Pressão arterial ideal que devemos atingir? Sistólica abaixo de 110 ou 100?

[scta123]

@DeStrider

L-citrulline

SInce I have been taking L-citrulline I have seen a drop of about 4-5 points. Went from average of 111/66 to 106/64.

@Ziegelhausen

Typically, my BP drops over night while asleep, then comes up 5-10 points around wakeup.

This is my pattern as well. I have highest BP readings around my wake up time.

[DeStrider]

It could also be the Taurine. According to Consumer lab, Taurine reduces SBP by 7 and DBP by 5 over long term use (12 weeks). Another great reason to take taurine!

[ng0rge]

Mine averages 115/74. I’ve been taking 3g citrulline and 1 gram of taurine daily but has had no effect on my BP. The few times it went below 110/70 were at night.

[RobTuck]

Sorry for lowering the level of conversation but those of us over 65-75 should be equally concerned with low BP. A conk on the head can be more life threatening than BP in the upper normal range. I have had several relatives with this problem and I suspect I am at risk. My measured BP varies across the day from 125/75 to 110/68 but I suspect that it drops below that. My daytime resting pulse is in the mid- to high 40’s my sleeping pulse is in the mid to low 40’s. Some of this is due to a lifetime of distance running and some is genetic. I have yet to be dizzy from transitory low BP but I am prepared for it to happen as I age.

[adssx]

@RobTuck

My measured BP varies across the day from 125/75 to 110/68 but I suspect that it drops below that.

I’m not an expert but I think these are normal numbers. Hypotension is defined as <105/65 on average during daytime (nighttime: <90/50, 24h: <100/60). You’re above that. And you say you don’t even have hypotension symptoms. (Adding one more morning coffee can help increase BP if needed.)

[Virilius]

40mg of telmisartan a day brought my numbers down to 126/79 after a week of use (hypertension is huge in my family tree). It also made me much more active which is a welcome side effect.

[adssx]

What was your BP before starting?

4 weeks of telmisartan 20 mg and 2 weeks of 40 mg only decreased mine from 133/79 mmHg to 125/73 (per Aktiia). So I’ve just added amlodipine 2.5 mg. Wait and see…

What do you mean by more active? I also felt something like this but I wasn’t sure it was linked to telmisartan. In Parkinson’s patients, candesartan significantly reduced apathy:

• A randomized clinical trial of candesartan for cognitive impairment in Parkinson’s disease

By the way, on Aktiia: it’s hard to compare to a proper cuff as it takes measure randomly. I tried to compare and there were sometimes large differences between Aktiia and my cuff (I’d say +/- 10 mmHg for SBP and +/- 5 mmHg, I didn’t do this very conscientiously…) but the daily and weekly averages were almost identical. So I trust the device to give trends. The app and the reports suck: you cannot set your own thresholds, they don’t provide proper time in range data, nor do they give pulse pressure and MAP. I now wear it 24/7, including while showering: no issue so far (I have the new waterproof model).

[Virilius]

@adssx

What was your BP before starting?

12X-13X / 9X.

What do you mean by more active? I also felt something like this but I wasn’t sure it was linked to telmisartan.

I seem to have much more energy and motivation without feeling restless. Stuff that I’ve procrastinated doing for months I’ve finished in days. I don’t think that’s placebo because all I expected of telmisartan was to have some additional protection from cardiovascular disease and kidney protection. I only noticed today that it might be related to telmisartan itself as that was the only medication/supplement I started recently.

In Parkinson’s patients, candesartan significantly reduced apathy:

I don’t think I have Parkinsons…

[adssx]

@Virilius

12X-13X / 9X.

Wow impressive réduction then! You should look at your PP and MAP before/after as well.

@Virilius

I don’t think I have Parkinsons…

Of course I didn’t say this but what you describe is also exactly what I felt: increased motivation, aka lower apathy. And if they were able to measure that in PD patients it might be a general “side effect” of some ARBs. There’s also an ongoing trial of ARBs for depression (but the leading researcher never answered my email…), and decreased motivation is one depressive symptom (among many others).

[Virilius]

Hey if it helps resolve my low-grade depression as yet another benefit I’m perfectly fine with this side effect. SSRI didn’t help me at all in that regard, rather they just made me lethargic and content so I quit them after a few months.

