Brief Answer:
How's your blood pressure treating you these days?

Detailed Answer:

Hello,

First, many thanks for the kind comments you shared after the last consultation question. I'm glad I was able to give you some ideas.

Now, on this 2nd go around you've pressed the envelope to a slightly different level on the playing field so to speak by asking me what you can do until you've seen an appropriate...to which I must confess I am a bit stumped for an answer other than the most obvious perhaps which would be....see an appropriate as soon as possible.

Recommending treatments in the conventional sense of the term can only come after a full history, physical examination, and proper diagnostic testing have been performed. Even more in the setting of a telemedicine consultation which is occurring from a remote location where I've not even had the pleasure of knowing even what your appearance may be like.

In other words, it has always been a firm policy and teaching of mine that one should not treat what one does not know. You've already added one additional piece of information to the mix which we did not have before regarding your blood pressures and heart rates. At first glance, I would say that for an 88 year old a blood pressure of 128 systolic is extraordinary. Of course, you're also on blood pressure medications (multiple) which I must raise a concern against it.

Typically, it is NATURAL for blood pressure to rise slightly as we age due to loss of elasticity of the blood pressure walls and other metabolic factors where certain chemicals normally in the circulation that regulate pressure, and wall tension may be depleted due to lower levels of production- expected consequence of aging. Therefore, I PERSONALLY do not throw out too many concerns for patients of MINE who have systolic blood pressures that run a bit on the higher side such as in the 140's, 150's, and even 160's. I do not believe that those numbers for someone in their 9th, nearly 10th decade of life (those numbers are not typos!) should be terribly aggressive with in terms of trying to lower.

In fact, I might even suggest that you've given some key information which could explain in large degree the other symptoms that we discussed as either aura to an acephalgic migraine or TIA. With heart rates in the 50's and 60's and blood pressures as low as you're reporting who is on THREE ANTIHYPERTENSIVES,I would first, before anything on my physical examination, measure what's called ORTHOSTATIC pressures and I would use a method known as a MODIFIED AMINOFF protocol.

Blood pressures are taken in different positions over a period of roughly 8-10 minutes and the numbers are looked at for extreme drops in pressure from one positional change to another as well as the presence or not of extreme vs. normal rises in HEART-RATE depending upon the position under discussion.

Now, Alfuzosin is also used as a relief drug for urinary retention due to an enlarged prostate gland, however, it can also cause or amplify the effects of lowering blood pressure. The hydrochlorothiazide is a diuretic which is primarily used to lower blood pressure but because it makes patients urinate more and frequently, I question why this drug should be necessary especially if you've got an enlarged prostate which already may make it difficult to void. Adding the diuretic in my opinion is potentially the equivalent of adding insult to injury and therefore, I would reconsider that combination.

Therefore, I believe one POSSIBLE MECHANISM to explain the PRIOR symptoms you mentioned about blurry vision and other aura that we've previously described is that you may be really suffering from the amplified effects of having your cardiovascular system adversely kept in check by way of both BLOOD PRESSURE and HEART-RATE, both of which are too low to keep up with system demands.

Therefore, the upshot of that volume deficiency could be lack of blood supply to the head (especially in the standing or seated positions) resulting in the aura you report, blurred vision, and generally not feeling well. My guess is that your symptoms are not likely present so long as you maintain the recumbent position.

In conclusion, based upon this newer information I would suggest that you have a clear discussion with your provider who prescribed all those medications as to whether or not they'd be willing to slowly back you down or even eliminate 1 or 2 of those medications to see if these other symptoms don't improve or even resolve.

That is where I would start, even before seeing any neurologists,
neuro-ophthalmologists, cardiologists etc. Look at the most common manifestations of excessively lower blood pressure in an 88 year old gentleman and I think you'll get some mileage before going through a lot of elegant tests spending a lot of time and potentially money looking for things that are not present. Make sense?

What measures can possibly counter the exaggerated effects of antihypertensive medications (aside from stopping them or pulling back on their dosages?)? Well, all the ones your mother told you about.....DRINK PLENTY OF WATER AND OTHER GOOD FLUIDS....get rid of caffeinated, soda pop, and alcoholic beverages in order to maintain good vascular volume. Secondly, you could perform ACE WRAPS of the legs, all the way up to the thighs or purchase some THIGH HIGH TED HOSE from the local pharmacy to put on during the day, you can remove them at night.

Finally, there is the old standby of increasing your salt intake to at least 3000-4000mg. of good old table salt, or salt tablets and this will increase fluid volume. But remember, at the same time, you name to get your heart rate a bit faster as well. I think this will happen as you cut back on some of these other medications.

Those are the things sir that I would recommend doing or discussing as soon as possible with your primary doctor (or whomever prescribed those medications).

Once again, Tally Ho!

Hope I have answered your query. Let me know if I can assist you further.

Thank you.

Regards,
Dr. Dariush Saghafi
Neurologist

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Brief Answer:
BLOOD PRESSURE control varies with age

Detailed Answer:

Hello,

The concept of blood pressure as being contributory if not causative for many cases of strokes, TIA's, and heart attacks is a well known and documented fact, however, the question is one that is not as obvious and has an answer that varies more with each patient's personal/individual status. While it is never a good idea to have HIGH blood pressure on a chronic basis, one has to also understand that in certain ages and genders of our population, the natural tendency for blood pressure to rise as a result of the loss of elasticity in the walls of the arteries and arterioles is not necessarily as dangerous as in young people. In other words, although the blood pressure guidelines do not specifically distinguish age groups against limits of normal blood pressures the fact is..we should not be highly aggressive to lower blood pressure in someone who is >65-70 years of age if it is not excessively elevated over what we would naturally expect according to the aging process. The reason is that in being overly aggressive with medications, the OPPOSITE effect which can be just as undesirable can occur.

I believe there is a POSSIBILITY that this is what is occurring in your case and your symptoms are more a reflection of overzealous BP control. In my personal clinic and practice I am not terribly aggressive with someone of your age group with systolic pressures in the 150's. I may get more excited if that number were to rise into the 160's or 170's. But again, I don't know that I would use triple drugs to bring it down into the 120's which is what you say you've been at. I think that is probably a bit low for you to function optimally because your vascular system simply is not as plastic as it used to be. Forcing the blood pressure into those lower numbers makes it very difficult for your body to tone up the vasculature as needed to compensate for your bodily activities especially if you've also been told to exercise or stay fit, etc. etc. Makes sense?

Therefore, my suggestion is that you work with your doctor to dial down some of those high powered anti-hypertensives and see where your symptoms go to and make that your "happy medium" without getting terribly excited about specific numbers.

By the way, I too do all my hospital work through the Neurology Service at the XXXX Medical Center in XXXXXXX so I do know what you may sometimes experience in terms of getting appointments etc., though in my opinion, there have been improvements. Cheers Soldier!

That is why I also recommended the use of the MODIFIED AMINOFF ORTHOSTATIC BLOOD PRESSURE TEST as a way of gauging first whether or not the medication load you were on could perhaps be a little too much.

Hope I have answered your query.

Thank you.

Regards,
Dr. Dariush Saghafi
Neurologist

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