Â鶹Éç

Downloaded from

Ìý

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.Ìý BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE Â鶹Éç CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

Ìý

Ìý

INSIDE HEALTH – Programme 1.

Ìý

TX:Ìý 08.01.19Ìý 2100–2130

Ìý

PRESENTER:Ìý MARK PORTER

Ìý

PRODUCER:Ìý ERIKA WRIGHT

Ìý

Ìý

Porter

Hello. ÌýWe will be here every week for the next three months, and we start with a special programme dedicated – unusually for us – to just one topic – high blood pressure. ÌýBut why?

Ìý

Well, it’s known as the silent killer for good reason, being the single biggest risk factor for an early heart attack or stroke. ÌýAnd it’s common, affecting around 12 million adults the UK, half of whom are undiagnosed and blissfully unaware that they have a problem.Ìý And it’s a threat that isn’t well managed, with only a third of those affected being diagnosed and treated as advised in the latest guidelines.

Ìý

And what do the readings actually mean – 120/80 is widely regarded as a healthy level. ÌýThe lower diastolic figure being the baseline pressure in the circulation, and the higher systolic one the peak reached each time the heart beats. ÌýBut how high do the numbers have to rise to become unhealthy and what should be done about it? ÌýEven that’s not straightforward...

Ìý

Messerli

My name is Franz Messerli, I am Professor of Cardiology here in Bern, Switzerland at the university hospital.Ìý Let’s assume it’s a 63-year-old patient who has a blood pressure of 148/86 after multiple readings.Ìý Now, just a few years ago we would have said – well, she has a little high blood pressure but probably with a little exercise and a little salt restriction she should do fine, there’s no medication needed.Ìý When you look now at this woman, the first question is, where should her blood pressure be?Ìý In other words, what is the target blood pressure?Ìý And the target blood pressure, according to the latest American guidelines, should be below 130/80.Ìý However, when you look at the GP guidelines in the United States her blood pressure could be distinctly higher – 150/90 – so, she would be perfectly fine.Ìý And the European guidelines says it should be a blood pressure below 140/90.Ìý

Ìý

We have three different sets of guidelines.Ìý Clearly this is up most confusing.

Ìý

Porter

But Franz, all of these people are looking at the same evidence but presumably drawing different conclusions, how does that come about?

Ìý

Messerli

Well this is exactly the major issue.Ìý As you state the evidence for the three sets of guidelines is absolutely identical, they are based on the very, very same studies.Ìý So, obviously the interpretation is completely different.

Ìý

Porter

What about the consensus on treatment?Ìý Let’s forget, for a minute, that we’re arguing about whether you’ve got high blood pressure or not, are we all agreed on what we should be doing about it, in terms of interventions?

Ìý

Messerli

Well absolutely not, when we go back to our patient, as I said, the blood pressure is 148/86, the patient is 63-years-old.Ìý So, American Heart Association guidelines you would start with one drug, the European guidelines you would start with two drugs and the American GP guidelines you would not use any drug because that blood pressure is perfectly acceptable.Ìý So, clearly, again, the treatment recommendations are different from one guideline to the other.

Ìý

Porter

Professor Franz Messerli. Ìý

Ìý

There may be some disagreement as to when and how to intervene in people with high blood pressure – or hypertension as it also known – but there is an international consensus on one thing – it’s bad for you. ÌýSo, to help us unpick the latest thinking here in the UK, on who should be offered what and when, I am joined by our very own Dr Margaret McCartney, a GP in Glasgow, and Bryan Williams, who’s Professor of Medicine at University College London and past Chair of the NICE Hypertension Guideline Development Group.Ìý

Ìý

Bryan, it is a bit confusing.

Ìý

Williams

So, there has been a number of debates around the fact that the United States decided to reclassify hypertension and call people with a blood pressure above 130 systolic, that’s the top number, or 80 diastolic, the bottom number, as hypertensive.Ìý And they did that because they wanted to increase participation in lifestyle interventions to try and prevent hypertension developing.Ìý In Europe and in the United Kingdom, in particular, we regard blood pressure in the doctor’s office above 140/90 as being hypertension because that’s the level of blood pressure at which treatment is known to be effective at reducing risk.Ìý And so, we define hypertension on the basis of whether you’re likely to need drug treatment.

