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Old 01-20-2005, 05:14 AM   #1
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Angry Unsuccessful Doc's appointment

Hi All,
I had my three monthly BP check with the doc this morning. I don't have a regular doc, i get whoever is available at the time. Last time i had an appointment my BP meds (Perindopril) was increased from 2mg to 4mg. The doc wanted to see my readings around 130/80 not the 140ish/85 i was getting. Anyway my readings have not improved since the increase in meds. When i went this time i asked if i could check my BP device against hers and she said no i should make an appointment with the nurse for that or better still send it away to be re-calibrated. I didn't think that was a very helpful comment. On top if that she said the nurse will monitor my readings and decide if i should be refered to the doc again for an increase in my meds. It seems like one step forward and two steps back. I saw the nurse for 4 months prior to my referal to the doc, and now i am going back to her. The other doc i saw last time plainly said see how the meds go for 3months and come back for a check with one of the doc's. Today's doc two readings, the first 165/90 and the second 144/85, she said there is a large margin of error there and the nurse should look in greater details. Maybe i have got it all wrong but to me it seems obvious that i have a touch of white coat, and the longer i am there the calmer i become. She never gave me the impression she though this.

After all this i don't know whether to go to the nurse and then the doc, or just to ignore her and go back to the original doc i had 3months ago.

I hear so many people saying that with meds they are around the 120/80 mark. I feel if i must take meds i want to be atleast 130/80. Do you think i am silly wanting another increase in dose or even try another med to get reading like this. I just feel that why am i taking meds if i am still get average readings of 140/80ish.

Thanks
Paul

 
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Old 01-20-2005, 07:03 AM   #2
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Re: Unsuccessful Doc's appointment

Paul,

I strenoulsy recommend being happy with 140/90. I posted a rant on the subject yesterday.
Taking more and more drugs to get to some fanciful notion of perfection is striking me more and more as a fool's paradise.
My goal is an UNMEDICATED, consistent, 140/90 (and I am very close.) Further conversations with any doctor of the matter will soon become VERBOTEN!

I think the way to medicate is to take the LEAST amount of drugs to get to the 140/90, at home, relaxed in a comfortable chair.

When White Coat enters the picture, unless you have a COMPLETELY understanding doctor who is willing to accept UNQUESTIONINGLY your home numbers, there is simply no point in EVER broaching the subject of hypertension with him. It becomes similar to trying to describe a beautiful TURNER painting to a person who has been blind from birth...a contradiction in terms!

Last edited by Lenin; 01-20-2005 at 07:04 AM.

 
Old 01-20-2005, 07:55 AM   #3
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Re: Unsuccessful Doc's appointment

Very well put Lenin. I have white-coat at the doc. of 156/86 many times. On my own it averages 114/66 medicated on Atenolol and Lotrel. I am only 34 & have white-coat. Un-medicated it was 135-137/74-80 for years. The meds. do have terrible side-effects (at least for me). I would not want an increase in dosage. I want off of the meds!!! The side-effects aren't worth it.

 
Old 01-20-2005, 11:26 PM   #4
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Talking Re: Unsuccessful Doc's appointment

Thanks for your replies. I average the 140/80ish mark, but i do spike occasional throughtout the day to 158/95. When i look back over last years readings though it doesn't seem as though the meds i take work that well, i reckon my systolic has reduce 10points max before and after taking meds. After your comments it makes me wonder if it was worth me starting to take meds to begin with. Mind you i did get larger spike of up to 180/100.

regards
Paul

 
Old 01-21-2005, 03:30 AM   #5
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Re: Unsuccessful Doc's appointment

Paul,


Lenin's Rant (good title for a short story) notwithstanding, I know from many other posts of yours that you've been concerned about your MEDICATED BP for a long time. Your #s have been on the slightly high'ish side since you were 21, right?

What are/were your UN-MEDICATED #s???

