#555 - Blood Pressure Targets, “Dirty Dozen/Clean Fifteen” 2024, All In?
Take 3 – Practical Practice Pointers©
From the Literature
1) Blood Pressure Lowering – How Much and For Whom?
Ever since the SPRINT trial, we’ve been litigating the value of ever lower goals for hypertension therapy. SPRINT did show a reduction in major adverse cardiac events and overall mortality for elderly patients at high risk for heart disease, but unfortunately, the major US guidelines (from the American Heart Association (AHA)/American College of Cardiology (ACC)) on hypertension used that information to lower blood pressure goals for everyone. The American College of Physicians and the American Academy of Family Physicians disagreed and still recommended 140/90 goals for adults < 60 years and a 150/90 goal for adults 60 years and older (though the AAFP has recently reduced the goal to below 140/90 for all).
In the Lancet, a new study from China has been published – an open-label, but blinded outcome trial of intensive vs. less intensive treatment of systolic blood pressure (SBP). Patient in the intensive group were treated to less than 120 mg Hg SBP and the less intensive group was treated to less than 140 mm Hg. Importantly for generalizability reasons, the patients had “high cardiovascular risk” – defined as a diagnosis of cardiovascular disease (coronary artery disease, stroke, etc.) or two major cardiovascular risk factors (>=60 years for men, >=65 years for women, diabetes, hyperlipidemia, or current smoking). The study was done well overall in terms of validity criteria (except for being open label), and they overcame some limitations due to the COVID-19 pandemic. The median follow up was 3.4 years. The primary outcome was a composite outcome (major vascular events) – i.e., myocardial infarction, revascularization, hospitalization or emergency department visit for heart failure, stroke, or death from cardiovascular causes. The authors also examined side effects such as hypotension and advancement of chronic kidney disease.
There were 11,255 subjects with a mean age of 64.6 years, 41.3% were women and 38.7% had diabetes, 28.9% had coronary heart disease, and 26.9% had stroke. At randomization, both groups had SBP in the mid-140s, and both groups met their target SBPs on average in the trial. The intensive group needed 2.7 medications on average, versus 2 medications in the less-intensive group. The primary (composite) outcome occurred in 547 (9.7%) of participants in the intensive group and 623 (11.1%) in the less intensive group (hazard ratio (HR) 0.88; 95% confidence interval (CI) 0.78 to 0.99; p=0.028). This results in an approximate number needed to treat (NNT) of 71. One of the limitations of composite outcomes is that it is possible that the least severe outcome ends up accounting for all the effect. Not in this case. Cardiovascular death was significantly less likely in the intensive group (HR 0.61; 95% CI 0.44 to 0.84, NNT ~ 167). The risk of death from any cause was also significantly reduced (HR 0.79; 95% CI 0.64 to 0.97). None of the other outcome differences were individually significant.
For adverse events, the composite kidney outcome (end stage renal disease, glomerular filtration rate (GFR) decline) occurred in 3.0% of the intensive participants and in 1.8% of the less intensive group (HR 1.70; 95% CI 1.33 to 2.17, number needed to harm (NNH) ~83). The overall rate of serious adverse events was equal between groups, but syncope (sometimes resulting in hospitalization or fractures) was more frequent in the intensive group (HR 3.0; 95% CI 1.35 to 6.68, NNH~333).
John’s Comments:
I think the point is made about treating patients at high cardiovascular risk to lower SBP goals. However, it takes an additional medication (3 vs. 2), on average, to get people to these goals. For those of you watching (or being measured on) HEDIS metrics, you’ll note that they don’t really capture the subtlety of high vs. average risk when defining SBP goals – instead, I think they’re aiming in the middle, as recommended by the ACC/AHA guidelines. Control of hypertension is clearly an important clinical goal, but we face multiple barriers – inadequately specific metrics, therapeutic inertia on the part of clinicians, cost to patients, etc.
Reference:
· Liu J, Li Y, Ge J, et al. Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial. The Lancet. 2024;404(10449):245-255. Link
From the Environmental Working Group (EWG)
2) The Fresh Produce “Dirty Dozen” and “Clean Fifteen” 2024
The Environmental Working Group (EWG) is a nonprofit organization focused on human health and the environment. Since 2004, EWG researchers have published an annual report regarding pesticide content in fruits and vegetables called the “Dirty Dozen” and the “Clean 15,” creating the rankings based on laboratory tests done by the FDA and the U.S. Department of Agriculture's Pesticide Testing Program.