Ìý

Porter

Margaret, if we take it as read that high blood pressure is associated with increased risk and affects mortality, are we equally as convinced that intervening, from a medical point of view, to lower that pressure has benefits?

Ìý

McCartney

Yeah, I mean there’s loads of high control randomised control trials looking at treating blood pressure and we’ll see benefits.Ìý I think, though, we should keep in perspective the magnitude of those benefits.Ìý So, the lower the risk you are at heart attack or stroke the lower your chance of benefit is going to be.Ìý The higher the risk of heart attack or stroke you are the more likely you are to benefit.Ìý It’s really interesting as well that one of the groups most likely to benefit from treatment are people who have an Afro Caribbean heritage, so black people, in general, are at higher chance of benefiting from treating high blood pressure than many other groups.

Ìý

Porter

Why does it matter – we do all this measuring but what happens if we miss high blood pressure?

Ìý

Williams

So, if you look at a population level, whether it’s UK or globally, let’s say globally for the moment, the latest statistics say that about 10 million people a year die as a consequence of undetected or poorly treated hypertension.Ìý And that is the biggest single important factor contributing to premature death.Ìý Now when I first read those statistics I was surprised because you think about smoking, you think about obesity, diabetes and everything else but high blood pressure trumps all of them in terms of risk.Ìý Recently, there was a paper published projecting what is going to be the commonest cause of death in 2040 across the world and what is going to be the most important risk factors.Ìý And the commonest cause of death will be heart disease and stroke, still – that’s still the commonest – and in 2040 high blood pressure will remain the most important preventable cause of death.

Ìý

Porter

And when you say death?

Ìý

Williams

Stroke, heart disease, heart failure, kidney failure.Ìý So, the main organ systems that are battered by the high blood pressure, that’s what the causes the premature death in these patients.

Ìý

Porter

Margaret, statistics wise, this is a fast-changing field, there are far more people now that we’re diagnosing as having high blood pressure than there was when you and I qualified, certainly when I qualitied.

Ìý

McCartney

Yeah, I think what we have to do is remember we have to keep this in context.Ìý Hypertension, high blood pressure is a risk factor, it’s a risk factor for cardiovascular disease, it’s one of many risk factors for cardiovascular disease and I think we spend a lot of time trying to find it, monitoring it, treating it, monitoring the drugs that people are taking for it.Ìý And it is one factor that contributes to your cardiovascular risk and there are many others.Ìý And I sometimes worry that we don’t put it in context enough, the entire purpose of treating it to try and lower your cardiovascular risk, so that you don’t end up having an avoidable heart attack or stroke.Ìý And it’s also important to remember that some people have heart attacks and strokes with no risk factors at all.Ìý But there are certainly some people that do have risk factors are amenable to change and hypertension is one of them.Ìý But there are many others.Ìý So, when someone has got a new diagnosis of high blood pressure it’s not just the blood pressure that should be on our minds, you know, there are things like diet, exercise, alcohol, smoking – all the other factors that can contribute.Ìý And I sometimes think that we are so fixed on the numbers on the blood pressure, there are perhaps other numbers we should think about – numbers of minutes exercise per week, number of centimetres around your waist – that kind of thing.

Ìý

Porter

What about the two figures?Ìý We talk about systolic and diastolic, for the sake of this we’ll talk about upper and lower figures, does it matter if both are raised, if one is raised, is one more important than the other?

Ìý

Williams

Traditionally, over many years, diastolic was the one that was used by the regulators to evaluate drugs, the lower figure.Ìý But more recently, over the last 10 or 15 years, it’s well recognised that systolic blood pressure, the top number, is the most important.Ìý And in fact, that’s the one that’s usually elevated, particularly as we get older where most hypertension occurs.

Ìý

McCartney

And we know that these vary for everyone through the day.Ìý So, if you do people’s blood pressure 50 or 100 times, you’ll find it constantly changing – during exercise it can go up dramatically and only fall afterwards.

