{"version":"1.0.0","segments":[{"startTime":0.629,"endTime":3.24,"body":"[intro music]"},{"startTime":3.24,"endTime":5.64,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.24,"endTime":5.64,"body":"to Harrison's Podclass"},{"startTime":5.64,"endTime":8.77,"body":"where we discuss important"},{"startTime":5.64,"endTime":8.77,"body":"concepts in internal medicine."},{"startTime":8.77,"endTime":9.91,"body":"I'm Cathy Handy."},{"startTime":9.91,"endTime":11.84,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.91,"endTime":11.84,"body":"Wiener, and we're coming to you"},{"startTime":11.84,"endTime":13.69,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.81,"endTime":20.19,"body":"Welcome to today's episode, a"},{"startTime":15.81,"endTime":20.19,"body":"68-year-old with hypertension."},{"startTime":20.19,"endTime":22.81,"body":"Hey Cathy, today we're doing"},{"startTime":20.19,"endTime":22.81,"body":"another special segment with"},{"startTime":22.81,"endTime":24.662,"body":"one of our Harrison's editors joining us."},{"startTime":24.662,"endTime":26.204,"body":"[Dr. Handy] Great, let's"},{"startTime":24.662,"endTime":26.204,"body":"jump right into the case"},{"startTime":26.204,"endTime":27.162,"body":"and the question."},{"startTime":27.162,"endTime":29.73,"body":"[Dr. Wiener] Okay,"},{"startTime":27.162,"endTime":29.73,"body":"today's patient is Mr. W."},{"startTime":29.73,"endTime":32.39,"body":"He's a 68-year-old African-American male"},{"startTime":32.39,"endTime":34.38,"body":"who's brought to the"},{"startTime":32.39,"endTime":34.38,"body":"emergency room by his wife"},{"startTime":34.38,"endTime":36.67,"body":"because of worsening"},{"startTime":34.38,"endTime":36.67,"body":"headache over the last day"},{"startTime":36.67,"endTime":39.11,"body":"and confusion starting about an hour ago."},{"startTime":39.11,"endTime":42.75,"body":"His blood pressure on"},{"startTime":39.11,"endTime":42.75,"body":"presentation is 230/140,"},{"startTime":42.75,"endTime":44.89,"body":"and his heart rate is 90 per minute."},{"startTime":44.89,"endTime":47.92,"body":"His arterial oxygen saturation is 95%."},{"startTime":47.92,"endTime":50.98,"body":"On examination, he's moving"},{"startTime":47.92,"endTime":50.98,"body":"all his extremities equally,"},{"startTime":50.98,"endTime":52.52,"body":"and there are no obvious deficits"},{"startTime":52.52,"endTime":55.86,"body":"in his cranial nerve function,"},{"startTime":52.52,"endTime":55.86,"body":"but he's clearly delirious."},{"startTime":55.86,"endTime":58.09,"body":"Cardiac examination reveals an enlarged"},{"startTime":58.09,"endTime":61.3,"body":"and a forceful PMI and an S4 gallop."},{"startTime":61.3,"endTime":63.54,"body":"His lungs are clear to auscultation."},{"startTime":63.54,"endTime":65.94,"body":"You get some quick laboratories"},{"startTime":63.54,"endTime":65.94,"body":"and they show a creatinine"},{"startTime":65.94,"endTime":68.57,"body":"of 2.4 mg/dL,"},{"startTime":68.57,"endTime":72.05,"body":"++ protein in his urine with hematuria,"},{"startTime":72.05,"endTime":75.22,"body":"a hematocrit of 32% with"},{"startTime":72.05,"endTime":75.22,"body":"a normal platelet count."},{"startTime":75.22,"endTime":77.04,"body":"You examine his peripheral blood smear"},{"startTime":77.04,"endTime":78.98,"body":"and notice schistocytes."