Ad hoc blood pressure lecture

I am attending on the dialysis service in December and the residents requested a lecture on hypertension. This was a sharp group so I decided to do an update on the literature and go through four papers in the session. It went well. We had lots of great discussions and answered a lot questions.

SPRINT. We talked about the impressive results but really focused on the very selective patients population and how it was not consistent with a lot of patients we see in clinic. We also focused on how they assessed blood pressure and how different it is than standard blood pressure assessment.

• NEJM
• PDF
• NephJC

The next study was HOPE-3 shows that when you apply what you know from SPRINT but use a standard blood pressure assessment and pair it to a less sick population you get a negative result.

• NEJM
• PDF
• NephJC

Then we looked at PATHWAY-2 to put add some evidence to the question of how should we treat resistant hypertension.

• Lancet
• PDF
• NephJC

Then we finished with "Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials" a fascinating meta-analysis that looked at dose response curves, and side effects. Really interesting paper. H/T Ricky Turgeon PharmD. The conclusion from the data is that adding additional drug classes at lower than standard doses results in a nice blood pressure improvement with a clean side effect profile.

• The BMJ
• PDF

Other suggestions that didn't make the 40 minute cut:

@kidney_boy HYVET

— Ross Nesbit (@RossNesbit) December 30, 2016

Treatment of Hypertension in Patients 80 Years of Age or Older

Agree this is an important study.

• NEJM
• PDF

@kidney_boy Bit late to this but ASCOT-BPLA

— Annette Neary (@feline_charm) December 30, 2016

Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial

I almost feel that a trial that has Atenolol in the control arm is practically a placebo. That drug never reduces events. I think the official tag line is "Atenolol: when all you care about is reducing the number on the dial."

• The Lancet

@kidney_boy ACCORD BP (lower not always better, esp. In Diabetics) since SPRINT included non-Diabetics. Would also include HYVET

— James Pritsiolas, MD (@Nephro_Doc) December 29, 2016

Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus

This is the opposite side of the SPRNT coin. Low blood pressure appeared to be of no benefit and possibly harmful (Table 2). Nice reduction in stroke though (Figure 2). 

• NEJM
• PDF

@kidney_boy ... and Symplicity HTN-3

— Indranil Dasgupta (@idasgupta7) December 29, 2016

A Controlled Trial of Renal Denervation for Resistant Hypertension

The mother of all medical reversals. Great study. Totally upset a runaway freight train of interventions. To me this shows that industry sponsored trials (when designed with the intension of FDA approval) are not marketing shams but can add clarity to medical knowledge.

• NEJM
• PDF

Why I am going along with the ABIM shakedown

So I received the e-mail telling me it's time to pay the ABIM or I will get the dreaded "not participating in maintenance of certification" addendum to my board certification.

This is horrible. If you make people take a massive high stakes exam to be board certified for the next decade then the ABIM should not effectively revoke that board certification (or at least put it in doubt) because I am not participating in continuing medical education in the way they see fit. I am an adult and can study and maintain my skills as I see fit. Taking, and passing the recertification exam proves I am responsible for my own education. It makes me so angry and it really feels like it is there just as a money grab. Don't tell me that I passed a 10 year recertification exam and then discount your own exam after  couple of years with that damn asterisk.

That said my whole career is built on certification. The privileges of being a doctor are due to a complex interplay of private and public certifications. Much of the edifice of nephrology is based on certification and hospital privileges preventing just any person or even any doctor from providing dialysis. I feel that since I receive so much from these certificates it is a bit hypocritical to pick and choose when I want to participate. I have cast my lot with the certification process so I will continue to participate.

Additionally, even though I have am angered and feel ripped off by the ABIM protection racket, when I try to explain the controversy to non-doctors they don't get it. People put so much trust in doctors and they are rightly terrified of getting a bad one. This is why Top Doctor issues of the local glossy magazine are so popular. People want a good doctor and intuitively know that their ability to recognize quality from personal interactions or or other superficial experiences it limited. People want systematic mechanisms in place to weed out poor ones and make sure all doctors are maintaining a level competency. Unfortunately, I feel that ABIM is not a good mechanism for this aim. But people are naturally suspicious when they hear that doctors are complaining about how onerous a certification process is. I think their first inclination is, "Yes! Hold those doctors to task." And while physicians fret about the nightmare that occurs to individuals that fail to maintain their board certification, the public feels the opposite, and are thankful that somebody is at the wheel trying to maintain the quality of the physician workforce.

So I am going to pay my pound of flesh and continue to work with ABIM to reform the system rather than leave it entirely.

Update:

Imagine if a year or two after graduating college, you get a letter from your alma mater telling you, that even though you completed all of the coursework and payed all the tuition bills, everytime someone inquires into if you actually graduated they were going to tell them "Yeah, but we don't think he is so serious about maintaining his skills and have reason to doubt his commitment." We would be happy to change this message to simply "Yes, he graduated" if you pay us $353.00 every year. It sure would be a shame not to get full credit for all the work you've done getting that degree, and compared to how much money you earn because of the degree, $353 is just not that much money."

I remember feeling screwed that my board certification, unlike people just a few years older than me, would require constant recertification. Ten years between board exams is not too onerous, but then after that they made the deal worse still, and now I need to recertify every ten years and pay them yearly, so ABIM doesn't smear my name in the public.

Maybe I should just pray they don't alter the deal any further.




Update. Even better video:

.@kidney_boy @rcamd @EleanorLederer This video better encapsulates the @ABIMCert 'deal' https://t.co/FhH8JiDVC1

— Just Some MD (@justsome_md) March 8, 2017

The pioneering generation of nephrologist is dying

Larry Fleischman, a pediatric nephrologist, and pioneer in dialyzing children has passed.

Larry was always a positive role model for me when I was a medical student.

Diuretic Infographics

For the second time I in the last month I was looking for these graphics n PBFluids and for the second time I couldn't find them. I was sure I had posted them, but I hadn't.

So here are my loop and thiazide diuretic infographics. Enjoy.