If, UN-medicated you could get yourself into the so-called pre-hypertension range (120-139/80-140) that could be a good case to get off the meds, while adopting healthy lifestyle changes if you haven't already.

Plenty of routine daily exercise, low sodium diet, diet lower in saturated fats, more fish and chicken, less red meat, lots of fruit and veg, lose weight if overweight, alcohol in moderation.

You once mentioned that your BP remained elevated while on a 24-hour ambulatory hook-up...this virtually takes "white coat" out of the picture and gives one is a pretty definitive indication of whether you have true hypertension or not. What #s did you get then???


I agree that having to go back to the nurse again seems like a waste of time. I'd bypass that step and go straight back to the orig doc you saw...

What #s to shoot for is a very personal decision. If your present meds aren't making much of a dent for you but you want those #s down, then a med adjustment or switch might be in order.

Must ask this...Given that you are young, that your BP started to rise in your 20's, and various medication isn't quite doing the trick, has the doctor ruled out the possibility of secondary causes of HBP? ( which can be any number of kidney disorders, renovascular causes and endocrine tumor (usually benign) of the adrenal glands.)


Ultrasound, CT scan or MRI of your kidneys would rule out renal artery stenosis (obstruction of the renal artery) and kidney problems including cysts or scarring.
And a 24 hour test for PLASMA METANEPHRINES is the most specific test for the adrenal gland tumor called pheochromocytoma. There is also a 24-hour urine test for this, but it's not as definitive.

For years most emphasis was placed by clinicians on the diastolic BP but now, the systolic is considered a far greater predictor of future or present cardiovascular risk. I personally would be a much happier camper with a systolic of 120 (or even 130) than 140.

I know our blood pressure fluctuates all day every day...the important and most salient questions are how often DOES it spike? How often DOES it stay elevated? Does it spike just once in a blue moon? A couple of times a day? A few times a week? And how long does it stay elevated before "normalizing?

Obviously, the more hours during the day that one's blood pressure is high, the worse it is on the cardiovascular system.

zuzu xx

 
Old 01-21-2005, 05:32 AM   #6
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Talking Re: Unsuccessful Doc's appointment

Hi Zuzu, thanks for your help. My average readings prior to meds were 154/85, with spikes of around 171/94. I am not 100% sure of my readings whilst on the 24hr monitor because at that time the doc never diagnosed me with HBP so i didn't take it too seriously, but i think it was around 143/85ish.

I have to admit i find lifestyle changes a problem, I go good for a while then I have a bad patch. I don't smoke, my diet and alcohol intake could be better, I get exercise walking my dogs, but to be honest they seem to stop more than walk. So i really have plenty of room for improvement.

With regards to test so as to rule out secondary hypertension, well i think that has been extremely limited. I have had the 24hr monitor, a blood test and an ECG. After that the doc's decided that i should be treated and that was the end of story. I am considered a long term meds taker by my doc's.

About my meds, I have taken 25mg atenolol, 50mg atenolol, 2mg perindopril and finally 4mg perindopril. Besides my unmedicated readings given above all of these meds have roughly maintained an average BP of 140/80. It just seems wasted my taken these meds if i can't budge further than these figures.

regards
Paul

 
Old 01-21-2005, 05:50 AM   #7
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Re: Unsuccessful Doc's appointment