},{"startTime":78.98,"endTime":81.08,"body":"His ECG shows findings consistent"},{"startTime":81.08,"endTime":82.84,"body":"with left ventricular hypertrophy,"},{"startTime":82.84,"endTime":86.35,"body":"but no acute ST segment"},{"startTime":82.84,"endTime":86.35,"body":"elevations or depressions."},{"startTime":86.35,"endTime":89.81,"body":"An emergent brain MRI shows"},{"startTime":86.35,"endTime":89.81,"body":"old microvascular changes,"},{"startTime":89.81,"endTime":92.27,"body":"but no acute infarction or hemorrhage."},{"startTime":92.27,"endTime":94.28,"body":"So that's a lot, let's pause for a second"},{"startTime":94.28,"endTime":95.81,"body":"and just talk about what's going on."},{"startTime":95.81,"endTime":97.9,"body":"[Dr. Handy] So it sounds"},{"startTime":95.81,"endTime":97.9,"body":"like malignant hypertension,"},{"startTime":97.9,"endTime":100.46,"body":"given the very elevated blood"},{"startTime":97.9,"endTime":100.46,"body":"pressures that you mentioned"},{"startTime":100.46,"endTime":103.9,"body":"to 230/140, and evidence"},{"startTime":100.46,"endTime":103.9,"body":"of end organ damage"},{"startTime":103.9,"endTime":105.25,"body":"in multiple systems."},{"startTime":105.25,"endTime":108.99,"body":"So he has evidence of CNS"},{"startTime":105.25,"endTime":108.99,"body":"involvement with his delirium,"},{"startTime":108.99,"endTime":111.617,"body":"the kidney damage is evident"},{"startTime":108.99,"endTime":111.617,"body":"by his elevated creatinine"},{"startTime":111.617,"endTime":114.44,"body":"and proteinuria, and"},{"startTime":111.617,"endTime":114.44,"body":"he has hemolytic anemia"},{"startTime":114.44,"endTime":115.85,"body":"on his blood smear."},{"startTime":115.85,"endTime":118.17,"body":"I'm assuming that he has"},{"startTime":115.85,"endTime":118.17,"body":"longstanding hypertension,"},{"startTime":118.17,"endTime":119.37,"body":"but you didn't mention that."},{"startTime":119.37,"endTime":121.13,"body":"[Dr. Wiener] Yes, his wife"},{"startTime":119.37,"endTime":121.13,"body":"tells you that he's had"},{"startTime":121.13,"endTime":123.892,"body":"hypertension for over 20"},{"startTime":121.13,"endTime":123.892,"body":"years, and recently she's been"},{"startTime":123.892,"endTime":126.73,"body":"concerned that he's not"},{"startTime":123.892,"endTime":126.73,"body":"been taking his medications."},{"startTime":126.73,"endTime":128.167,"body":"He also has hyperlipidemia,"},{"startTime":128.167,"endTime":130.88,"body":"but has never had a known"},{"startTime":128.167,"endTime":130.88,"body":"myocardial infarction,"},{"startTime":130.88,"endTime":133.44,"body":"stroke or other cardiovascular event."},{"startTime":133.44,"endTime":134.955,"body":"[Dr. Handy] All right, well,"},{"startTime":133.44,"endTime":134.955,"body":"let's take care of the acute"},{"startTime":134.955,"endTime":137.23,"body":"problem, so maybe we'll"},{"startTime":134.955,"endTime":137.23,"body":"have time to discuss"},{"startTime":137.23,"endTime":139.07,"body":"the chronic issues a little bit later."},{"startTime":139.07,"endTime":140.715,"body":"[Dr. Wiener] Okay, well,"},{"startTime":139.07,"endTime":140.715,"body":"that's what the question is"},{"startTime":140.715,"endTime":144.26,"body":"addressing, the question says,"},{"startTime":140.715,"endTime":144.26,"body":"regarding his acute blood"},{"startTime":144.26,"endTime":146.41,"body":"pressure management,"},{"startTime":144.26,"endTime":146.41,"body":"which of the following"},{"startTime":146.41,"endTime":148.91,"body":"would be the most reasonable"},{"startTime":146.41,"endTime":148.91,"body":"therapeutic course?"