The Art of Medical Practice: What is the Ideal BP?

Medical practice has evolved into a science that has become too guideline-centric. New graduates and practitioners alike are now so focused with guidelines-driven medical practice that they have now forgotten the very fundamental ethics in medicine and that's not only to " Do No Harm " but also must include us to think in a more rationale way on how to treat our individual patients.  HMO's find guidelines very handy as their bible to decide on which modality of treatment to cover or not and this is where the flaw and cracks start to irritate in me as a medical practitioner.

Blood pressure management has been a focus of endless debates and revisions over what is ideal and what is not. Too many guidelines that has confused not only the medical community but patients alike. We know for a fact as doctors of medicine of one fundamental truth....that is  " normal blood pressure has been conclusively shown to be associated with lower major cardiovascular events i.e. congestive heart failure, heart attacks and strokes " yet, our guidelines have always focused on cut-offs as if all patients are created equal. Authorities as what they call themselves must realized that we are not into the McDonalds business where french fries tastes the same regardless of which outlet you get it from. Our patients are not the same and will never be and that's where the fundamental flaw comes into play. 

The latest JNC-8 published in December 2013 on BP management boldly raised the threshold and recommended therapy on over 60 years old if their BP goes >150/90mmHg and >140/90 mmHg for those younger than 60 yrs old. This was done despite the lack of evidence supporting their recommendation while virtually ignoring the very basic evidence we have that targeting  less than 140mmHg have been shown to save lives.

I have always believed that each patient is unique and must be dealt with and approached individually rather than just another warm body that is either 60yrs old or less.  My guiding principle has always been to individualize therapy rather than just blindly following what guidelines want us to do. We know our patients more than anybody else and I believe that a targeted BP of 120-130mmHg or lower (as long as tolerated) remains to be the optimum target REGARDLESS OF AGE. It has worked for many in the past with studies to back it up so why should we just change because of some JNC-8 authors believe otherwise?

In the latest publication from a NIH-sponsored study  SPRINT (Systolic Blood Pressure Intervention Trial) on 9,200 patients published Sept. 11, 2015 conclusively showed a significant reduction by almost a third in the incidence of myocardial infarction, congestive heart failure and stroke for those randomized to a target BP of 120mmHg vs the recommended 140mmHg. This same group also benefited by having a reduced incidence of overall death by almost a quarter.

With these most recent findings I feel vindicated on what I have always  been doing and believed in......to keep BP goal as low as possibly tolerated regardless of age. This is in keeping with the hippocratic oath we all vowed as medical practitioners to do no harm and with good intentions do whatever we think  is best for the patient regardless of guidelines. 

It is not the intention of this article to bash on guidelines because it is for the most part evidence-based and our way of measuring what good clinical practice is all about. It is my belief however, that physicians  must not feel hostage to it and it is hoped that we physicians exercise open-mindedness and independence even if it means thinking outside the box  to do what is best for our patient because after all, the practice of medicine is an art and not a perfect science.