Quote:
Originally Posted by *Paul
Last time i had an appointment my BP meds (Perindopril) was increased from 2mg to 4mg.
I could tell from the name it was an ACEI (-pril suffix), but I hadn't ever heard of it. So, I looked it up. I'm wondering why the doctor even wasted your time trying the 2 mg dose in the first place. This is from the label:
Quote:
Pharmacodynamics: In placebo-controlled studies of perindopril monotherapy (2 to 16 mg q.d.) in patients with a mean blood pressure of about 150/100 mm Hg, 2 mg had little effect, but doses of 4 to 16 mg lowered blood pressure. The 8 and 16 mg doses were indistinguishable, and both had a greater effect than the 4 mg dose.
...
Use in Uncomplicated Hypertensive Patients: In patients with essential hypertension, the recommended initial dose is 4 mg once a day. The dosage may be titrated upward until blood pressure, when measured just before the next dose, is controlled or to a maximum of 16 mg per day. The usual maintenance dose range is 4 to 8 mg administered as a single daily dose.
It looks like the 2 mg dosage is really only made for folks with reduced renal function. The drug itself is a rather strange choice. It appears to be a very expensive ACEI. In fact, it appears to be more expensive than most ARBs! So, I am a little puzzled as to why anyone would ever use this drug. I didn't see anything about it that appears superior to lisinopril or any other ACEI.

Pal

 
Old 01-21-2005, 06:27 AM   #8
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Re: Unsuccessful Doc's appointment

Ultrasound, CT scan or MRI of your kidneys would rule out renal artery stenosis (obstruction of the renal artery) and kidney problems including cysts or scarring.
And a 24 hour test for PLASMA METANEPHRINES is the most specific test for the adrenal gland tumor called pheochromocytoma. There is also a 24-hour urine test for this, but it's not as definitive.


I never had any of this Zuzu. They just did a CBC, thyroid test, metabolic function test (basically all of the blood tests), urine check (a quick one), 2 EKGS & 1 chest xray. All of my #'s were good for kidney function. The doc. said that pheo is so rare that she didn't think that I needed that test.

 
Old 01-21-2005, 09:59 AM   #9
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Re: Unsuccessful Doc's appointment

Axe-

All these additional tests are not necessarily "de rigeur" unless the patient is in their 20's, OR symptomatic of pheo etc, OR BP control seems elusive when on 3 or more drugs simultaneously.

However, that said, when a person is under 40 and presents w/ hypertension for the first time many doctors believe that at the very least, the 24-hour urine test should be done which establishes whether there are any excess urine metanephrines or urine catecholamines. (hormones)

If any of these are abnormal, it might indicate a "pheo". Yeah, pheos are not common but it's possible to have one (or more) of these small tumors for years, since they are normally benign, with the only symptoms being panic/anxiety and sporadic/intermittent hypertension.

zuzu xx

 
Old 01-21-2005, 10:14 AM   #10
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Re: Unsuccessful Doc's appointment

Paul,


You've been hyperstensive since aged 21.. BUT before your doctor throws you into the "meds-for-life" pile, personally I would insist on the 24-hour urinalysis for catecholamines and the plasma free metanephrines test. They are simple and non-invasive.

It may be that in fact you have essential (primary) hypertension and not secondary... but again, you are only 29 and in my very very humble opinion, your youth warrants a little deeper "delving".

P.S.
Now if we could only get our dogs to NOT stop at every tree!

 
Old 01-21-2005, 10:16 AM   #11
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Re: Unsuccessful Doc's appointment

Thanks for your reply Zuzu. I do have anxiety. Have had it since I was diagnosed with HBP. My 2nd doc. in the last 2 years said tests for Pheo for me were not necessary. She wanted to watch my glucose since it was 103 & she switched me from 100 MGS of Toprol to 100 MGS of Atenolol. She left the practice one month later. She wanted to wean me off of the Atenolol in time & didn't believe in Xanax. She immediately tried to wean me off of Xanax & put me on Paxil, which made me feel like I had a 5 day stomach flu.... brilliant. My 3rd doc. who is in the same building said that Xanax is fine for me & that SSRI's like Paxil don't work for him personally either. He is very wishy-washy when it comes to weaning me off of Atenolol or Lotrel, even though I am averaging 112/62-68, 99% of the time outside of his office. I set an appointment with a specialist, because it seems that none of these GP's seem to really understand white-coat or anxiety. They do understand prescribing HBP pills though. When I mention the side-effects, he says to eat something. I tell him that I do & he says well it beats getting a stroke. How am I going to get a stroke when my B/P outside of his office goes to a max. of 140/83 when I am really really stressed at the very worst. I am tired of dealing with GP's that are incompetent, so maybe the specialist will put me on a better path of less or no meds. or one med. without all of the side-effects. My appt. is 2/16. It's been almost 2 years. I just want my life back......