},{"startTime":148.91,"endTime":152.1,"body":"And the options are A. 0.1"},{"startTime":148.91,"endTime":152.1,"body":"mg of clonidine orally;"},{"startTime":152.1,"endTime":154.141,"body":"And the options are A. 0.1"},{"startTime":152.1,"endTime":154.141,"body":"mg of clonidine orally;"},{"startTime":154.141,"endTime":157.29,"body":"B. 20 mg of oral lisinopril;"},{"startTime":157.29,"endTime":160.51,"body":"C. 20 mg of intravenous labetalol"},{"startTime":160.51,"endTime":162.51,"body":"and start a continuous parenteral drip"},{"startTime":162.51,"endTime":164.51,"body":"for a goal mean arterial blood pressure"},{"startTime":164.51,"endTime":168.15,"body":"of 125 mmHg in the first hour;"},{"startTime":168.15,"endTime":172.58,"body":"D. 90 mg of immediate"},{"startTime":168.15,"endTime":172.58,"body":"release oral nifedipine;"},{"startTime":172.58,"endTime":175.653,"body":"or E. emergent plasmapheresis."},{"startTime":175.653,"endTime":177.77,"body":"[Dr. Handy] In the setting"},{"startTime":175.653,"endTime":177.77,"body":"of hypertensive emergency,"},{"startTime":177.77,"endTime":180.04,"body":"which we discussed already he has that,"},{"startTime":180.04,"endTime":182.43,"body":"you want a reduction of"},{"startTime":180.04,"endTime":182.43,"body":"the mean arterial pressure"},{"startTime":182.43,"endTime":185.12,"body":"in minutes to hours by 25%."},{"startTime":185.12,"endTime":188.08,"body":"And that's because most"},{"startTime":185.12,"endTime":188.08,"body":"patients, including this patient,"},{"startTime":188.08,"endTime":190.498,"body":"presenting with malignant"},{"startTime":188.08,"endTime":190.498,"body":"hypertension will also have"},{"startTime":190.498,"endTime":193.13,"body":"longstanding chronic"},{"startTime":190.498,"endTime":193.13,"body":"elevations in blood pressure."},{"startTime":193.13,"endTime":195.13,"body":"So they have a change in the set point"},{"startTime":195.13,"endTime":196.97,"body":"of the cerebral autoregulation."},{"startTime":196.97,"endTime":199.78,"body":"Reducing the blood pressure"},{"startTime":196.97,"endTime":199.78,"body":"rapidly to normal levels"},{"startTime":199.78,"endTime":202.76,"body":"for the regular population"},{"startTime":199.78,"endTime":202.76,"body":"often leads to hypoperfusion"},{"startTime":202.76,"endTime":205.43,"body":"and can lead to watershed"},{"startTime":202.76,"endTime":205.43,"body":"cerebral infarcts."},{"startTime":205.43,"endTime":207.39,"body":"[Dr. Wiener] Okay, so which of"},{"startTime":205.43,"endTime":207.39,"body":"the choices that I mentioned"},{"startTime":207.39,"endTime":210.34,"body":"of the medications would"},{"startTime":207.39,"endTime":210.34,"body":"be best to achieve that?"},{"startTime":210.34,"endTime":212.342,"body":"[Dr. Handy] Parenteral therapy"},{"startTime":210.34,"endTime":212.342,"body":"is more rapid onset and"},{"startTime":212.342,"endTime":214.75,"body":"much more easily titrated"},{"startTime":212.342,"endTime":214.75,"body":"than oral therapy,"},{"startTime":214.75,"endTime":217.32,"body":"so I would go with an IV"},{"startTime":214.75,"endTime":217.32,"body":"option over an oral option."},{"startTime":217.32,"endTime":220.37,"body":"Oral options in this setting"},{"startTime":217.32,"endTime":220.37,"body":"really would be inappropriate."