Recent American Heart Association guidelines recommend that before your next physician office visit, you record at least 2 morning and 2 evening readings every day for 1 week but to discard the readings of the first day, which gives a total of 12 readings on which your physician can make decisions.
- Long-term observation:
- For stable normotensive (controlled) patients, patients should conduct HBPM a minimum of 1 week per quarter (an average of 12 morning and evening measurements under conditions described above)
runninglow: How low is too low for blood pressure before you start to worry?
Speaker_-_Dr__Mohammed_Rafey: Generally, blood pressure around systolic (the top number) 115 mmHg (of mercury) is a good number. If your blood pressure goes lower than this and you feel tired, dizzy getting out of a bed or chair, then you need to consult your physician to make sure that the medication is adjusted.
brandnew: BP registers around 130/70 on Diovan. Often BP drops to 105/50 – is this important and why?
Speaker_-_Dr__Mohammed_Rafey: You may have labile hypertension and need to be thoroughly evaluated by a hypertension specialist or nephrologist. Hypertension centers like ours have specialized testing equipment that may identify the cause of sudden drops in blood pressure.
Hypertension & Chronic Kidney Disease (CKD)
johnsonb: Are 3 kidney cysts considered chronic KD? What should be done? What symptoms should be watched for?
Speaker_-_Dr__Mohammed_Rafey: The number of cysts depending on age could define a person as having cystic disease. If you have cysts on the kidneys, you should see a kidney specialist (nephrologist) to confirm that you do not have cystic kidney disease.
Early in chronic kidney disease, the patient may not have any symptoms. As the disease advances, they may get short of breath; have a decreased appetite, uncontrolled hypertension and some of the chemicals in blood like potassium may become elevated and cause heart problems.
playboy: How is GFR measured? How is a GFR tested? Can dehydration and certain antibiotics cause CKD?
Speaker_-_Dr__Mohammed_Rafey: There are several ways to measure the GFR (glomerular filtration rate). The gold standard is Iothalamate GFR. Very few laboratories in the world perform this test. The Nephrology Department at Cleveland Clinic is one of the foremost centers for this test. Other laboratories around the world follow the standards set by us in measuring GFR.
There are other ways to estimate GFR which may not be as accurate but require serum creatinine, race, gender & age.
Severe dehydration & certain antibiotics can lead to acute renal failure. If a person has CKD they may have worsening of kidney function as a result of this acute renal failure. It is possible they may not fully recover to baseline kidney function.
Hypertension & Blood Pressure Monitors
play422: Good name for BP monitor?
Speaker_-_Dr__Mohammed_Rafey: The top four arm cuff style monitors as ranked by Consumer Reports are: Omron Women's Advanced Elite; CVS by Mirolife Deluxe Advanced; Omron HEM-711AC & ReliOn HEM-741CREL (Wal-Mart)
Make sure that the monitor is an arm cuff style monitor. Wrist and finger monitors are not accurate.
The prices range from $40 -$100 and they are available in all pharmacies. Make sure that you purchase a monitor with a proper cuff size to your arm circumference.
plankett: How accurate is a wrist monitor? Is one type of monitor more accurate than another? What is considered low blood pressure?
Speaker_-_Dr__Mohammed_Rafey: Wrist and finger blood pressure monitors are not reliable. The arm cuff style monitors mentioned earlier were tested by Consumer Reports (as reported in the September 2008 issue) and are considered more accurate than others.
Hypertension & Medication
pat224: When is the best time to take BP medication, in the morning or before going to bed?
Speaker_-_Dr__Mohammed_Rafey: Most of the medications now come in long acting forms. If you are taking them in the morning or night, it does not make a difference.
It is important to check your blood pressure in the night and the morning prior to taking medications, at least twice per week.
It is also important to discuss these results with the primary care physician so that the anti-hypertensive medications can be tailored based on home readings.
mattersnow: I don’t really notice a difference when I stop taking my blood pressure medications. What happens if I stop taking my pills?
Speaker_-_Dr__Mohammed_Rafey: Hypertension is a SILENT DISEASE. The majority of the patients who do not receive adequate treatment may experience the effects on the heart, kidney and brain a few years later in the form of heart attacks, heart failure, kidney failure and strokes.
Therefore, even if you do not experience symptoms, please make sure your blood pressure remains well controlled so that later complications can be prevented.
susieQ: My doctor wants to put me on three medications for my blood pressure. Is it necessary to take a combination of pills, or should I just be taking one medication?
Speaker_-_Dr__Mohammed_Rafey: In the past 30 years, major clinical trials in hypertension have demonstrated that to control blood pressure to goal at least 3-4 medications are required. Your physician is probably correct when he is recommending more medications. On your part, please make sure that you continue to follow healthy lifestyle which includes low salt in your diet (low sodium diet), as this may help in reducing the number of medications required to control your blood pressure.
eddieb: What specific (name) medication would you recommend for a man with high blood pressure who is also incontinent (from a retro public radical prostatectomy & radiation for prostate cancer)?
Speaker_-_Dr__Mohammed_Rafey: Most of the medications for hypertension would be effective in this case. It is important that you be followed by a urology expert to make sure that you are treated for incontinence.
