Targeting hypertension - patient conversation:
Patients can be resistant to taking anti-hypertensive treatment. Patients can cite side-effects that in many instances they have never experienced, and may only have heard from others or read about, as reason for avoiding treatment with anti-hypertensives. And a good many of such reasons can be myths. Nonetheless, real fears about duration of treatment and side-effects of treatment must be addressed in the patient who is planning on starting treatment. Failure to educate and address what and how patients feel about antihypertensive management and treatment is an invitation for non-compliance with treatment. First, I encourage my patients to get a home BP monitoring kit and then we agree on what are normal levels. I define our targets going forward. It is good practice when possible to have patients demonstrate the correct use of their home unit in the office. We at the same time get an opportunity to compare, adjust and correct for readings with our in-office equipments.
Often one encounters the patient whose sole reason maybe that s/he dislikes the idea that s/he might have to take blood pressure medication "forever". As a Provider, be prepared to welcome the "forever" conversation. Patients like to present the "forever" argument making sure to strip the "forever" of all its qualifications and metrics except the infinite duration of therapy implied. It is a very convenient and simple argument, afterall, who in his/her right mind would want to be swallowing pills "forever" , indefinitely, when there are more fun things to be doing? But "forever" can really mean for how long each person lives with and without treatment. I begin by trying to quantify and examine how long is "forever" with my patients. Simply put, "forever" may mean five years more or less before a cardiovascular event like a fatal or non-fatal stroke in a patient who is not taking medication to treat her/his hypertension. "Forever" may also mean years, in multiples of five, in a patient who takes h/her daily antihypertensive pill before any adverse cardiovascular event occurs and maybe never will have an event because her/his hypertension is controlled. In other words, I tell patients that every patient's forever is unique to that patient and is capable of being shortened or extended by what the patient chooses to do. Daily pill to keep blood pressure at a safe level can extend one's "forever". Given a choice, most patients would like to extend their "forever" with the daily pill. A good number of people come around to accepting that "forever" without BP pill can significantly be less than "forever" with BP the pill, and the choice begins to get clearer when presented in these terms.
The next thing is that some patients suggest cutting back treatment doses when blood pressure approaches 100 -120 mmHg systolic, even when they deny any symptoms indicative of a low blood pressure, believing that their pressure is getting very low. It is almost as if you did not have the all important conversation about targets. So we go over targets as many times as needed. I'd like to explain that it makes sense to get the benefit and the full benefit, when possible, of taking medications that one already has started taking in the first place, especially in treatment of hypertension. Studies show that keeping blood pressure below a systolic pressure reading of less than 120 mmHg is superior to target of less than 140 mmHg in preventing fatal and non-fatal cardiovascular events and death from any cause. This observation is particularly true in persons who do not have diabetes and those with type 2 diabetes who do not have any evidence of established cardiovascular disease. Click here to go to the Study. Even though side effects are slightly more with targets of less than 120 mmHg in some studies, they do not include injurious falls. Even among adults 75 years and older, treating to target below 120 mmHg is not associated with any more side effects than treating to targets below 140mmHg. READ MORE
https://www.ncbi.nlm.nih.gov/m/pubmed/24352797/