},{"startTime":220.37,"endTime":222.762,"body":"So of the choices that you"},{"startTime":220.37,"endTime":222.762,"body":"listed answer C. is what"},{"startTime":222.762,"endTime":225.35,"body":"I would go with, the"},{"startTime":222.762,"endTime":225.35,"body":"20 mg of IV labetalol,"},{"startTime":225.35,"endTime":227.76,"body":"and then I'd start a continuous IV drip."},{"startTime":227.76,"endTime":229.82,"body":"And thinking about some"},{"startTime":227.76,"endTime":229.82,"body":"of the other options,"},{"startTime":229.82,"endTime":232.69,"body":"immediate release nifedipine,"},{"startTime":229.82,"endTime":232.69,"body":"it is particularly potent,"},{"startTime":232.69,"endTime":235.16,"body":"but it's associated with a"},{"startTime":232.69,"endTime":235.16,"body":"higher risk of myocardial"},{"startTime":235.16,"endTime":237.15,"body":"infarction when used in this setting."},{"startTime":237.15,"endTime":240.32,"body":"[Dr. Wiener] Okay, so four of"},{"startTime":237.15,"endTime":240.32,"body":"the options mentioned drugs,"},{"startTime":240.32,"endTime":243.238,"body":"you excluded the three"},{"startTime":240.32,"endTime":243.238,"body":"oral drugs and you chose"},{"startTime":243.238,"endTime":246.69,"body":"the parenteral therapy,"},{"startTime":243.238,"endTime":246.69,"body":"what about plasmapheresis?"},{"startTime":246.69,"endTime":248.63,"body":"This patient has shistocytes,"},{"startTime":248.63,"endTime":250.74,"body":"does that make me think that"},{"startTime":248.63,"endTime":250.74,"body":"this patient has some other"},{"startTime":250.74,"endTime":253.58,"body":"disorder besides just simple hypertension?"},{"startTime":253.58,"endTime":255.17,"body":"[Dr. Handy] Well, so"},{"startTime":253.58,"endTime":255.17,"body":"malignant hypertension"},{"startTime":255.17,"endTime":257.11,"body":"or hypertensive emergency can cause"},{"startTime":257.11,"endTime":259.07,"body":"an intravascular hemolytic anemia,"},{"startTime":259.07,"endTime":262.2,"body":"so that is not abnormal for"},{"startTime":259.07,"endTime":262.2,"body":"the case that's presenting,"},{"startTime":262.2,"endTime":263.9,"body":"but in terms of plasmapheresis,"},{"startTime":263.9,"endTime":265.799,"body":"that would be warranted"},{"startTime":263.9,"endTime":265.799,"body":"if this were a case of"},{"startTime":265.799,"endTime":268.59,"body":"thrombotic thrombocytopenic"},{"startTime":265.799,"endTime":268.59,"body":"purpura or TTP,"},{"startTime":268.59,"endTime":270.01,"body":"but that's unlikely in this case"},{"startTime":270.01,"endTime":271.87,"body":"and he has normal platelets as well."},{"startTime":271.87,"endTime":273.79,"body":"[Dr. Wiener] Great, so"},{"startTime":271.87,"endTime":273.79,"body":"the question also includes"},{"startTime":273.79,"endTime":276.21,"body":"that the patient is an"},{"startTime":273.79,"endTime":276.21,"body":"African-American man,"},{"startTime":276.21,"endTime":278.506,"body":"let's turn to our expert, Dr. Loscalzo."},{"startTime":278.506,"endTime":281.12,"body":"[Dr. Handy] Welcome back to"},{"startTime":278.506,"endTime":281.12,"body":"the podclass, Dr. Loscalzo."},{"startTime":281.12,"endTime":282.32,"body":"[Dr. Loscalzo] Thank you, glad to be here."},{"startTime":282.32,"endTime":284.29,"body":"I'm glad I wasn't tossed off the program"},{"startTime":284.29,"endTime":285.642,"body":"for my last performance."},{"startTime":285.642,"endTime":287.633,"body":"[Dr. Weiner and Dr. Handy chuckle]"},{"startTime":287.633,"endTime":288.88,"body":"[Dr. Weiner] Well,"},{"startTime":287.633,"endTime":288.88,"body":"let's get right into it."