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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

What Your Doctor Is Reading What Your Doctor Is Reading

Update From the Medical Journals: December 2013

January 02, 2014

By Mary Pickett M.D.

Harvard Medical School

What's the latest news in the medical journals this month? Find out what your doctor is reading.

New Guideline Shifts Blood Pressure Goals

Most doctors rely on recommendations from the Joint National Committee (JNC) on Hypertension to treat high blood pressure (hypertension). This group last published comprehensive guidelines in 2003. Now, the group has issued updated guidelines. The guideline changes mean many people, especially older adults, are being treated more aggressively than they need to be. The guidelines will become the new standard for treatment of hypertension. The guidelines — the eighth set of recommendations published by this expert panel over the years — are named "JNC8." JNC8 was published online by the Journal of the American Medical Association (JAMA) on December 18.

For the first time, the guidelines are based as much as possible on randomized controlled trials. Such studies are considered the highest standard of evidence. They assign similar people to different treatments or a placebo and then compare the effectiveness of each one. If studies were lacking, the guidelines relied on expert opinion. The new guidelines include several major points.

Blood pressure goals:

  • If your blood pressure is higher than 140/90 (no matter your age), it's important to exercise regularly, watch your weight and reduce the amount of salt in your diet.
  • Blood pressure is too high if either the top (systolic) or bottom (diastolic) number is too high. (Both numbers count.)
  • Adults age 60 and over who do not have diabetes or kidney disease should take blood pressure medicine to keep blood pressure below 150/90.
  • Adults age 60 and over who have diabetes or kidney disease should take blood pressure medicine to keep blood pressure below 140/90.
  • All adults younger than age 60 should take blood pressure medicine to keep blood pressure below 140/90.

Blood pressure medicines:

  • People of any race with kidney disease should first try a medicine from one of these drug groups:
    • ACE inhibitors: lisinopril (Zestril, Prinivil), enalapril (Vasotec) or captopril (Capoten)
    • Angiotensin receptor blockers: losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro) or candesartan (Atacand)
  • Blacks  without kidney disease should first try medicines from these drug groups:
    • Thiazide diuretics: hydrochlorothiazide (HCTZ) or chlorthalidone
    • Calcium channel blockers: amlodipine (Norvasc) and diltiazem extended release (Cardizem CD)
  • Non-blacks without kidney disease should first try medicines from these drug groups:
    • ACE inhibitors: lisinopril (Zestril, Prinivil), enalapril (Vasotec) or captopril (Capoten)
    • Angiotensin receptor blockers: losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro) or candesartan (Atacand)
    • Thiazide diuretics: hydrochlorothiazide (HCTZ) or chlorthalidone
    • Calcium channel blockers: amlodipine (Norvasc) and diltiazem extended release (Cardizem CD, Cardizem LA, Cartia XT, Dilacor XR)
  • When more than one drug is needed, choose drugs from different groups. But do not use ACE inhibitors and angiotensin receptor blockers together.
  • For some medicines, Doctors can start with a higher starting dose, compared with what has been typical practice. This may help to lower blood pressure to the goal more quickly.

In the past, adults over age 60 had the same blood pressure goal as younger patients did. Now, the blood pressure goal for older people is higher than younger patients' goal. The goal for older adults with diabetes or kidney disease is the same as the goal for younger people.

Until now, people with kidney disease and many people with diabetes were also treated with medicine to lower blood pressure to a certain goal. The new goal is higher. If you are in one of these groups, you might be taking more medicine than you need, according to the new guideline.

Older adults who are already taking medicine and have blood pressures significantly lower than 150/90 don't need to stop their medicines or lower their doses unless they're having side effects. Still, many older adults may want to check with their doctor to review possible side effects, and to see if a less aggressive treatment plan is appropriate.

