High Blood Pressure: What You Need to Know About Medications

Podcast Transcript

Speaker 1:  Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart and Vascular Institute. These podcasts will help you learn more about your heart, thoracic, and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy.

Speaker 2:  I'm here this morning with Dr. Luke Laffin, who's a staff cardiologist in our section of Preventive Cardiology, and he's also a clinical specialist in hypertension. And he's here to talk to us about high blood pressure and control of high blood pressure, and a lot of questions that patients ask about high blood pressure. Dr. Laffin, the CDC says that one in three people in the United States have high blood pressure. It's just a large population of patients. So the first question that I have is about medications. That seems to be the biggest question as a nurse that I get, how do you even choose medications? How do you start a patient on medication? When do you start a patient on medications?

Dr. Luke Laffin: So generally there's three classes of medications that are our first line treatment for hypertension. The guidelines for when to start medications on patients have been changing recently, but we tend to say that if they've had elevated blood pressures, two or more visits in the clinic, then we should consider, one, lifestyle modification, but then, based on the level, potential addition of medical therapies.

Dr. Luke Laffin: So the three classes of medications that we prescribe as first line therapy are as follows. The first one is renin-angiotensin system blockers. So they are, essentially what they do is they block this hormone system that regulates blood pressure and fluid within the body. Another class of medicines that people are often on are diuretics, the water pills, and they help get rid of sodium and water via the urine. And then finally there's another class of medicines called calcium channel blockers. And how they work is, they relax the blood vessels within the body to provide lower blood pressures as well.

Dr. Luke Laffin: Now there's other medication classes. There's numerous other ones that we can use to treat hypertension. And in certain patient populations they've been maybe more efficacious. For example, patients with certain cardiovascular disease, recent heart attacks, et cetera, they may be prescribed a Beta blocker, which is another class of medicine. So there's many different choices, but those are the first line therapies.

Speaker 2:          And how come some patients are only on one medication, sometimes patients are on two medications, how do you make that choice for a patient?

Dr. Luke Laffin: So that's generally based on how much blood pressure lowering we need. There's good data that being on two medications that have some synergy, so they work together at effectively lowering blood pressure, at moderate doses, can be better than just a maximum dose of one medication. Right now the guidelines suggest that anyone that has multiple blood pressures in the office that are higher than 140 over 90 generally should be started on combination therapy. So two doses, maybe not at maximum strength, but two different medications.

Speaker 2:          So are there side effects that people should think about or watch out for?

Dr. Luke Laffin: Yeah, definitely there is. The nice thing about blood pressure medicines is that they've been around for a while and are well studied. So these side effects are predictable. The one complaint or the one comment that oftentimes physicians hear is that, "Oh, I'm tired when I started taking my blood pressure medicines," especially if you started at a higher blood pressure and we're significantly lowering it. That can be classified as a side effect, but that's just the body adjusting to the lower blood pressures. In terms of specific medication classes and their side effects, oftentimes when we begin a diuretic, especially the stronger diuretics, people can complain of cramping in their legs. This generally tends to last for two to three days. It's oftentimes attributed to low potassium, although it's not always low potassium, it's more likely to be the fluid shifts, the body getting rid of extra water and salt. And so we can see that. But the nice thing that we told them is that after two or three days, especially if you're on a low salt diet, this cramping tends to go away.

Dr. Luke Laffin: Other medicines that commonly have predictable side effects include calcium channel blockers. The most commonly used is one called amlodipine or the brand name is Norvasc. About, on the five milligram dose, which is a moderate dose, about 30 percent of people experience some degree of lower extremity swelling. So a little bit of puffiness in their ankles or feet. It's not dangerous, it's just cosmetically, some people don't like it. And then at the 10 milligram dose, about a little bit more than half of people actually have this side effect. It's important to remember that that's how the medicine works. It's a vasodilator, it increases the size of the blood vessels. So you are going to have some degree of swelling. But as I said, it's not dangerous.

Speaker 2:          So are there any of those side effects that they should definitely call their doctor for, or are these things that just kind of go away with time?

Dr. Luke Laffin: Well, I think coming back to what I said about being tired, you don't want to be so that you're so tired that you can't get out of bed. That just suggests that perhaps your doctor overshot in terms of how much blood pressure medicine that we're giving. We don't want people walking around with blood pressures under 100 millimeters of mercury for their systolic. Similarly, certain medicines, especially in the class of medicines called ACE inhibitors, so the most commonly used is Lisinopril, they can have effects such as swelling of the lips, of the airway. Those are side effects that you need to alert your doctor promptly and if it's significant, then indeed you need to go the emergency department.

Speaker 2:          Do you ever send patients home with ... To do home blood pressure monitoring? Is that something that would help with the medications too?

Dr. Luke Laffin: Yes, I think definitely. It's really a cornerstone of my practice, which predominantly involves patients that have resistant hypertension. So blood pressure not controlled on three different medicines. And we do it very commonly, and that's actually one of the emphases of the newer 2017 hypertension guidelines by the American Heart Association and American College of Cardiology. And what we recommend is, when we've changed antihypertensive therapy, to check three to four times per week in the morning before you take your medicines. And then what I have is, I have patients send them to me about two or three weeks after their ... They might keep it on an Excel spreadsheet or they may just write it down on a piece of paper and they send it to me via our electronic medical record, so we can make adjustments in between appointments rather than waiting three or six months until we see them again. And it can be very helpful in terms of guiding what we do if we add, subtract, or change medicines.