},{"startTime":288.88,"endTime":291.33,"body":"Dr. Loscalzo, the patient in this question"},{"startTime":291.33,"endTime":292.86,"body":"is an African-American man"},{"startTime":292.86,"endTime":295.41,"body":"with hypertensive emergency or urgency."},{"startTime":295.41,"endTime":298.14,"body":"We have all of these huge"},{"startTime":295.41,"endTime":298.14,"body":"epidemiologic studies"},{"startTime":298.14,"endTime":301.57,"body":"that frequently include"},{"startTime":298.14,"endTime":301.57,"body":"subanalyses by race and sex,"},{"startTime":301.57,"endTime":303.67,"body":"but we know that there's"},{"startTime":301.57,"endTime":303.67,"body":"a lot of variability"},{"startTime":303.67,"endTime":306.17,"body":"within these groupings,"},{"startTime":303.67,"endTime":306.17,"body":"not only with race,"},{"startTime":306.17,"endTime":310.62,"body":"but also with social constructs"},{"startTime":306.17,"endTime":310.62,"body":"and socioeconomics and even"},{"startTime":310.62,"endTime":314.13,"body":"variability in how some of"},{"startTime":310.62,"endTime":314.13,"body":"these determinants are defined."},{"startTime":314.13,"endTime":317.44,"body":"How do you use these data"},{"startTime":314.13,"endTime":317.44,"body":"from these large studies,"},{"startTime":317.44,"endTime":319.46,"body":"if at all, in determining the treatment"},{"startTime":319.46,"endTime":322.73,"body":"of an individual patient"},{"startTime":319.46,"endTime":322.73,"body":"in the outpatient setting?"},{"startTime":322.73,"endTime":324.4,"body":"[Dr. Loscalzo] Well, thank"},{"startTime":322.73,"endTime":324.4,"body":"you for posing that important"},{"startTime":324.4,"endTime":326.1,"body":"question, Charlie. First of all,"},{"startTime":326.1,"endTime":329.01,"body":"let me just remind the listeners"},{"startTime":326.1,"endTime":329.01,"body":"that hypertension affects"},{"startTime":329.01,"endTime":330.87,"body":"about 83 million Americans,"},{"startTime":330.87,"endTime":334.13,"body":"that's using the latest cutoff of 130/80"},{"startTime":334.13,"endTime":336.34,"body":"and hypertensive"},{"startTime":334.13,"endTime":336.34,"body":"emergency as in this case,"},{"startTime":336.34,"endTime":338.89,"body":"is defined as an acutely marked elevation"},{"startTime":338.89,"endTime":341.64,"body":"in blood pressure with"},{"startTime":338.89,"endTime":341.64,"body":"target organ damage,"},{"startTime":341.64,"endTime":344.74,"body":"so fairly far advanced vascular disease."},{"startTime":344.74,"endTime":346.33,"body":"Epidemiology studies, as you point out,"},{"startTime":346.33,"endTime":348.73,"body":"have consistently shown that hypertension"},{"startTime":348.73,"endTime":350.62,"body":"disproportionately affects blacks,"},{"startTime":350.62,"endTime":353.73,"body":"and in particular, black males"},{"startTime":350.62,"endTime":353.73,"body":"who also have higher rates of"},{"startTime":353.73,"endTime":357.23,"body":"complications, such as"},{"startTime":353.73,"endTime":357.23,"body":"myocardial infarction, stroke,"},{"startTime":357.23,"endTime":358.6,"body":"and sudden death."},{"startTime":358.6,"endTime":361.77,"body":"But as you also highlighted,"},{"startTime":358.6,"endTime":361.77,"body":"Charlie, race is a really poor"},{"startTime":361.77,"endTime":364.63,"body":"surrogate for the biological"},{"startTime":361.77,"endTime":364.63,"body":"basis of any disease"},{"startTime":364.63,"endTime":366.64,"body":"or response to therapy."