Ask the Doctors May 2013 Issue

Ask The Doctors: May 2013

My blood pressure lately has been at or around 124/64. I think the systolic (top) number puts me in the “pre-hypertensive” range, but the diastolic (bottom) number seems okay. What should I make of these numbers? Why the disparity?

By our most recent guidelines for the evaluation and treatment of hypertension, your blood pressure barely makes it into the “prehypertensive” range, defined by a systolic blood pressure (SBP) between 120 and 139.  As you suggested, the diastolic blood pressure (DBP) < 80 is normal. I assume from your note that you have never been diagnosed with hypertension, and that you are not currently on medications for it. My first suggestion is to please be reassured that your blood pressure readings are not worrisome.  To consider the systolic reading “high” and in some way a dangerous finding would certainly be an overinterpretation of the data.  If I were seeing you in my clinic, I wouldn’t even consider placing you on antihypertensive medication. As for why your SBP is in the prehypertensive range while the DBP is in the normal range, there is no clear answer.  These values vary considerably between individuals, without an obvious biological or pathological mechanism. It is known that for individuals younger than 50, DBP is a more significant risk factor for cardiovascular disease than SBP, but after 50, SBP becomes more important.

For those with diabetes or chronic kidney disease, our target is a SBP < 130 and a DBP < 80. For all others, the goal is for a SBP < 140 and a DBP < 90. Patients in your range are not prescribed medications. Rather, they are encouraged to pursue so-called “lifestyle modifications.” These include increasing physical activity, losing weight (if the BMI is >25), moderating alcohol intake if necessary, decreasing sodium intake to < 2,400 mg per day, and pursuing a diet rich in fresh fruits and vegetables and low-fat dairy products, and low in saturated fat. I’d recommend having your blood pressure checked again in a year by your physician.

I am a 60-year old-female doing well five years after bypass surgery. I also have two drug-eluting stents. I received conflicting answers from my doctors regarding how long to take Plavix. Some say “forever,” others say “two to three years per the studies.” I have an ejection fraction of 50 percent and my labs are good, but I am very bruised. Your thoughts?

First of all, I am glad to hear that despite the significant diagnosis of coronary artery disease (CAD), you have undergone bypass surgery and coronary artery stenting, and are now doing well with good cardiac pump function.  This is something to be glad for, at the very least. Regarding the issue of duration of Plavix (clopidogrel) therapy, one of the reasons why the responses from your doctors have differed is that the standard recommendations have changed considerably over the last 10 years. As data was uncovered regarding likelihood of clot formation in drug-eluting stents, referred to as “in-stent thrombosis” or IST, we tended to make the open-ended suggestion of taking Plavix for at least two years. In the last few years, however, more recent data has trimmed the recommendation down again. One certain thing is that you will need to stay on low-dose aspirin (generally 81 or 162mg daily in the United States) for life. The extensive bruising you have experienced is, unfortunately, not rare amongst patients taking both Plavix and aspirin. When my own patients have this problem, I try to balance the discomfort and unsightliness of bruising against the risk of IST and heart attack. Most patients with modern drug-eluting stents typically only need to be on Plavix for one year, but the location and size of the stents can affect such decisions. Please discuss this issue further with your own physicians, in order to make the safest and best choice for you.

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