Wednesday, August 29, 2018

Monitoring Your Blood Pressure at Home

On a recent visit to see my mother, I watched her check her blood pressure with her home machine.  I was surprised to find out that she wasn't really following the best procedures for getting an accurate blood pressure reading.  I thought a discussion of home blood pressure monitoring would make a good subject for our Health Tip today.

The latest guidelines for the treatment of high blood pressure put more emphasis than ever before on home blood pressure monitoring.  There are different options for checking blood pressure at home.  First I'll talk about the different options, then how to make sure you get accurate readings.

There is a device, called an ambulatory blood pressure monitor.  This device is about the size of a portable radio with an attached belt or strap that is worn on the body.   This is something that your doctor may ask you to use to get a better picture of what your blood pressure is doing throughout the day.  You would get it from your doctor's office.  Throughout the day, the machine will automatically check your blood pressure about every 30 minutes, and usually every hour overnight.   When you are using this machine, you are also given a diary to write down your activities.  When the 24 hours are over you take the machine back to your doctor's office along with the diary.  Your doctor will then review the blood pressure readings in the context of your activities.

In many cases, rather than using an ambulatory blood pressure monitor, we simply recommend that you take your blood pressure at home, or have it checked at your local pharmacy, intermittently at different times of the day.  If you are taking your blood pressure in this way, there are a few things that you should do in order to get an accurate reading.
  • Choose a good quality cuff that fits your upper arm well.  Your pharmacist can help you find the right machine for you.  Do not use a cuff that measures anywhere besides your upper arm.
  • Occasionally take your machine with you when you see your doctor, so that the doctor or nurse can check how accurately it is measuring.
  • Avoid caffeine, exercise, and smoking for at least 30 minutes prior to taking your blood pressure.
  • Always sit in a chair that supports your back and allows your feet to be flat on the floor.  Sit in this way for at least 5 minutes before you start your machine.  (If you sometimes take your blood pressure while leaning back in your recliner, that's ok, but you have to indicate this when you write that reading down, because it should be interpreted differently by your doctor.) 
  • Make sure that your arm that is being used for the blood pressure reading is well supported (resting on a table for instance) and relaxed at the level of your heart.
  • Make sure that the blood pressure cuff is high enough on your arm.  The middle of the cuff should be at about the same level as the middle of your breast bone.
  • Keep a good record of your readings, including the date and time of day.  If you did anything out of the ordinary, for instance if you had just stopped exercising, always write that down along with your reading so that your doctor will know how to interpret that particular reading.  Be sure to take these readings in when you see your doctor.
If you have any questions about monitoring your own blood pressure at home, please log into your account and send us your question. We are here to help.

Monday, August 20, 2018

New High Blood Pressure Treatment Guidelines

Recently, I was asked a question about when a person should be started on blood pressure medication.  This made me think about how the treatment recommendations have changed over time, several times in fact since I was in medical school.  The latest guidelines for treating blood pressure were published in November 2017.  I thought you might be interested in hearing about these new guidelines.
It is important to first realize that in the United States, high blood pressure accounts for more deaths from cardiovascular disease than any other modifiable risk factor.  It is second only to cigarette smoking as a preventable cause of death for any reason.  This makes treatment of high blood pressure really important.  From age 20-39, as long as it is normal, you should have your blood pressure checked about every 3-5 years.  As you get older, the chance of high blood pressure increases, so you should get it checked once a year after you turn 40.  Of course if it is elevated, you will need to have it checked more frequently.

Guidelines such as these are given a lot of thought.  A committee of 21 scientists and health experts with different backgrounds came together and reviewed a great deal of research (more than 900 published studies!).  They have been meeting and working on these guidelines since 2014.  They considered the health risks associated with different blood pressure levels as well as the risks and benefits of different treatments.
Here are the new blood pressure categories defined in the new guidelines:
  • Normal – Less than 120/80
  • Elevated – Systolic (top number) between 120-129 and diastolic (bottom number) less than 80
  • Stage 1 – Systolic between 130 -139 or diastolic between 80-89
  • Stage 2 – Systolic at least 140 or diastolic at least 90
Here are some other changes found in the new guidelines:
  • High blood pressure should be treated earlier with lifestyle changes, starting at 130/80, Stage 1, rather than the old recommendation of 140/90.  Lifestyle changes alone are recommended for most adults newly classified as having Stage 1 hypertension.  This includes weight loss, a heart healthy diet, sodium restriction, increased physical activity with a structured exercise program.
  • Lifestyle changes plus medication are recommended for patients with Stage 1 hypertension if they have already had a cardiovascular event, such as a heart attack or stroke, or if they are at high risk of heart attack or stroke based on risk factors that can include diabetes, cholesterol levels, age, etc. 
  • Lifestyle changes plus medication are recommended for all patients with Stage 2 hypertension.
  • They stress the importance of using proper technique for measuring blood pressure, as well as stressing the importance of using an average of at least 2 readings obtained on at least 2 (but can be more) separate occasions.
  • Recommend use of home blood pressure monitoring to help with diagnosis and treatment.
By using these new guidelines, we should be able to decrease the number of patients who die of heart attacks or strokes, and that sounds like a good plan to me!

