519 - HTN in the Elderly (2), Stains and DM, The Wounded Healer
Take 3 – Practical Practice Pointers©
From the Literature
1) More on How We Treat Hypertension in the Elderly
Last week, we discussed some considerations in treating hypertension in the elderly –there is an short-term increased risk of falls, fractures, and acute kidney injury (AKI), so caution is warranted when starting antihypertensive therapy. So, should we be worried about patients who already have some low blood pressure symptoms before treatment of their hypertension? This week, we examine a meta-analysis of hypertension trials studying the outcomes (all-cause mortality and a composite of non-fatal cardiovascular events or all-cause mortality) associated with treating hypertension in the setting of baseline orthostatic hypotension (a change of 20 mmHg of systolic blood pressure (BP) or 10 mmHg in diastolic BP when going from sitting to standing) or standing hypotension (a standing BP of <=110/60 mmHg).
This meta-analysis looked at trials comparing “intensive blood pressure management” with conventional treatment. All the appropriate quality boxes were checked in this review. Nine trials contributed data on over 29,000 patients. The mean age of the included patients was 69 years, with equal sex distribution, and about ¼ of the participants were of black race. All-cause mortality was associated with orthostatic BP (hazard ratio (HR), 1.24; 95% confidence interval (CI), 1.09-1.41) and standing hypotension (HR, 1.38; 95% CI, 1.14-1.66) prior to hypertension treatment. The composite outcomes of non-fatal CV event and all-cause mortality was also significantly associated at a similar effect size.
Intensive BP treatment lowered both outcomes (composite and all-cause mortality) for patients without orthostatic hypotension (HR, 0.81; 95% CI, 0.76-0.86 and HR, 0.84; 95% CI, 0.760.92 respectively). The authors state that, in addition, intensive treatment “lowered risk of CVD or all-cause mortality among participants with orthostatic hypotension (HR, 0.83; 95% CI, 0.70-1.00)”, but reported a confidence interval that contains the possibility of no effect (1.00). For standing hypotension, the authors showed significant reductions in the composite outcome in the non-hypotension groups, and non-significant reductions in the standing hypotension counterparts. However, because of small sample sizes of patients with standing hypotension, the authors claimed that the statistical results for the two groups were not significantly different from each other and concluded that intensive treatment in the setting of standing hypotension resulted in similar reduction in risk of the composite outcome.
This whole study reads like it has an agenda to justify intensive blood pressure treatment in the elderly by somehow reassuring us it is safe. I think the learning point from this meta-analysis is that orthostatic hypotension and standing hypotension are both risk factors for bad outcomes. As I wrote last week, for the elderly in whom you treat hypertension, start low and go slow and monitor for hypotension, especially if they already have baseline low BP. This study doesn’t reassure me that treatment is either particularly beneficial or without risk in this population.
- Juraschek SP, Hu JR, Cluett JL, et al. Orthostatic Hypotension, Hypertension Treatment, and Cardiovascular Disease: An Individual Participant Meta-Analysis. JAMA. 2023;330(15):1459. Link
From the Literature and a Question From a Patient AND a Colleague
2) Revisiting the Impact of Statin Medications on Blood Sugar
Question: “Why are statin medicines being recommended for those with diabetes if taking them could potentially make diabetes worse?!”
Answer: Statins are generally well tolerated and have shown benefits in lowering cardiovascular morbidity and mortality. However, their association with an increased risk of new onset diabetes led the US FDA to approve a label revision in 2012 to add that increases in glycated hemoglobin (HbA1c) and fasting glucose levels have been reported for those taking statins. The US Preventive Services Task Force reference this in their 2022 recommendation on statin use for primary prevention of CVD, as does the American College of Cardiology/American Heart Association 2018 guideline on statin use.
Consensus exists that the increased rates of diabetes in people who take statins are due to statins. The precise mechanisms by which statins increase the risk of diabetes are not fully understood. Evidence suggests that statins may contribute to both key pathophysiological drivers of type 2 diabetes: multi-organ insulin resistance and dysfunction of insulin secreting pancreatic beta cells.
Based on estimates from RCTs, the number needed to harm (NNH) is one additional person will develop diabetes attributable to taking statin for every 100-250 over 2-5 years. This is compared with a number needed to treat (NNT) of between 50-150 over 5 years to prevent one major adverse cardiac event for primary prevention.
Factors that can increase the risk for developing diabetes with statin use include:
- Higher dose intensity and cumulative dose
- Preexisting diabetes risk factors
- Presence of hepatic steatosis
- Older age (> 65)
Considerations for practice could include:
- Check A1c at initiation of statins, at 3-6 months, after dosage increase, and yearly
- Perform intentional risk stratification and modification for diabetes risk for those who are taking statins
- Thoughtfully assess need for higher intensity statins
A reminder that for persons with diabetes, both the American Diabetes Association and the American College of Cardiology/American Heart Association recommend the following: For patients with diabetes aged 40–75 years (A) and >75 years (B) without ASCVD, use moderate-intensity statin in addition to lifestyle therapy.
As we know, the clinical practice of medicine is all about trade-offs and for trying to apply statistical probabilities for individual patient care. Statins have proven benefits at reducing ASCVD but may indeed have some effect (long term) in worsening diabetes control. Even for primary prevention, the numbers favor treatment, and the scales are tipped even more for greater CVD risk factors, including diabetes. Seems a great opportunity to educate our patients.
From PeerRxMed ( www.PeerRxMed.org )
3) The Wounded Healer: There is Power in Sharing Our Stories
It’s likely happened to all of us, many times in fact, but the “gut punch” impact doesn’t wane. Perhaps it was a letter notifying you of a malpractice case or board of medicine inquiry, or a message about a peer review concern. Or perhaps it was your own realization that you had overlooked a lab or x-ray abnormality, or had misprescribed a medication. It may have been a patient complaint, or a colleague being critical of our care.
In any case, the immediate reaction is a sense of dread, or anger, or numbness … or more likely a combination of a myriad of difficult to access emotions – and of perhaps the desire to want to hide. Over time if not addressed appropriately, these emotions can expand to a chronic sense of shame, fear, vulnerability and can lead to indecision, apathy, a loss of confidence – and isolation.
This was the case for me after receiving an inquiry from our state board of medicine in 2007 regarding a patient death. What ultimately transpired was a long, drawn out, and emotionally exhausting process that I’ve only recently had the courage to revisit at the invitation of a colleague for the podcast Rx For Success: Life Changing Moments.
What I shared surprised even me, and it wasn’t until I listened to the interview that I realized while the circumstances of my story are perhaps unique, the importance of what I have learned from this prolonged journey of emotional healing is more universal for physicians. And as I became tearful around minute 30, I also realized that there was some unprocessed emotional residue still lingering from that time – that my healing was not yet complete.
Perhaps it is only in telling our stories that true healing can come, or perhaps serving as witness to another’s story is enough. In either case, I would encourage you to listen to the entire interview. At the least, it may provide a model and some encouragement for you to share your own stories of the traumatic emotional wounds obtained on this professional journey with a trusted colleague (your PeerRxMed partner?). More so, maybe you will hear some of your own story in mine, and in that case my ongoing journey of healing might be a catalyst for your own as well. Either way, you come out a better person on the other side.
Seems like a worthwhile investment to me … click here to give a listen:
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.