Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, April 11, 2009

Hypertension for Lawyers

I got an email the other day from this crotchety guy in his 80's who I've known for years. His current beef is that he resents being labeled "hypertensive" even though his blood pressure has been well-controlled on medication for many years. As so many others do, he quotes his Wikipedia professor from the university of Google:
Hypertension, also referred to as high blood pressure, HTN or HPN, is a medical condition in which the blood pressure is chronically elevated. In current usage, the word "hypertension" without a qualifier normally refers to systemic, arterial hypertension.
The article continues:
Hypertension can be classified either essential (primary) or secondary. Essential hypertension indicates that no specific medical cause can be found to explain a patient's condition. About 95% of hypertension is essential hypertension. Secondary hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another condition, such as kidney disease or tumours (pheochromocytoma and paraganglioma). Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic renal failure.
He asks for my response.


The problem here is entirely semantic. Then again, the guy is a lawyer, so he tortures words for a living.

For starters, in medicine the terms "hypertension" and "high blood pressure" are not technically synonymous, although they are often sloppily used as such. Not every patient whose blood pressure measures above the normal range has the disease "hypertension", and not every "hypertensive patient" has measurably high blood pressure.

The main problem is that I take issue with the description of "essential hypertension" as "no specific medical cause can be found to explain a patient's condition." I prefer to define essential hypertension as follows:
A complex multi-system disorder in which the body's assorted regulatory mechanisms interact in such a way as to keep the blood pressure too high.
The body has many ways to regulate blood pressure: how fast the heart beats; how hard it beats; total blood volume, regulated by total body sodium content as controlled by the kidneys; caliber of arterioles as controlled by smooth muscle in the blood vessel walls. Different antihypertensive medications work on each of these and other parts of the varying control mechanisms, which is why moderate doses of meds in different classes often work better than maxing out a single drug.

The problem is that even though the blood pressure itself may be kept within the normal range, the condition apparently has other effects not directly related to the actual blood pressure. This is probably why people with this condition are at a higher risk for heart attack and stroke, even when the BP is optimally controlled. For example, there seems to be a relationship with elevated serum cholesterol levels, another known risk factor for cardiovascular disease (and also modifyable with medication.)

By analogy, a father is defined as a man who has children, even when they are not physically with him. In a group of unaccompanied men, it may not be possible to discern which ones are fathers and which are not, just as simply measuring blood pressure cannot differentiate between non-hypertensives and patients with controlled hypertension.

Therefore just because your blood pressure is controlled does not mean you no longer have the disease "essential hypertension."

Hope that clears things up.


At Sat Apr 11, 02:44:00 PM, Blogger Dr. Deb said...

My hubby is a lawyer which makes for interesting conversations too. You explained things so well here that the best litigator - or google wiki user- could not object anymore.

At Sat Apr 11, 06:50:00 PM, Anonymous Anonymous said...

Yeah, there's this crotchety guy in his 80's who I've known for years too -- and he's a lawyer as well. (In fact I'm having Easter dinner at his house tomorrow.) I think he misses doing litigation (when he actually got paid for appearing to be all worked up over something) so now he looks for situations in his (actually very smooth) life where he can exercise those same "righteous indignation" mental/emotional muscles. For example, he's complained to me about how absurd it is that a bank puts a hold on the starter checks he writes on a new account. I just listen to him argue his case, say "I hear ya!" and don't get worked up myself. Unless I'm feeling litigaty myself and feel like arguing the other side (as I occasionally do). I usually get the conversation to a fairly quick conclusion by agreeing that he has a point. (I don't always say it's a GOOD point, of course.) Saying "I love you" usually changes the course of the conversation for the better as well, but I'm sure you've tried that tack as well. Carry on, Dr. D!

Kensington MD

At Sat Apr 11, 07:23:00 PM, Blogger Unknown said...

Interesting that, based on your patient's question, you looked at and apparently read the wikipedia page, composed a lengthy, well-thought-out, interesting and informative reply, sent that reply to him, made a blog post about it, and then, among all those things, didn't edit the wikipedia page. That would have improved wikipedia, perhaps kept future people (your patients or otherwise) from coming to the same misunderstanding, and, best of all, would have allowed you to say to him "No, you're wrong. Wikipedia doesn't say that. Read it again!" (which may have the added benefit of enlightening your patient as to the trustworthiness of medical advice from wikipedia)

At Sat Apr 11, 10:56:00 PM, Blogger ShrinkingDoc said...

At least he's smart enough to not make the next jump and ask why he can't just stop the blood pressure medicine now that his blood pressure is normal...

At Sun Apr 12, 08:39:00 AM, Blogger Dr. RB said...

I sure hope I don't spend my "golden years" arguing with my doctor semantics such as these. Get this man a different hobby.


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