#81

Low BP not due to sarcopenia, cancer, bad health is probably a good prognostic indicator.

For patients who are having significant postural hypotension or other symptomatic low BP, the most common is fludrocortisone which is mostly a mineralocorticoid type cortisone and will result in retention of fluid.

Things we use in hospital for sepsis, etc, including alpha and beta agonists, but really isn’t an option out patient. Midodrine is sometimes used which is an alpha-1 agonist

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#82

Thank you @DrFraser. Great Info.

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#83

> Key is, how do you feel and function at 100/60? If fine, then you’re OK. I’m not a doctor, what does your doc say?

Funny, I was just talking to a general practitioner today about fear of hypotension at night, and she said the body has “mechanisms” to ensure adequate BP. I had no clue what she was talking about, but it felt good mentally

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#84

creatinine? wow, I have light ckd so I will pay attention. Telmisartan was doing work on my proteinuria though on the first reading (smaller/ very little protein), which is one of the reasons I thought to go high on it (I read higher is good for CKD)

what are the most common symptoms of too low bp? Worryingly I’ve had intermittient breathing problems at night but I thought it was my anxiety regarding low bp or GERD

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#85

My experience with 30 years of acute care, 27 years as an emergency physician, has me contemplate on symptoms vs. objective data.

So “dizzy” with normal or high BP … makes no sense. So low blood pressure can cause light headedness, and in extreme cases loss of consciousness typically while standing.

Shortness of breath with normal oxygen saturation and venous blood gas makes no sense.

What I do in the ER with patients with these symptoms generally, unless there are objective abnormal items yields nothing.

Sure we work folks up for every last thing, but … yield is typically negative.

So symptoms do not equal disease. Symptoms can equal disease, but only in the small % tile’s in my experience. I suspect @KarlT who has been in the ER possibly longer than me would concur.

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#86

Yes, couldn’t agree more. This is definitely a case of me pushing the limits too far to the point it hurt. Lesson learned.

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#87

Is there objective evidence that reducing SBP and/or DBP to a point short of incurring risks of dizziness, etc. confers health benefits? Some metrics once believed to be more-or-less linear have turned out to be some form of U-curve. I wonder this, for example, about the current push to reduce inflammation metrics to the lowest possible level.

#88

Yes, and no there are few U-shape curves in reality that aren’t fake by residual confounding. At least for the more popular metrics of health.

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#89

I am probably misunderstanding your point. I can think of a large number of health metrics for which some form of U-shaped number/benefit relationship applies. Of course, we will see various degrees of kurticity such as the steep peak for serum potassium, etc.

Serum-Based Metrics

  1. Serum Cholesterol (Total) – Both very low and very high levels are associated with increased risk of mortality.
  2. Low-Density Lipoprotein (LDL) Cholesterol – Excessive lowering of LDL may be harmful, as very low levels are linked with certain diseases.
  3. High-Density Lipoprotein (HDL) Cholesterol – Very low levels increase cardiovascular risk, while very high levels are paradoxically associated with adverse cardiovascular events.
  4. Triglycerides – Low levels can be associated with malnutrition, while high levels are linked with cardiovascular risk.
  5. Blood Glucose (Fasting) – Hypoglycemia and hyperglycemia are both harmful; moderate glucose levels are optimal.
  6. Hemoglobin – Anemia (low hemoglobin) and polycythemia (high hemoglobin) both increase morbidity and mortality.
  7. Blood Urea Nitrogen (BUN) – Both low and high BUN levels may indicate kidney or liver dysfunction.
  8. Alkaline Phosphatase (ALP) – Very low and very high levels are associated with increased mortality, particularly in older adults.
  9. Ferritin – Both iron deficiency (low ferritin) and iron overload (high ferritin) are associated with increased morbidity and mortality.
  10. Thyroid-Stimulating Hormone (TSH) – Both hyperthyroidism and hypothyroidism (low and high TSH) increase cardiovascular and all-cause mortality.
  11. Uric Acid – Low levels may suggest neurodegenerative disease risk, while high levels are linked to gout and cardiovascular disease.
  12. Calcium (Serum) – Both hypocalcemia and hypercalcemia are associated with increased risk of cardiovascular disease and mortality.
  13. Sodium (Serum) – Both hyponatremia and hypernatremia can increase the risk of mortality, particularly in the elderly.