Ìý

Porter

Looking purely at the numbers, Bryan, what would an ideal blood pressure be for a typical middle-aged man or woman in terms of optimum health, purely from the blood pressure point of view?

Ìý

Williams

Well, optimal blood pressure’s usually defined as a top number – systolic less than 120 – and a bottom number less than 80.

Ìý

Porter

Most people out there are going to be above that, so, does the risk start to increase thereafter then, is it a sort of linear relationship between…

Ìý

Williams

It’s a pretty much linear relationship.Ìý The reason why we choose one – because some people will say well if optimal is 120, why are you waiting until 140 before you call it high blood pressure?Ìý Well, that’s because we’ve only done trials in people with a blood pressure above 140, where we can define that the treatment is going to be beneficial.Ìý It’s likely to be beneficial even at lower levels of pressure, however, you would have to treat many more people to see the benefit and that probably isn’t justified.

Ìý

Porter

Margaret, you’re like me the sort of person that’s likely to initiating somebody on treatment for their high blood pressure, what do you tell them about the likely benefit?

Ìý

McCartney

What I’m always keen to do is to have an all-encompassing discussion.Ìý So, hypertension is one factor in many factors in someone’s life and you have to know how to fits in.Ìý And very often people are coming in, not just with one problem but with four or five different problems, others of which might be far more important at that time.Ìý So, it can be very difficult to get to grips with this stuff.

Ìý

The other thing I always say to people is that I find treating high blood pressure distinctly unsatisfactory.Ìý And the reason is that I never know when it’s worked, I never know if someone has avoided having a heart attack or stroke because of it.Ìý And even if someone does have a heart attack or stroke, I don’t know if it’s been delayed or is less severe or whether the treatment didn’t make any difference.Ìý So, it’s one of those things that I always say, we only know this works because of big trials.

Ìý

Porter

So, what do they tell us because I still, as your patient, before I take this pill, I want you to give me some idea of the likely protection – of benefit that I’m to get from it?

Ìý

McCartney

So, let’s take one [indistinct word], my Cochrane Review, in women aged 55 years and over they had a 25% reduction in fatal and non-fatal cardiovascular events but that’s a relative risk, so you have to put that in to a form is how likely am I, as an individual, to get a benefit from that.Ìý Well over five years, just five years, you’re expected to take it for a long time, you need to treat about 58 women for one to benefit.Ìý Now some women will look at that and think fantastic, that’s great, I want to have that chance, other women will think actually I’m sick of taking these tablets, they make me feel rubbish, it’s not worth the candle.

Ìý

Porter

Let’s move on to measurement now.Ìý We’ve had an email from a listener in Singapore who’s confused about the best way to take their own blood pressure.

Ìý

Listener

When I got a blood pressure monitor, it was clear that the readings I was getting at the GP’s was not representative of what my blood pressure was for most of the time.Ìý And when I have asked doctors about this in the past, I’ve also got conflicting information about it.Ìý One guy said, the first measurement is the one that counts and the second one, which is low is artificially low because of the release of the pressure.Ìý Another one has told me, you should take an average of the first and second readings.Ìý And then some online guidance from pretty authoritative sources – I think the American Heart Foundation is one – who say you should wait until it’s stabilises and take the average as maybe the second, third and fourth measurement, something like that.Ìý So, this is really my point, that when they issue 120/80 as being what we should aim at for a healthy blood pressure it seemed to me that this was a pretty meaningless thing to say unless you also gave some pretty clear guidance as to the conditions under which you should in fact measure it.

Ìý

Williams

So, the recommendation is that you do sit down, you rest for about five minutes, you press the button on the monitor, you take the first reading and then you take a second reading about a minute later.Ìý And you do that in the morning and you do that in the evening for a minimum of three days and ideally slightly longer and then you average all of those readings to get the average blood pressure on your home value.Ìý So, it’s the average of all of those readings.Ìý It’s well accepted that if you do one reading and the second one can sometimes be much lower than the first.Ìý Some people then say if that is the case you can take a third and take the average of the last two but if you’re just doing your own monitoring at home then I would recommend that you do two readings a minute apart, twice a day, seated and comfortable.