[DeStrider]

Higher BP increases plaque formation.

Blood Pressure: Changing Artery Plaque Formation

[adssx]

@DrFraser you’ll like this: Efficacy and safety of a four-drug, quarter-dose treatment for hypertension: the QUARTET USA randomized trial 2024

Ultra-low dose quadpill of candesartan 2 mg, amlodipine 1.25 mg, indapamide 0.625 mg, and bisoprolol 2.5 mg vs. candesartan 8 mg for 12 weeks (and “If BP was >130/>80 mm Hg at 6 weeks in either arm, then participants received open label add-on amlodipine 5 mg.”).

Results of the quadpill compared with candesartan 8 mg:

• SBP: −4.8 mm Hg (95% CI: −10.8, 1.3, p = 0.123)
• DBP: −4.9 mmHg (95% CI: −8.6, −1.3, p = 0.009)

I find the protocol weird; adding amlodipine 5 mg to amlodipine 1.25 mg raises the risk of edema significantly. A better protocol would have been to say “If BP >130/>80 mm Hg at 6 weeks, then double the dose”. This is probably why “A somewhat higher proportion of participants experienced one or more adverse events in the intervention arm compared with the control arm (63% versus 47%, p = 0.210).” I’m not convinced by the addition of bisoprolol either, 2.5 mg is not that low a dose: the starting dose of bisoprolol for heart failure is 1.25 mg.

It’s still interesting to see that an ultra-low dose drug combination achieves faster and better BP control than the standard dose of a single antihypertensive:

These findings were observed despite a substantially lower odds of amlodipine 5 mg add-on at six weeks in the intervention arm compared with the control arm (19% versus 53%, model estimated Odds Ratio = 0.08 [95% CI: 0.02, 0.41], p = 0.003). A higher proportion of participants achieved hypertension control defined as blood pressure <130/<80 mm Hg (66% versus 54%) in the intervention arm compared to the control arm, but the results were imprecise (model estimated Odds Ratio = 2.85 [95% CI: 0.94, 8.59], p = 0.063).

I can’t wait for the results of the GMRx2 trial (telmisartan, amlodipine, indapamide in various doses).

[DrFraser]

I agree. The general strategy with blood pressure management - at least for my patients is to gently hit multiple receptors. The rate of side effects with most pharmacologically active substances goes up as you head to maximal dose - and tends to be very low when just giving a tiny dose. Yet the benefit for most drugs is significant at low doses.
One of the substances I have some patients on for blood pressure if Hawthorne Extract - which is a fascinating extract from a berry that has multiple pharmacologic activities similar in a lot of ways to this combination they provided.
@adssx is absolutely correct - the logical approach is to double the dose of the very low dose combination.
One of the things pointed out here is just how little of an impact this had on BP. If you had a SBP of 160 mmHg - getting this down to 155 isn’t going to have you very impressed with the drug you are taking. I commonly have patients in the ER with SBP of 200 or 220 mmHg. It’s usually not an emergency to manage this as there is no short term health risk to high blood pressure (in most cases). But thinking forward as to how I’d manage them if I were their primary care physician, a combination that takes 5 mmHg off … is pretty much worthless.

[adssx]

@DrFraser

But thinking forward as to how I’d manage them if I were their primary care physician, a combination that takes 5 mmHg off … is pretty much worthless.

Yes, it must be hard to reduce BP in these cases! In QUARTET the ultra-low quadpill decreased SBP by about 15 mmHg:

For GMRx2, they note: “The systolic BP (SBP)-lowering efficacy of GMRx2 strengths 1, 2 and 3 (Table 2) from a baseline SBP of 150 mmHg are expected to be approximately 13 mmHg, 18 mmHg and 25 mmHg, respectively.”

So how do you reduce SBP beyond 25 mmHg? I’d say:

• Lifestyle: reduce alcohol and salt intake, use potassium salt, more exercise, eat less, sleep hygiene, etc.
• Lower weight and insulin resistance (the association is impressive) with SGLT2i and GLP-1RAs
• Add another BP-lowering drug: low-dose beta blocker? spironolactone? terazosin?