We have a number of experts here at Cleveland Clinic Glickman Urological & Kidney Institute who have experience with treating this condition. For more information, you may visit our website at www.clevelandclinic.org/glickman
punnd: Many foods add potassium while lowering sodium – how does this affect medications such as metaformin & ACE inhibitors?
Speaker_-_Dr__Mohammed_Rafey: If you have kidney disease you must be careful about potassium intake as it can adversely affect the heart. If you are taking an ACE inhibitor, you need to be monitored closely for potassium levels.
platinum: I have been taking Lisinopril 10mg daily for 4 months. Side effect is a cough which keeps me up at night. What alternative medicine would you recommend? My doctor prescribes this on the basis of one elevated BP. Do you feel this was appropriate treatment on the basis of one elevated BP reading?
Speaker_-_Dr__Mohammed_Rafey: To begin a medication for hypertension, you need to have documented repeated elevated readings on different occasions. In addition, before starting medications for hypertension, you should be evaluated for modifiable factors such as excess salt intake, smoking, obesity & a sedentary lifestyle.
If your blood pressure readings are not too high, then a healthy lifestyle intervention should be the initial therapy. But, if your blood pressure is high to begin with, then starting medications in addition to healthy lifestyle interventions is recommended. Cough is a fairly common side effect of Lisinopril. If it is severe, you should discuss it with your physician and try other medications that are equally good without the side effect of cough.
scary13: I was on anti-arrhythmia drugs and anti-hypertension drugs. My blood pressure was 99/50, is this ok?
Speaker_-_Dr__Mohammed_Rafey: It all depends on any associated symptoms like dizziness when getting out of bed or up from a chair or a tired feeling in which case your physician may need to readjust your medication.
gettingold: Do hypertension drugs cause joint pain?
Speaker_-_Dr__Mohammed_Rafey: Water pills, which are part of hypertension medication, may worsen gout and lead to joint pain. Therefore, they should be avoided in patients who have gout.
clinker: Being on an aspirin regimen for heart disease – can this effect my kidneys? What questions should I ask my primary MD?
Speaker_-_Dr__Mohammed_Rafey: Aspirin therapy is relatively safe in those individuals with CKD.
If you have kidney disease you should avoid medications like Motrin ®, Advil ® & Aleve ®. Tylenol® is considered to be safer for the kidney point of view. You should make sure that all of your medications are dosed to your kidney function level. Some medications are exclusively excreted in the urine by the kidneys. In those individuals with kidney failure, the levels of these medications will get elevated and cause toxicity.
Hypertension & Sodium (Salt)
nattieb: Is Salt Sense® brand a good salt substitute?
Speaker_-_Dr__Mohammed_Rafey: Generally, most of the salt substitutes are high in potassium. Therefore, if you have kidney disease, you need to also be careful about the potassium and speak with your kidney specialist.
newtonm: How does plain soda seltzer affect your kidneys? How about other sodas or carbonated drinks?
Speaker_-_Dr__Mohammed_Rafey: Plain seltzer soda should not affect your kidney. Most other sodas have high salt content. Drinking sodas will increase your salt (sodium) intake. If you have hypertension or kidney disease, your recommended salt intake is <2g (grams) over 24 hrs. Therefore, you need to be careful not to exceed that limit.
If you drink a soda, look at the sodium content per servings PLUS the number of servings listed for the entire can or bottle.
Hypertension & Other Conditions
jaded: I have diabetes. Is there a separate set of guidelines for where my blood pressure should be?
Speaker_-_Dr__Mohammed_Rafey: If you have diabetes, your blood pressure should be maintained less than 130/80 mmHg. This is different from the general population where the goal is less than 140/90 mmHg.
nellmell: How is Microalbunira diagnosed?
Speaker_-_Dr__Mohammed_Rafey: A simple urine test in your physician’s office will help in knowing if you have microalbuminuria.
Albumin is a protein that should not be present in the urine. Microalbuminuria occurs when there is an injury to the kidneys from a disease like diabetes.
newtonm: How does Parkinson’s affect your kidneys?
Speaker_-_Dr__Mohammed_Rafey: Parkinson's disease does not directly affect kidney disease. It is a neurological disorder.
handyman: What does blood in the urine mean?
Speaker_-_Dr__Mohammed_Rafey: Normally, blood should not be present in the urine. Blood may present in urine if there is a urinary tract infection, kidney stones or several kidney diseases may also present with blood in the urine (hematuria.)
In older individuals, one of the important causes for blood in the urine is cancer. It is important to see a kidney specialist to make sure the patient is thoroughly evaluated for the above mentioned diseases.
handyman: How can you control anemia? (male, 75 yrs old)
Speaker_-_Dr__Mohammed_Rafey: The normal kidneys produce a chemical called erythropoietin that helps the body to produce adequate red blood cells. With kidney disease, there is a reduction in erythropoietin production which leads to anemia. This can be treated by regular injection of epoetin alfa which has similar effects as erythropoietin.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Mohammed Rafey is now over. Thank you again Dr. Rafey, for taking the time to answer our questions today.
Speaker_-_Dr__Mohammed_Rafey: It was my pleasure.
- For additional information about Cleveland Clinic Glickman Urological and Kidney Institute and the Center for Blood Pressure Disorders, please visit us on our website clevelandclinic.org/nephrology or call us locally 216.444.6771; toll free 800.223.2273 ext 4-6771.
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This chat occured on March 16, 2009.
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