Ìý

Porter

And please once you’ve collected your 12 plus readings, work out the averages and means yourself and bring them in with your doctor, it saves a lot of time.

Ìý

McCartney

Certainly, the cost of blood pressure monitors has come down hugely, so they’re much more accessible now than they used to be, I remember when they used to cost 50 or £100, they’re now being picked up for 15 or 20.

Ìý

Porter

The question for both of you – can we trust those readings in terms of when we’re looking at historically all the research that’s been done in the world of high blood pressure, it’s been based on hospital and GP surgery measurements, so do we know what the equivalent is in someone’s home – it’s likely to be lower isn’t it?

Ìý

Williams

It is a bit lower.Ìý So, the average of 12 readings, minimum, should be less than 135/85.Ìý So, 135/85 at home is about equivalent to about to 140/90 in the doctor’s office.

Ìý

McCartney

And there’s a false positive and false negative rate attracted to both of these.Ìý So, people talk about massed hypertension where you really have got high blood pressure but when you’re in the doctor’s surgery it appears to be okay.Ìý And conversely at home the same thing can happen.Ìý So, both of them are capable of missing some people who either do or who don’t have high blood pressure.

Ìý

Williams

And probably the home reading is the one that’s the most accurate because that’s actually giving you your blood pressure in your normal circumstances.Ìý And this idea of white coat hypertension is really interesting because we think about 25% of people, who have their blood pressure measured by the doctor or the nurse, when they measure it themselves at home their blood pressure’s actually in the normal range and they almost certainly do not need treatment.Ìý That’s more likely to happen if your blood pressure’s not very elevated in the first place.

Ìý

Porter

What do you say to those people, then, who 60, in other wise super health but you’ve got high blood pressure, but why doc?

Ìý

Williams

It’s part of ageing.Ìý So, we now know that by the time you get to about 50 you’ve lost about half the elasticity of your large arteries and as those arteries get stiffer and less distensible, when the heart pumps it has to generate a higher pressure to get flow.Ìý So, it’s a bit like when you first blow up a balloon, it’s quite stiff to blow up and once you’ve blown it up a couple of times it’s easier, well when you’re young it’s like a balloon that’s been blown up a lot, like basically it’s easy to put the air in.Ìý As you get older the artery gets stiffer, it’s much harder.Ìý So, your heart has to pump harder to actually generate the flow around the body and as a consequence the pressure goes up and that is the reason why most people get high blood pressure because most people who get high blood pressure get it over the age of 50.Ìý And it’s usually the top number that goes up.

Ìý

McCartney

There are certainly a lot of people that you see with high blood pressure who have lots of risk factors for it, you know they’re perhaps overweight, sedentary, drink too much and have a very poor diet.Ìý But you also see quite a lot of people who don’t have any particular reason for having high blood pressure and often I think it’s quite hard for people, who feel as though they’ve been really quite unlucky and it’s not fair and indeed it is not fair for many people, I think there is a strong genetic element that is not amenable to altering your risk factors.

Ìý

Williams

I think they get reassured, I always say to them in clinic it’s not a very exclusive club I’m afraid.Ìý I mean there’s one in four adults, one in two adults over the age of 65 have a high blood pressure, so it really is a very common condition.

Ìý

Porter

Now treatment.Ìý We’ve found somebody who’s got high blood pressure, let’s look at lifestyle, what can they do to help themselves?ÌýÌý What, as an overview, works and what doesn’t?

Ìý

Williams

So, if you look at what the guidelines now say.Ìý Sodium restriction – that’s salt restriction, reducing the amount of salt in your diet.Ìý Alcohol intake in moderation and avoiding binge drinking, which can be associated with quite significant elevations in blood pressure.Ìý Healthy diet – well balanced healthy diet, maintaining an ideal bodyweight.Ìý Regular exercise, ideally aerobic exercise, walking is often sufficient five times a week.Ìý And stopping smoking, not because that has a major effect on blood pressure but because it’s important in risk management.