The 2023 European guidelines say:

[DrFraser]

These guidelines are very sensible. I think the issue is tolerability. As people get older, the tendency to have significant postural changes is a real risk for falls and loss of consciousness. There is a need for careful advice on change of position and making sure everything is doing well before just going from lying to standing and heading off. Most agents have significant risks - and when we are looking at moderate/high doses of 3-4+ classes of medications, there has to be a careful evaluation of risk/benefits.

I find that I can get most people controlled nicely with no more than 3 agents - and I do go stepwise with telmisartan, then amlodipine, then indapamide unless there is a reason to do something else. In violation of the usual approach of not pushing the dose of any drug - I will maximize telmisartan as the neuroprotection seems to occur at 80 mg but not necessarily at 40 mg.

This is an interesting area where there is nuance. Just in the same way one looks at colon, breast, prostate cancer screening and consider at what age stop doing this? It shouldn’t be the age - it should be the anticipated years of quality life potentially remaining. So if a person is expected to only live another 5 years - tightly controlling their blood pressure isn’t sensible if it risks falls and loss of consciousness - if the life expectancy might be 20 years - then managing this becomes more relevant -similarly with cancer screening.

It is complicated when having a gestalt of how long someone will live. I think I have a pretty good sense of this … as there are people who are 35 years old who are not likely to see age 40, and there are people who are 80 that I think are likely to live to 100.

[adssx]

@DrFraser

I will maximize telmisartan as the neuroprotection seems to occur at 80 mg but not necessarily at 40 mg.

Interesting. Which papers/data suggest this?

[DrFraser]

So this is an issue with PPAR-y activation which if one does a search on Pubmed you’ll see that the higher dose telmisartan seems to be important - whereas under 80 mg isn’t active.
You are much more skilled than am I finding all the references and citing them. But there are a whole lot in this space that I’ve looked through. I think if you are on telmisartan - this is a drug worth pushing to at least 80 mg before adding another drug. Also - for my patients who have risk of neurocognitive decline - if they have enough BP to allow adding this - as it usually doesn’t lower BP that much - I think it is very sensible to get them on this.
I must say the recent post by @RapAdmin showing dementia risk by ApoE status has me doubling down on the need to do everything possible to decrease risk and start as early as possible. My goal to live >100 years cognitively intact is threatened by my ApoE3/E4. I’m happy that I’m able to tolerate Telmisartan 80 mg with no seeming side effects.

[adssx]

Looks like you’re right!

“40 mg/day telmisartan failed to exert an appreciable clinical efficacy through PPAR-gamma activation, but showed clear effects at 80 mg”

(Telmisartan at 80 mg/Day Increases High-Molecular-Weight Adiponectin Levels and Improves Insulin Resistance in Diabetic Patients 2012)

[Neo]

@DrFraser

the recent post by @RapAdmin showing dementia risk by ApoE status has me doubling down on the need to do everything possible to decrease risk and start as early as possible. My goal to live >100 years cognitively intact is threatened by my ApoE3/E4.

Here is the post if anyone wants to take a look and can’t find it (was actually by me, in response to a different comment by RadAdmin):

Predicting Alzheimers

Part of that is that women live longer and AD incidence goes exponential around 70-80 and beyond, so men die before it explodes in prevalence. For virtually anyone who wants to live to 100 or beyond, if you don’t have Apo E2/2 you will be at an extremely high probability of getting AD unless you (and future science and medicine) find way to mitigate it. See here for an example of what things look like for late 90s and 100s: [IMG_7107] Full paper and discussion below. The conclusion of who will get AD is fundamentally different if we are talking about people who on average die by 77-82 years of age or who on average die in their 90s, 100s or beyond. (perhaps unless you are Apo E2/2 - even Apo E2/3 start dropping off the cliff with age, and Apo E2/2 might also once passed 100 years old we just don’t have the data) So all of us should be focusing on AD prevention as much as @AnUser focuses on minimizing cardiovascular risks. Exceptionally low likelihood of Alzheimer’s dementia…

[DrFraser]

Thanks @Neo for this great post.

I appreciate that Dr. Greger does cherry pick things a bit – but his take on ApoE is really interesting, given high prevalence on Nigeria, but low rate of AD. Here is a link to his video on this topic:
https://www.youtube.com/watch?v=zQBJScaGxJI