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Interview

Editor’s note: This interview was originally published in the My Blood Pressure Newsletter. If you are interested in having your blood pressure story told, please email Kellie or Steve at support@my-health-software.com.

Interview with Norman M. Kaplan, MD

Kellie’s note: I interviewed Dr Norman Kaplan on March 28th 2006, by phone.

Norman M. Kaplan, MD is the Clinical Professor of Medicine at The University of Texas Southwestern Medical Center Dallas, Texas, USA., where he has been
on the faculty for over forty years. Dr. Kaplan has published numerous books and papers on hypertension including the highly acclaimed clinical reference, Kaplan’s Clinical Hypertension which is now in its 9th edition.

Kellie: What role do you think home monitoring of blood pressure has?

Dr. Kaplan: The use of home monitoring is an essential part of proper management of hypertension. Only by repeated home monitoring can both the patient and the physician really know how well managed the hypertension is. Home monitoring is essential for the diagnosis of hypertension.

Kellie: What are the benefits that you see for home monitoring on an ongoing basis?

Dr. Kaplan: Home monitoring is a strong motivation for people to continue their treatment and stay under medical management. It’s one of the few things that has actually been shown to improve adherence to treatment. If the patient will take their own blood pressure they do much better in continuing on their management. So, I think it’s been shown to really be an important part of medical practice.

Kellie: I guess as hypertension is generally symptom less it’s hard for people to see the urgency. I guess that’s why it’s called the silent killer.

Dr. Kaplan: Absolutely! I often tell people that hypertension would be much easier to manage if it hurt. If it caused symptoms when blood pressure was elevated they would do something about it. But, unfortunately as you say it is usually an asymptomatic process until a heart attack or stroke develops.

Kellie: What is white-coat hypertension?

Dr. Kaplan: Many people who have a moderate degree of hypertension in the physicians’ office, find that when they take their own blood pressure at home they are normal-tensive. Those people have white-coat hypertension. There is no real certainty that it’s a benign condition because the latest data suggests that many will go into usual hypertension, a number above 140 over 90.

There is a very large group of people who have border line hypertension above the optimal 120 over 80. But, they are not yet at 140 over 90. Now, that group is being referred to as having pre-hypertension rather than a high-normal blood pressure which was our previous designation. I think the term pre-hypertension is appropriate because most of those people will proceed into definite hypertension.

Kellie: What are your thoughts on the treatment of pre-hypertension?

Dr. Kaplan: We don’t yet know for sure as to whether pre-hypertensive people should be given active drug therapy. However, in the current issue of the New England Journal of Medicine a paper was published by a group of investigators headed by Dr. Stevo Julius at the University of Michigan. They preformed the TROPHY (TReatment Of Pre-Hypertension). The study analyzed 800 pre-hypertensive patients with a blood pressure of between a 130 up to 139 systolic and diastolic from 85 to 89.

Half of these people were treated with an angiotensin receptor blocker and the other half they left on a placebo. After 2 years those who were on the active drug had 66% less chance of developing hypertension. Then they stopped the medication at the end of 2 years and watched these people over the next 2 years.

Most of those who had been normal-tensive on the medication during the first 2 years did in fact develop high blood pressure; that is their blood pressure went above 140 over 90. No one can claim earlier treatment will prevent hypertension. However, the TROPHY study gives us some strong evidence that we can at least delay the development of hypertension.

I think in the very near future, we will have an increasingly strong momentum towards earlier drug therapy for many patients, particularly if they are close to 140 over 90. We are also more likely to give earlier drug therapy to patients who have diabetes, have some renal damage or have been in heart failure due to their inherent high risk. I think that the same approach could be used for a lot of people, who are not necessarily at very high risk, in the attempt to prevent the development of hypertension.

Kellie: As a benefit of getting blood pressure down to say 120 over 80 or below, you are saying that it could help delay the onset of hypertension?

Dr. Kaplan: We hope so, we think so. There is a straight line up with every increase in the blood pressure an increase in heart attack and stroke. So many of us are coming around to a concept that the lower the readings the better off for the patient.

Kellie: Can everyone’s blood pressure be lowered to an optimum level?

Dr. Kaplan: There has to be a limit as we can’t give everyone medication and we can’t lower the blood pressure to 120 over 80, particularly in most of our older patients. People in their seventies and eighties who have predominantly systolic hypertension may find it very difficult to bring their systolic down.

They usually have a normal or even low diastolic and I think the majority of us will accept 160 as a reasonable level to try and achieve in the older patient that is over 65 or 70 years. But, that is a big group and a growing group and we need more evidence about treating those patients.

Kellie: What are your thoughts on encouraging people to home monitor their blood pressure?

Dr. Kaplan: Well there are people who think we have to pay patients to do what we want them to do! Unfortunately, we don’t have the money to do that. I would prefer to educate the patient and tell them the reward will be a longer life without cardiovascular disease.

The availability and use of home monitoring of blood pressure is not being as widely used as it should be. If it were to be widely used it would have a major impact on a large population of people with hypertension. I am a strong advocate of people monitoring their own blood pressure. Of course if they do being sure that they translate that information to their health care provider and take appropriate action.

Kellie: What changes do you see in the future for the management of hypertension?

Dr. Kaplan: If I were to predict the future I would say that we will begin treating hypertension like we now treat diabetes. The patient will monitor their own problem and adjust their therapy according to what they find at home. We are doing that routinely for Type 1 diabetes.

A diabetic patient must take their blood sugar levels with a needle to obtain blood. This is obviously more painful and difficult than taking your blood pressure. They do that 4 times a day! And then they adjust their insulin dose accordingly. The diabetic is in a much more vulnerable situation than a patient with hypertension. So the need to do this may be less obvious in hypertensive, but I think all of us should take the longer view that what we are doing today is going to have an impact in the future.

Kellie: Thank you for your time Dr Kaplan. All the best!

Dr. Kaplan has been a member of the Joint National Committees on Detection, Evaluation and Treatment of High Blood Pressure and served on the Executive Committee of the American Society of Hypertension from its founding. He has been made a Master of the American College of Physicians and given the Lifetime Achievement Award by the American Heart Association’s Council for High Blood Pressure Research. Dr Kaplan also sits on the World Health Organization/International Society of Hypertension (WHO-ISH) Guidelines Committee and National High Blood Pressure Education Committee (NHLBI).

Kellie’s note: Steve & I are grateful to Dr. Kaplan for sharing his time so generously and know many of you will benefit from his extensive experience and knowledge on
hypertension.

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About Kellie

Kellie is 37 years old and together with her brother Steve makes up the My Health Software team.

She helps on the websites and gathering news for the programs. Kellie worked in the medical industry prior to having her two children (8 and 6) and has a strong interest in self awareness and management of health conditions.


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