Ìý

Porter

Now if I did everything that you suggest, what sort of likely impact is that to have on the numbers, do we know how much it’ll drop them by?

Ìý

Williams

It’ll probably drop your blood pressure by about 10 millimetres of mercury.Ìý So, if you’re at a level at which your doctor’s thinking about treating you, you might be able to avoid treatment.Ìý In some people the response will be even more impressive if they’re particularly taking lots of salt in their diet and reducing that might be particularly beneficial.

Ìý

Porter

Well, we’ve had a question on salt too, from Glyn, who’s confused by recent reports in the media suggesting that salt may not be the great villain it’s portrayed to be.Ìý Katharine Jenner is Chief Executive of the Patients Association Blood Pressure UK and campaign director for Consensus Action on Salt and Health.Ìý

Ìý

Katharine, the controversy Glyn refers to seems to centre on whether you really need to worry about salt if you don’t have high blood pressure.

Ìý

Jenner

There is certainly some controversy with the evidence out there but that’s just a few limited studies.Ìý There’s certainly no harm in reducing population salt intakes.Ìý The few people that may have far too little amount of salt have probably got another problem.

Ìý

Porter

Do we know how we’re faring in the reduced salt stakes?

Ìý

Jenner

So far, they’ve come down by about one and a half grams in 10 years, which doesn’t sound like a lot but it has naturally brought the population’s blood pressure down by just a few mils of mercury, which is enough to have prevented about 7,000 a year having an event such as a heart attack or stroke.

Ìý

Porter

That’s a prediction, that’s what…

Ìý

Jenner

It’s a prediction yeah.Ìý So, certainly it seemed to be very effective.Ìý But there’s so much further we could go.

Ìý

Porter

But one of the problems with salt is that people say, well I won’t add salt at the table, I won’t add during cooking but that’s not where they’re getting most of their salt from.

Ìý

Jenner

No, not really, in a few cases it is but generally about 15% of the salt is what’s naturally occurring, about another 10-15% is added at the table afterwards and that’s what you really taste.Ìý And the rest is in the food, whether it’s processed or cooking at home.Ìý So, all of those sauces that you use – stock cubes, soya sauces, table sauces, soups, bread – you never think of bread as being salty but it’s such a huge contributor because as a population we eat an awful lot of bread and one slice of bread can have as much as a packet of crisps, but you’d never know that.

Ìý

Porter

Last question on salt – lo-salt?

Ìý

Jenner

So, lo-salt is a potassium-based salt, it does have sodium in it as well.Ìý So, fruit and vegetable intake is really important for blood pressure that’s because they contain potassium.

Ìý

Porter

We think that’s good for people with high blood pressure?

Ìý

Jenner

We think that’s really good.Ìý So, potassium has the opposite effect to sodium and in fact the best evidence is that you want to increase your potassium, through fruit and vegetables, and decrease it through salt.Ìý But I will add that we’re also trying to get people used to having less salt, it’s a very habitual addition to your food.Ìý Lo-salt and other salt replacers taste salty, so you’re more likely to get real salt in other areas if you have it.Ìý So, I’d say ideally reduce it all.

Ìý

Porter

Thank you, Katharine.

Ìý

Margaret?

Ìý

McCartney

Well I think there are significant uncertainties in what we know.Ìý So, a Cochrane Review was performed in 2016 and it looked at the effect of reducing salt on blood pressure in people who had high blood pressure and had normal blood pressure.Ìý And they found reductions in both of those groups.Ìý The reduction was just about an average of 1 millimetre of mercury for a normal blood pressure and 5.5 if it was high.Ìý So, you see a more impressive reduction in people whose blood pressure was high.Ìý But critically what we really want to know is will this reduce heart attacks and strokes because that’s the whole point in treating high blood pressure, you’re trying to stop the complications from it.Ìý And another Cochrane Review, done in 2014, found very weak evidence of benefit only and they didn’t feel it was strong enough that we could say for certain to individual people with high blood pressure, if you cut down your salt intake you will reduce your risks of heart attack or stroke and that’s one of the gaps I think in the evidence as we currently have it.