Speaker 2:          So you said just once a day in the morning, because I know patients, sometimes they're like, "Should I take it at night in the mornings? Should I take it three times a day?" So you're just really saying they could take it once a day in the morning.

Dr. Luke Laffin: Right. That's generally what we recommend. Throwing in an evening blood pressure is fine every once in a while. However, we know that in the majority of people, blood pressure tends to decrease at night. It drops about 10 to 15 percent. Then, starting at 4:00 AM, there's a sharp upward rise and blood pressure peaks in most people between 6:00 AM and noon. Not coincidentally, that's when the majority of strokes and heart attacks happen, between 6:00 AM and noon. So what we try and do is we try and catch that peak blood pressure and make sure you're protected throughout the day.

Dr. Luke Laffin: One common mistake that I see patients making is they say, "Okay, well I'm going to take my blood pressure medicine and then I'm going to check two or three hours after taking." I don't think that's the right strategy to take, because that can give people a false sense of security. That's when the medication is having its peak effect, is about two ... Although it works all day, it's having its peak effect two to three hours after. But we want to know when it's the highest and treat so that it's under that.

Speaker 2:          So a lot of times patients ask, "Should I take my blood pressure medicine at night or in the morning?"

Dr. Luke Laffin: That's a very timely question because there's actually a trial released within the past week looking at this. It was published in the American Heart Association's hypertension journal called the Harmony Trial. And what they did was they said, one group of patients can take their blood pressure medicine in the morning, all in the morning or all at night, and then they looked to see if there was a difference in 24 hour blood pressure. So they wore a monitor for 24 hours, and they showed no difference whatsoever. I was lucky enough to have the opportunity to write the editorial in that, that accompanied that paper, and what it comes down to, likely, is that the medicines we use are long acting, the majority of them, so they work over 24 hours. So it probably doesn't make a difference when we're taking our medicines, in the morning or at night.

Dr. Luke Laffin: There is one caveat to that, and that is, there are certain medicines that we probably don't want to take it at night because they're going to disrupt our sleep. And we know that disrupted sleep can lead to elevated blood pressures. So, for example, if someone's taking a diuretic or water pill, they shouldn't be taking that at 7:00, 8:00 at night, because it's going to have its peak effect when you're going to bed at 10 or 11 o'clock. Similarly, the class of medicines, calcium channel blockers, if someone has significant acid reflux or heartburn, if they're taking that at night, it can sometimes relax the muscles in the esophagus and the stomach, and the connection between those. And so it can worsen acid reflux. So if that's the case, we recommend they take that medicine in the morning as well.

Speaker 2:          I'm sure that you get this question a lot: Can I come off my medicine? Once I start a blood pressure medicine, is it ever a chance that I could take less, or get off that medication?

Dr. Luke Laffin: Yes. It's a very common question that we get, and it really depends on the patient themselves. Now, if someone is overweight, has a sedentary lifestyle, so they're not exercising or active, and has a high sodium diet, then there is a possibility that they can come off blood pressure medicine. It depends, obviously how high their blood pressure is. There's good data that shows that by losing weight, exercising, and a low sodium diet in combination, we can drop our systolic blood pressure by at least 15 millimeters of mercury, maybe even more, and that's oftentimes all patients need. Now, there is a subset of patients that they're maybe 70, 75, they have stiff blood vessels and that's an effect of aging, and somewhat of genetics as well. Those patients, they may not be overweight and they may be active and they may be watching their sodium, but their blood pressure is still high. Those patients, I tell them no, they cannot come off medicines, but we try and keep them at the same number of medicines, just try and optimize the dosing for them, get them on the most potent medicines to control their blood pressure while also minimizing side effects.

Speaker 2:          Very interesting. So if you could leave this with the three most important points you would want to give your patients who have high blood pressure, what would that be?

Dr. Luke Laffin: I think the first thing is that it's understandable. No one likes to take medicines. I don't like to take medicines. However, that's the problem with hypertension, is that oftentimes we don't know when our blood pressure is high. That's why they call it the silent killer. And it's the number one risk factor for things like stroke. So when we start medicines and move someone from, let's say, a blood pressure of 160 or 170 systolic, down to 140 or 130, yes, you may feel tired when you start taking the medicine. That's natural. That's just the body adjusting to living at a lower blood pressure. But that effect goes away after 10 days to two weeks. And so that's important to know, that, don't give up on it just because you're a little bit more tired. Because it's going to, you're going to feel better in the long run and you're going to protect your major organs, your kidneys, your heart, and your brain.

Dr. Luke Laffin: So that would be point number one. Point number two is, have a discussion with your doctor about the side effects associated with some of these medicines. Because oftentimes it can be a trade off, and just because one person can tolerate lower blood pressures for the systolic, you maybe can't. So have a discussion with them.

Dr. Luke Laffin: And then the third thing I'd say is that, for those patients that may be taking three or more medicines, hopefully in, let's say within the next five to 10 years, we'll have therapies that are not medicine based, that they're more device based therapy. I actually have a call right after this podcast talking with a company that we're looking to start, at least do some clinical trials in that. So there is the possibility in the future of device based therapy for hypertension where we'll eliminate the need for medications.

Speaker 2:          Very interesting. Well, thank you so much for being here today. I want to thank Dr Laffin for being with us to answer questions about high blood pressure.

Dr. Luke Laffin: Great. Thanks very much for having me.

Speaker 1:          Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Please subscribe and share the link on iTunes.