The 2024 guide includes data from 47,510 samples of 46 fruits and vegetables. The USDA peels or scrubs and washes produce samples before testing, whereas the FDA only removes dirt before testing its samples. Even after these steps, the tests still found traces of 209 different pesticides. Some of the USDA’s tests show traces of pesticides long since banned by the Environmental Protection Agency. Non-organic produce is loaded with fungicides that may harm human hormone systems – four of the five most frequently detected chemicals are fungicides.
The 2024 “Dirty Dozen” list, in descending order: 1. Strawberries; 2. Spinach; 3. Kale, Collard, and Mustard Greens ; 4. Grapes; 5. Peaches; 6. Pears; 7. Nectarines; 8. Apples; 9. Bell and Hot Peppers; 10. Cherries; 11. Blueberries; 12. Green Beans.
Over 50 different pesticides were detected on every type of crop on the list, except cherries. More than 90% of samples of strawberries, apples, cherries, spinach, nectarines and grapes tested positive for residues of two or more pesticides. Kale, collard and mustard greens, as well as hot peppers and bell peppers, had the most pesticides detected of any crop — 100 pesticides in total. The neurotoxic organophosphate insecticide acephate, prohibited from use on green beans in 2011, was detected on six percent of green bean samples.
The 2024 "Clean 15'' is a list of the produce least likely to contain pesticide residue. The list, in descending order: 1. Avocados; 2. Sweet corn; 3. Pineapples; 4. Onions; 5. Papayas; 6. Sweet Peas; 7. Asparagus; 8. Honeydew Melons; 9. Kiwis; 10. Cabbages; 11; Watermelon, 12; Mushrooms; 13. Mangos; 14. Sweet Potatoes; 15. Carrots.
Almost 65 percent of the Clean 15 samples had no detectable pesticide residues. Avocados and sweet corn were the cleanest produce – less than 2% of samples showed any detectable pesticides. Just over 10% of Clean 15 samples had residues of two or more pesticides. No sample from the first six Clean 15 items tested positive for more than three pesticides.
Mark’s Comments:
It is difficult to estimate the extent of the health hazard from this, as there are many variables (amount of exposure, type of toxin, etc.). Unfortunately, there are no cleaning processes that can effectively eliminate toxins but washing with water has been shown to be beneficial in at least removing some of the pesticide residue.
Critics not involved in the report say they worry the list will discourage people from eating fruits and vegetables. Certainly, minimizing exposure as much as possible would seem to be prudent, which may mean avoiding or buying organic for the “dirty dozen.” However, the EWG does recommend eating produce even from the Dirty Dozen rather than foods or snacks that are less healthy, such as processed foods laden with fat, sugar, salt, or additives.
Note that the government labels as “organic” food grown without synthetic chemicals or fertilizers, genetic engineering, radiation, and sewage sludge. Unfortunately, in general organic food is more expensive and not accessible to many.
References:
From PeerRxMed ( www.PeerRxMed.org )
3) “Hatching” New Insights through Nested Meditations – I’m “All In”
After more than 4 ½ years, the SARS-CoV-2 virus finally caught up to me this week. Being in isolation has provided a lot of reflection time, so I didn’t consider it at all a coincidence when I received a text from one of my faculty colleagues with a picture of a poem I had written and shared with some or our residents in June of 2022 as part of our R&R (“Reflection & Renewal”) resident support group, which I co-facilitated. As you might recall, it was around that same time we were really looking to “open up” due to a relative decline in COVID activity, and there was much uncertainty, disagreement and various levels of comfort around doing so, even within the medical community.
In writing the poem, I was inspired to use a particular structure called a “nested meditation,” which was originally introduced to me through the work of psychologist Kevin Anderson, PhD. A nested meditation is a brief, accessibly written meditation that begins with a single line, then repeats, adding one additional line at a time. As each line is added, the meaning of the piece shifts and when read slowly with a pause after each stanza, important insights or “Aha’s” often emerge.
The poem “All In” attempted to help sort out some of my own thoughts and emotions during that time (and now!). Though when I wrote it I had no idea where it would finally “land,” I was pleased where it did. As you read it, stop after each stanza to see what bubbles up for you and then consider trying to write one yourself (would start with 4 stanzas). You might be quite surprised as to what surfaces for you. Then take the time to share some insights (and perhaps your newly written nested meditation) with your PeerRx partner, a colleague, a friend, or even me. I’m all in! How about you?
All In
We’re all in!
We’re all in
this together ...
We’re all in
this! Together
we will find the way out!
We’re all in
this. Together,
we will find the way out
of our collective disconnection.
We’re all in
this …. Together
we will find, the way out
of our collective disconnection
is to honestly share our joys and sorrows with others.
We’re all in
this together.
We will find, the way out
of our collective disconnection
is two; – honestly share our joys and sorrows with others
and – lovingly hear theirs in return.
______________
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.
Email: mhgreenawald@carilionclinic.org