Ìý

Porter

So, to be clear, it probably – if you have high blood pressure it’s good for the numbers but that might not translate into real benefit, which is actually what you want is protection against stroke and heart attack?

Ìý

McCartney

Absolutely.Ìý Now there’s reason why you could say well it sounds sensible, it looks sensible but I think we should really be aiming for better quality of evidence here.Ìý There was another study published in the Lancet last year, in 2018, that found that sodium intake was associated with cardiovascular disease and strokes but only when people had higher levels of salt intake, they said usually five grams a day.Ìý And they felt that by targeting people in the higher end of intake that’s the people who are much more likely to benefit and reduce the risk of heart attacks or strokes through it.Ìý But I think there are gaps in the evidence that we really should address.

Ìý

Porter

So, does salt feature in your discussion when you’re talking to somebody that you’re treating for high blood pressure?

Ìý

McCartney

Well certainly with high blood pressure yes, but I have to confess not really discussing it very much in people who are otherwise fit and well.

Ìý

Porter

What about other unanswered questions looking at lifestyle measures, is there anything else that stands out?

Ìý

McCartney

Yeah, it would be absolutely fantastic to have better trials on this.Ìý So, another study was published last year in the British Journal of Sports Medicine looking at exercise.Ìý And I was really astounded to find there had been no head to head studies, randomised control trials, comparing exercise directly with blood pressure and medication.Ìý Now that’s a really good trial that could be done to find out what the chances were of an improvement of your numbers depending on what intervention you went for.Ìý I think this happens informally in a lot of GP surgeries already, I think it’s quite common to suggest to people to try exercise first but it would be really great to have some data to give to patients to say look this has got X percentage of chance of working compared with medication.

Ìý

Porter

Okay, we’ve tried lifestyle measures but their blood pressure is still too high and we need to start treatment.Ìý Bryan, what should we be starting with and is there one family of drugs that’s better than others?

Ìý

Williams

I don’t think there’s an individual family that’s necessarily better than the others.Ìý What’s happened, that’s been really good in the last five years across the whole guideline spectrum across the world, is we’ve pretty much all agreed on the best drugs to use.Ìý The second thing that’s come across is that most people, to get their blood pressure controlled, need two drugs.Ìý And I think that’s an important message because often patients feel very disappointed when they discover that their blood pressure hasn’t responded to one drug, when in reality most people need two.Ìý In fact, in Europe the recommendations are now that most people should start treatment with two drugs simultaneously, alongside the lifestyle advice that they’ll already be getting.Ìý

Ìý

So, the question is what are those combinations and the prils and the sartans are the two classes combined with either a thiazide diuretic, that’s usually Bendrofluazide or Indapamide, they’re the two that get used a lot in the UK.Ìý Or with a calcium channel blocker, which is usually Amlodipine.

Ìý

Porter

And that opens the blood vessels up.

Ìý

Williams

Yeah, that’s a vasodilator.Ìý So, one is a diuretic that gets salt off, the other one is a vasodilator that opens up the blood vessels.

Ìý

Porter

And when using drugs, Margaret, in the UK, at the moment, we start with one drug at a time and then introduce a drug.Ìý Do we use that drug right up until its maximum dose, is that the best way forward?

Ìý

McCartney

Sometimes, sometimes.Ìý The classic example is Amlodipine, which is a calcium channel blocker, and at five milligrams generally is pretty well tolerated, most people wouldn’t have significant side effects with it.Ìý But when you put it up to 10 milligrams almost everybody gets ankle swelling.Ìý So, I think that’s the kind of classic one that many doctors and patients will choose not to go up to the 10 milligrams but to start another drug instead.

Ìý

Williams

As we’ve heard, I mean some of the drugs at high dose are more likely to cause side effects.Ìý So, there’s really good evidence that actually taking two drugs in middle dose or low dose is much more effective…

Ìý

Porter

The sweet spot.

Ìý

Williams

… than taking one drug at high dose.