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More News In Brief

  • Walking Helps Heart Risk More than You Might Expect. People who are sedentary usually take fewer than 3,000 steps per day. People who are very active may take about 10,000 steps per day. A new study looked at the number of steps taken by 9,300 adults from 40 countries. They  all had pre-diabetes, meaning they had blood sugars that were slightly higher than normal. This put them at extra risk for heart disease. Researchers found a remarkable connection between daily step counts (using pedometers) and the risk for heart attack and stroke. For every 2,000 steps in a person's daily routine, the risk was significantly lower. The results were released online December 20 by The Lancet. The researchers followed the participants for about 6 years. They noted the number of steps people took before the study as part of their normal routines. The participants were encouraged to increase their daily activity. Adults with pre-diabetes had a 10% lower risk of heart attack and stroke during the study for every 2,000 steps.  For most adults, 2,000 steps is roughly the same as walking one mile. Step counts were rechecked 12 months into the study. Every 2,000 steps that people added to their daily routine by the end of the first year was associated with an 8% decrease in heart attack and stroke during later years of the study.

  • Acid Blockers Can Lead to Low Vitamin B12: Many people use anti-acid medicines to help symptoms of acid reflux (heartburn). Long-term use of these medicines can lead to a deficiency of vitamin B12. A new study published in the December 11 issue of the Journal of the American Medical Association (JAMA) compared the use of anti-acid medicines and the rate of B12 deficiency in different groups of people. The study suggests that use of proton pump inhibitor medicines for longer than 2 years could increase the risk for vitamin B12 deficiency by about 65%. Examples of proton pump inhibitors are omeprazole (Prilosec), esomeprazole (Nexium) and pantoprazole (Protonix). The use of weaker anti-acid medicines called H2 blockers was associated with a 25% increase in risk. Examples of H2 blockers are ranitidine (Zantac) and famotidine (Pepcid AC). When it is not treated, vitamin B12 deficiency can cause anemia, neuropathy (numbness or weakness from poorly functioning nerves) and dementia.

  • Multivitamins Are A Waste of Money. Multivitamins are widely used by people who hope the supplements will protect them from illness. But are multivitamin pills beneficial? The author of an editorial published December 17 in Annals of Internal Medicine says they do not have health benefits, and that they are a waste of money. The author based his opinion on two new studies released in the same issue of Annals. One study enrolled male doctors who were older than age 65 when the study began. After 12 years, the men who took a multivitamin every day had the same average scores on cognitive tests as did men who were randomly assigned to take a placebo pill instead. So multivitamins don't seem to prevent dementia. Another study randomly assigned 1,708 people who had suffered a recent heart attack to get a high-dose multivitamin or a placebo pill each day. At the end of the study both groups had essentially the same chance of having a repeat heart attack, dying during the years of the study, needing a stent or surgery procedure due to coronary artery disease, having a stroke, or needing to be hospitalized due to chest pain. The U.S. Preventive Services Task Force (USPSTF) previously reviewed evidence looking for a connection between multivitamin use and cancer, cardiovascular disease and premature death. The USPSTF reported that they could not show any connection.

  • Guideline Says Screen Women for BRCA Gene if Family Has Breast or Ovarian Cancer History. Do one or more relatives in your family have a history of breast cancer or ovarian cancer? Did cancer occur in a relative at an early age, or did breast cancer occur in a male? Do you have Ashkenazi Jewish heritage? If you answered yes to any of these questions, you may carry a BRCA gene. This gene increases your risk for breast and ovarian cancers. The U.S. Preventive Services Task Force (USPSTF) recommends that you talk with your primary care doctor about your family history. A variety of questionnaires can assign a risk score to your reported family history. If your family history triggers enough concern, it is recommended that you see a genetic counselor or get genetic testing to find out if you have a BRCA gene. The cancer risk is high enough in BRCA carriers that many women who are aware they are carrying the gene opt to have preventive surgery, or to take medicines to reduce the risk for cancer. The new guideline by the USPSTF was published online December 24 by the Annals of Internal Medicine.

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Mary Pickett, M.D., is an associate professor at Oregon Health Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.

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