 
Old 01-21-2005, 10:20 AM   #12
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Re: Unsuccessful Doc's appointment

I was also 32 when I was 1st put on B/P meds. Now I am 34, so my 20's aren't that far away. I also look 24.

 
Old 01-24-2005, 05:21 AM   #13
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Talking Re: Unsuccessful Doc's appointment

Hi Zuzu,

Thanks for the advice. I have just spoken to the nurse at my medical centre, she is requesting the doctor consider me for 24hr urine test, so i very happy with that, some headway at last. Do you feel i should try requesting some of these other tests (Ultrasound, CT Scan MRI) or would i be pushing mt luck?

Is the 24 hr test for PLASMA METANEPHRINES the same as the 24hr urine, or are they two different tests that test for the same thing.

What does a 24hr urine test intial, or is it abit graphic to discuss on the forum.

It's funny after talking to the nurse on the phone she said your last reading was 144/88, and that she would be happy with that. Am i unreasonable to want better readings whilst on meds. If i could get these readings without meds i would only consider lifestyle changes, but if i must take meds than i don't want to settle with borderline.

Thank you (and everyone else) for your helpful comments.

Regards Paul

 
Old 01-24-2005, 10:45 AM   #14
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Re: Unsuccessful Doc's appointment

An ultrasound or CT scan would reveal physical abnormalities with your kidneys, although if there are adrenal tumors they tend not to show up on those tests. I had both tests which revealed my left kidney is bigger than my right, so we feared kidney obstruction, even though I have never had symptoms. I then was given a renal scan, which tests kidney function and there was no imparement in kidney function. So if a ultrasound or CT scan showed an abnormality it may or may not be significant.

The 24 hour urine test may or may not reveal a problem if one exists, it is somewhat unreliable. So just getting a negative with that test does not rule out a problem. This test is just as the name implies. To start the test, you get up in the morning and first thing void into the toilet. For the next 24 hours, whenever you have to urinate, you collect whatever you do and add it to a big jug they give you. So the following morning when you get up at the same time, you collect that morning sample and add it to the jug as your last "contribution". You have to keep this jug in the refrigerator until you can turn it in to your doctor.

You can look this test up on line. I was going to take this test and then didn't. My doctor told me there was nothing special I had to do in preparation, nor for the test. On line I've read there are dietary restrictions in preparation for the test. Ask your doctor about that.

 
Old 01-25-2005, 10:10 AM   #15
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Re: Unsuccessful Doc's appointment

Paul,

Just to add a bit to Mgraylorn's info,

I've heard that the blood test is more reliable (but more expensive I believe).I also read an article a while ago by a Dr. Graeme Eisenhofer, who is Director of the Clinical Neurochemistry Laboratory at NIH (National Institutes of Health), who concurs that the test for plasma metanephrines is a much more specific test for pheochromocytoma. It can be very useful in identifying pheos which are less active, and therefore difficult to diagnose.
As for the 24 hour urine tests...they're not quite as successful at picking up intermittently secreting tumors.

But it's a good start.

Later, if the urine test shows nothing, it's probable that a pheo can be ruled out, particularly since you have none of the big symptoms that usually accompany these tumors. If you were having huge and sudden SPIKES of elevated BP, sweats, panic attacks, severe headaches etc then I would insist on the plasma test. You may want to ask your doctor why NOT have the plasma test?

I would however get your doctor's feedback about a renal scan to look for renal stenosis. He shouldn't balk if you request it..If he does, I'd want to know why. Since I'm not a doctor, it would be good for all of us to hear the answer!

zuzu xx

 
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