January 10th, 2014

Walk with a Doc Newsletter

Good morning! As you are staying active for 150 minutes (or more) each and every week, we are sure this is finding you happy and healthy and warm.
Time to roll up our sleeves and dig into the new, controversial blood pressure recommendations
(I did that with Matt Lauer and everyone else 3 weeks ago, but go ahead David, play doctor)
There have been 3 hypertension guidelines over the past year but these are JNC 8's. To put that in perspective, whenever we (us doctors) were enjoying a spritzer at the club after a vigorous match of polo, JNC 7 was what we talked about. It's been ten years since the release of JNC 7, so JNC 8 is a really big deal. For the pop music aficionados in the group, it's the equivalent of Ace of Base.
The 9 essential points distilled from the 300 pages of recommendations:
  • In patients 60 years of age or older who do not have diabetes or chronic kidney disease, the goal blood pressure level is now <150/90 mmHg. Big change! Just a few weeks ago we were aiming for a target that was a lot lower.
  • In patients 18 to 59 years of age without major comorbidities, and in patients 60 years of age or older who have diabetes, chronic kidney disease, or both conditions, the new goal blood pressure level is <140/90 mmHg (previously 130/85) 
  • First-line and later-line treatments should now be limited to 4 classes of medications: thiazide-type diuretics (more commonly know as HCTZ) , calcium channel blockers (CCBs), ACEIs (inhibitors), and ARBs (big change here is that beta blockers - solely in regards to treating hypertension - have been shown the back door.) They are useful for a ton of things, but in my experience are not that effective at lowering BP. So, I agree it was time. 
  • Second- and third-line alternatives included higher doses or combinations of ACEIs, ARBs, thiazide-type diuretics, and CCBs
  • Several medications are now designated as later-line alternatives, including the following:
    • Beta-blockers
    • Alpha-blockers
    • Alpha1/beta-blockers (eg, carvedilol)
    • Vasodilating beta-blockers (eg, nebivolol)
    • Central alpha2-adrenergic agonists (eg, clonidine)
    • Direct vasodilators (eg, hydralazine)
    • Loop diuretics (eg, furosemide)
    • Aldosterone antagonists (eg, spironolactone)
    • Peripherally acting adrenergic antagonists (eg, reserpine)
  • When initiating therapy, patients of African descent without chronic kidney disease should use CCBs and thiazides instead of ACEIs
  • Use of ACEIs and ARBs is recommended in all patients with chronic kidney disease regardless of ethnic background, either as first-line therapy or in addition to first-line therapy
  • ACEIs and ARBs should not be used in the same patient simultaneously
  • For the asymptomatic patient over 60 who is averaging in the 120's/130's on 1 or 2 meds, the recommendation is don't mess. What I tell my patients is 'force my hand'. BP and weight are directly related. I want my patients to increase their activity and lose 5-10 pounds and maybe drop their BP to 105/whatever so I have to take away their medicines.  
  • *Critical take home - Through simple, regular activity and modest weight loss YOU are in control. Screw these medicines. You cannot get rid of them yet, but tell your doctor you are p------ off and fired up. Ask her, "What do I need to do?!"  You're Maverick. YOU call the ball.    
  •  

    For our subscribers that read the newsletter for its medical information; that portion is now complete. We offer a sincere thank you for your time and you are now free to roam the country.  

     

    Go on. Git, git. You're not missing a thing.   

     

    For those still in the house...parents just went to bed...time to get...just a little bit...funky. These are the minutes from the previous WWAD Board of Directors meeting and detail how we arrived at the 2013 WWAD Song of the Year.



    2013 WWAD Song of the Year
    Board Minutes

    While there are separate committee meetings every few months; it's only one day a year that all 12 of us on the Board of Directors come together. 

     

    December 19th, 2013 was that day.

     

    David: "Thank you all for being here this evening. I'd like to welcome all of you from around the US and a special thank you to our foreign visitors. 

    "These next 3 hours are of critical importance. The decisions made in this very room will shape not only the future of the program, but the future of medicine around the world. 

    "I leave this up to the group. Would you like to start with the P&L sheets, review our policies and procedures, or discuss the status of the Executive Director search?" 

    There is a pregnant pause as everyone looks around the room.  

    All attendees surrounding the table burst into uncontrollable laughter.

    "That's what I thought. Let's get it on! We can deal with all that other stuff at next year's meeting."

    Dr. Phillip Green: "That's what you said last year."

    David: "I know"

    More uncontrollable laughter from around the conference table.