Functional and Other Metrics:

  1. Body Mass Index (BMI) – Both underweight and overweight/obesity increase the risk of mortality, with a U-shaped curve for BMI and mortality.
  2. Resting Heart Rate (RHR) – Very low or very high resting heart rates are linked to increased cardiovascular risk, with moderate rates associated with better outcomes.
  3. Sleep Duration – Both too little sleep (<6 hours) and too much sleep (>9 hours) are associated with increased morbidity and mortality, forming a U-shaped curve.
  4. Vitamin D (Serum 25(OH)D) – Both deficiency and excessive levels are associated with adverse outcomes, such as cardiovascular disease, falls, and mortality.
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#90

My point is that many of them are fake, because of residual confounding.

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#91

What to the experts, users, and studies suggest is the common reduction of systolic and diastolic for 40 and 80mg doses?

#92

You can find it at the FDA label at Drugs@FDA. For systolic it’s about 9-13 mmHg at 40 mg, then 12-13 mmHg at 80 mg iirc. So the dose increase seems to tighten BP outcome space.

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#93

As a numbers guy, I can see that possibility. Do you have a couple of examples off the top of your head.

#94

BMI - fake.
HbA1C - fake.
LDL cholesterol - fake.
Dietary sodium intake - fake.
BP - fake.

The U-shape bottoms at being overweight, diabetic, with high LDL cholesterol and BP. All because of residual confounding. Of course too low is of course bad for many of these, just that the optimal range is way off.

Gil Carvalho did a video on this too.

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#95

I love the way you challenge conventional thought. I don’t even think you believe the things you just wrote, but it is more of challenge to individuals to think around the data.

So yes, you can claim confounding due to poor lifestyle, but ultimately, as a physician, these markers end up having an indicative part of my assessment of risk of premature death or disability.

Are there individuals with a BMI of 30 that are metabolically healthy? Absolutely, but are there folks with a a BMI of 50 who are ---- not a single one of them.

Same thing with the other measures - there is outcome data, and as much as there are confounders, as a human being, I’d much rather have my BMI at 23 than 50, my HbA1C at 4.7 than 10, my ApoB at 70, my sodium intake <1500 mg/day, and my SBP <120 mmHg. All of those items predict a better health and lifespan.

Now as to whether having good numbers is the direct cause of the mortality benefit - I don’t think it hugely matters - the actions required to get good numbers are important and the numbers are just an indication of those actions.

Very scared to start a challenge like this with you – I’ll likely bow out early!

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#96

I think you misunderstood my point.

The “good” numbers “discovered” in these studies, is actually in the true suboptimal range if they weren’t flawed with residual confounding, that’s my point. The lowest ACM is being diabetic. Same is being overweight. Or have high LDL cholesterol. That’s what the studies say.

That’s why the U-shape curves are fake, because they clearly are and because of other evidence showing it’s residual confounding placing where the bottom of the curve is.

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#97

Brilliant, we agree … so glad about this as you are way too smart to debate.

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#98

I think predictive and perhaps other forms of validity are being confused with the shape of a curve which was my original question. This becomes obvious when a (theoretically) “true” value is referenced.

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#99

It’s not going to be at the level where you’re not falling from dizziness.
I think optimal seems to be as low as you can go without that happening, with care if you’re older to be extra careful not to increase your risk for falls. Yanomami have quite low BP throughout their life, but it’s ecological data.

See this thread also:

#100

For this example, avoiding trauma as one gets older is critical, so a risk/benefit has to be part of the equation. It doesn’t help you to have a SBP of 90 and take a fall fracturing your hip at age 80 where you have a 50% mortality as a result in the next 12 months. The benefit in lowering BP as folks get in the 70’s+ also diminishes. Not to say we shouldn’t treat systolics of 200, but I’m not sure we have good evidence for pushing this down into the 110’s.
I tend to look at avoiding adverse outcomes in my practice, and as such, there is a need for a balanced approach. Perfection can be the enemy of good.

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