If you have any questions about blood pressure issues, just send a question to one of our doctors.

Friday, August 3, 2018

Obstructive Sleep Apnea

The Greek word "apnea" means "without breath".  In sleep apnea, there is an involuntary cessation of breathing that occurs while sleeping.  These pauses in breathing can last anywhere from 10 seconds to as much as a minute.  Snoring is also a common feature of sleep apnea.  While snoring can just be a nuisance, snoring associated with sleep apnea can signal a serious medical condition. If left untreated, sleep apnea can lead to the development of high blood pressure, heart failure, memory problems, and can increase the chance of having driving accidents due to excessive fatigue.

How does OSA develop?  The most common type of sleep apnea is called Obstructive Sleep Apnea (OSA).  This occurs when soft tissue in the back of the throat collapses during sleep, blocking off the airway. OSA is usually seen in overweight individuals.  Other risk factors for the development of OSA include: a large neck, a recessed chin, smoking, and alcohol use.  A typical patient with OSA will snore loudly after falling asleep. The snoring is then interrupted by silent periods during which no breathing takes place (apnea).  These apneic episodes are then followed by sudden efforts to breathe. The result is disturbed sleep, leading to excessive daytime drowsiness.

How is OSA diagnosed?    Most people with OSA will be unaware of their snoring or episodes of apnea. The predominant symptom will be excessive daytime drowsiness.  The snoring and apnea episodes are usually reported by a family member. The American Sleep Apnea Association has published a questionnaire known as the Snore Score.  A positive response to any one of the following questions points to the possibility of someone having obstructive sleep apnea:
  1. Are you a loud and/or regular snorer?
  2. Have you ever been observed to gasp or stop breathing during sleep?
  3. Do you feel tired or groggy upon awakening, or do you awaken with a headache?
  4. Are you often tired or fatigued during the waking hours?
  5. Do you fall asleep sitting, reading, watching TV or driving?
  6. Do you often have problems with memory or concentration? 
Other symptoms that can be associated with OSA include morning headaches, weight gain, attention deficits and memory loss. The diagnosis is usually confirmed after monitoring for apneic episodes in a sleep laboratory.

How is OSA treated?     Fortunately, there are a number of treatments available for OSA, depending on the severity and underlying causes.  These treatment options include:
  • Avoidance of alcohol and medications that relax the airway and/or reduce respiratory drive.
  • Weight loss is highly effective in obese individuals by reducing excess fat around the neck which is constricting the airway.
  • Positional therapy, i.e., avoiding sleeping on the back (for adults)
  • Oral appliances designed to keep the airway open.
  • Surgery (the most common procedure is called uvulopalatopharyngoplasty which removes excess tissue that is blocking the airway). 
  • Continuous positive airway pressure (CPAP)
The American Academy of Sleep Medicine recommends the use of an oral appliance as a first line treatment for patients with mild to moderate OSA.  In many patients, however, CPAP is the most effective treatment method.  It works by blowing pressurized air into the person's airway at a high enough pressure to keep the airway from collapsing.  A relatively new surgical procedure known as the Pillar Procedure has been found to be helpful in mild-to-moderate OSA. This procedure involves the placement of flexible implants into the soft palate to keep it from relaxing and blocking the airway.  For more on Obstructive Sleep Apnea, visit the American Sleep Apnea Association.

Sources for article: 

What Is Sleep Apnea? from the National Heart, Lung, and Blood Institute
Test Yourself from the American Sleep Apnea Association
Pillar Procedure from the Mayo Foundation for Medical Education and Research

If you have any questions about Obstructive Sleep Apnea, please log into your account and send us your question. We are here to help.