    David: "I realize this has grown contentious in the past. I'd like to remind everyone that we are all professionals. We have pediatricians, neurosurgeons, gastroenterologists, a clergy member, ENT's, hospital CEOs, high ranking strategic planners, and 2 heads of state. Most all of you have traveled a long distance to get here and it's important we treat everyone with respect. Dr. Browning, if you could please lead us off."

    Dr. James Browning: "My vote is for Katy's newest. It's inspirational with a clean message and my kids absolutely love it. I feel she has...

    Dr. Amy Goodwin: "Damn it Jim!. No!" Dr. Goodwin stands and slams her open palm back down onto the table. 

    "We went with California Gurls in 2010 and Wide Awake just last year. Ever since Kissed a Girl, you won't let up. We're not doing Roar!"

    She takes a long, exaggerated breath, trying unsuccessfully to release her frustrations, She can't let it go.

    "Jim, we looked like damn idiots last year. Call Me Maybe swept every list but ours. Makes us look like we are running around with our thumbs up our..."

    "Amy, Amy, Amy - we get it. What are your thoughts?" intervenes Mike Thompson, Hospital CEO in Harrisburg,PA.

    Amy wastes no time. "No question this year. Royals."

    Pause. Pause. Pause.

    At this point, our ENT, Dr. Michael Stone, can no longer take the elephant in the room.

    "Bob, what the HE-- are you wearing?!

    It's the question everyone wanted to ask. 

    All eyes immediately go to the other end of the conference table. 

    While 11 board members are in dark suits, Dr. Robert Witherspoon is not. Dr. Witherspoon has a full length fur coat (chinchilla), big, round black sunglasses, leopard pattern gloves that go to his elbow. and he's wearing a canary yellow fedora"

    In just about every respect, he is a classic neurologist. Introverted, pensive, and of very few words. A great thinker, that's why I elected him to the board.

    It's 72 degrees in the board room and from the amount of sweat that has already accumulated on his forehead, I'm worried about him. 

    Dr. Stone: "Bob, you're trying to push through Thrift Shop, aren't you?" 

    Dr. Witherspoon doesn't respond, sitting absolutely expressionless. 

    "You are, aren't you Bob? You know that was released in August of 2012, Bob." Stone is piling on now; those surgeons get right to the point

    It was almost indistinguishable through the large black sunglasses, but he looked down at his feet and I could tell he was upset. Breaks your heart.

    Stone accomplished his goal and felt the time had come to shift focus, 

    "Tim, what are you going with this year?"

    Dr. Timothy Callahan: "I spent a lot of time over this past week reviewing my favorites and I've arrived at I Believe by Josh Groban."

    David: "Okay, great. Who wants to...?"

    "Hold on David. Hey Timothy, sure I can't get you a Peach Bellini and a lavender neck pillow for the rest of the discussion?

    Timothy has shared his playlist with me in confidence, and let's just say that's not his only Groban song. I knew that comment would not be well-received.

    Dr. Tim reaches across the wide conference table and it appears he's literally trying to strangle Michael Fasiola - the Bellini offerer.

    I grab his arms, "MIKE! Please! We've all put a lot of time into this and all of us feel strongly about our choices. We need to respect that."

    The booming voice of the operator pounds down from the ceiling.

    "Code Blue ER Bed 99. Code Blue ER Bed 99. Code Blue ER Bed 99"

    Dr. Cynthia Cordain breaks the post announcement silence,

    "David, you haven't shared yours yet."

     That's a good question. There were a lot of great songs this year,

    "I'm liking White Walls right now."

    Our receptionist comes in, realizing not a single physician has left the board room and gone past her desk on their way to the ER.

    "That announcement? Isn't that really bad?! Shouldn't you people be down there now saving a life?"

    One thousand one. One thousand two. One thousand...

    Amber Wilmington, owner of a large Tulsa pediatric practice, grows concerned with the meeting's direction and jumps in.

    "Sara Bareiles - Brave. The song is inspirational. It's fun with a great message. We, of course, want all our Walk with a Doc guests to be brave. It's that song in the computer commercials. I think it's a perfect fit for 2013."  

    Eyes in the room search for the next objection and there is none.

    I stand up and pound my gavel.

    "Perfect, Brave it is. Meeting adjourned - See you next December, suckers!"

     

    Truth be told, I warned you. You will never get those four and a half minutes back. Gone. 

     

    Stay Hungry. Stay Foolish.

    David
    614.714.0407
    @justwalkevents

    #Ilovethewalk
    STAY CONNECTED

    Facebook    Twitter    LinkedIn    Pinterest