Ìý

McCartney

Start low and go slow, particularly when people are on lots of other medications already or where people are perhaps less mobile or more frail, there tends to be a much cautious approach and doing things much more gradually to make sure we’re not adding to the burden of treatment.

Ìý

Porter

Bryan, what do you take, as an expert, if you had a choice?Ìý I know there’s guidelines but what…

Ìý

Williams

Yeah, I’ll tell you what I do take.Ìý I take Losartan drugs and Amlodipine.

Ìý

Porter

An ankle sweller.

Ìý

Williams

And I think the reason for that is that we know the sartan drugs, the Losartan, Valsartan, Omesartan, that group, generally associated with very little side effects, in fact they actually have lower side effects than placebo in the trials, probably because they produce some beneficial effect on headache incidence and things.Ìý So, that’s a popular combination I use for my patients as well.Ìý And in fact, if you tell people – I take this one – really doctor?Ìý You know, they’re often much more encouraged.

Ìý

Porter

Depends how healthy you look Bryan.Ìý

Ìý

Margaret, side effects are very important here because this is a group of people that outwardly and as far as they’re concerned don’t have anything wrong with them, so they feel fine and then you put them on a drug that could give you….I mean in practice what sort of side effects do we see with this group of drugs?

Ìý

McCartney

Well the big issue is the fact that they’re working, so people get the symptoms of low blood pressure, if you did it too quickly, particularly in people who are taking lots of other medicines, who are perhaps quite frail, have lots of other medical conditions going on.Ìý So, the big side effect really is that of low blood pressure, so people feeling a bit dizzy when they’re getting up from their chair, that postural hypertension that the blood pressure doesn’t come up as quickly as they would like.Ìý So, that, I think, is the biggest one.Ìý And quite often people will come in with what I would describe as kind of non-specific symptoms as well, just not feeling quite right on new medication and sometimes that’s a case of just persisting because quite often things seem to settle down if the person is keen to go on them.Ìý Diuretics, Bendrofluazide, classically, makes people pee more.Ìý We all would give advice about taking that first thing in the morning rather than last thing at the night, for example.Ìý And of course, with ACE inhibitors, the prils and alapril, ramapril, one of the classic side effects from that is a cough but it can be treated by moving to a cousin, which will usually stop that side effect from happening.

Ìý

Porter

We talked about getting on to drugs, I’ve had an email here from a listener who wants to know what their chances are of getting off drugs.Ìý I mean once you start treatment for high blood pressure is it always lifelong?

Ìý

Williams

Mainly.Ìý By and large you’re making a decision about lifelong treatment.

Ìý

McCartney

I think things do change over time.Ìý I mean I do think that once people get to be quite frail, their mobility is affected, complaining of a lot of side effects of treatment, perhaps lifespan is not very, very long, people quite often want to have a full and frank discussion about what the benefits and harms are of what treatment they’re taking.Ìý And certainly, none of this should be considered to be compulsory, it should be about shared decision making, sitting down with someone and saying, look what are the pros and cons of each thing that I’m currently taking and what do I want to continue and what do I not.Ìý Because side effects, you might not have had at age 50, you might well have at age 70, 80, 90.

Ìý

Williams

The reality is that’s the age group in which you see strokes and you see the development of the complications we’re trying to prevent.Ìý So, there’s good evidence that treating people in those age groups, even over the age of 80 we saw a reduction in mortality, can you believe, with treatment.Ìý So, there is good evidence.Ìý I like to talk – and we do talk – about the biological age of the individual, rather than the chronological age.

Ìý

Porter

And I think most listeners would agree with that, we all like to think we’re only as old as we feel and like to be treated as such.Ìý Professor Bryan Williams, and Dr Margaret McCartney, thank you both very much.

Ìý

Just time to tell you about next week when I find out how eye drops are being used to treat children who are short sighted. ÌýAnd medication shortages, from commonly used anti-inflammatories and diuretics, to HRT and anti-coagulants. ÌýWhy are pharmacies finding it so hard to get supplies of day-to-day medicines?

Ìý

ENDS