},{"startTime":366.64,"endTime":369.74,"body":"There's growing recognition of"},{"startTime":366.64,"endTime":369.74,"body":"the inappropriate use of race"},{"startTime":369.74,"endTime":372.29,"body":"in diagnostic or therapeutic decisions"},{"startTime":372.29,"endTime":374.62,"body":"as it is a self-defined construct"},{"startTime":374.62,"endTime":377.23,"body":"and less likely biological in basis"},{"startTime":377.23,"endTime":379.4,"body":"than socioeconomic in origin."},{"startTime":379.4,"endTime":381.57,"body":"And really what we're thinking"},{"startTime":379.4,"endTime":381.57,"body":"about here in this discussion"},{"startTime":381.57,"endTime":384.17,"body":"is race-based medicine as a reflection"},{"startTime":384.17,"endTime":386.49,"body":"of the structural racism that's permeated"},{"startTime":386.49,"endTime":389.77,"body":"our medical care system"},{"startTime":386.49,"endTime":389.77,"body":"for the past 400 years."},{"startTime":389.77,"endTime":393.75,"body":"Socioeconomic disparities that"},{"startTime":389.77,"endTime":393.75,"body":"have grown out of that global"},{"startTime":393.75,"endTime":396.434,"body":"structural racism are much"},{"startTime":393.75,"endTime":396.434,"body":"more likely to contribute"},{"startTime":396.434,"endTime":399.33,"body":"to the prevalence of hypertension"},{"startTime":396.434,"endTime":399.33,"body":"and its complications,"},{"startTime":399.33,"endTime":401.35,"body":"including hypertensive emergencies"},{"startTime":401.35,"endTime":403.59,"body":"among self-identified blacks."},{"startTime":403.59,"endTime":407.14,"body":"So rather than using a"},{"startTime":403.59,"endTime":407.14,"body":"race-based decision algorithm in"},{"startTime":407.14,"endTime":408.78,"body":"pursuing therapeutic goals,"},{"startTime":408.78,"endTime":411.49,"body":"my view is to really tailor"},{"startTime":408.78,"endTime":411.49,"body":"the treatment to a patient's"},{"startTime":411.49,"endTime":413.58,"body":"individual hypertensive phenotype."},{"startTime":413.58,"endTime":415.2,"body":"We will touch more on that in a little bit"},{"startTime":415.2,"endTime":417.16,"body":"I think in one of the later questions."},{"startTime":417.16,"endTime":420.02,"body":"And most important, to develop"},{"startTime":417.16,"endTime":420.02,"body":"a trusting relationship"},{"startTime":420.02,"endTime":422.02,"body":"with the patient either directly,"},{"startTime":422.02,"endTime":424.28,"body":"or through another member of the care team"},{"startTime":424.28,"endTime":426.62,"body":"who has good chemistry with the patient"},{"startTime":426.62,"endTime":428.427,"body":"to ensure the patient feels comfortable"},{"startTime":428.427,"endTime":431.18,"body":"about recommendations"},{"startTime":428.427,"endTime":431.18,"body":"and is willing to adhere"},{"startTime":431.18,"endTime":433.23,"body":"to the therapies that are recommended."},{"startTime":433.23,"endTime":435.07,"body":"[Dr. Handy] Now, over"},{"startTime":433.23,"endTime":435.07,"body":"the past few decades,"},{"startTime":435.07,"endTime":437.93,"body":"there has been tremendous"},{"startTime":435.07,"endTime":437.93,"body":"progress in improving the rates of"},{"startTime":437.93,"endTime":439.97,"body":"complications from hypertension,"},{"startTime":439.97,"endTime":442.64,"body":"but heart disease is still the"},{"startTime":439.97,"endTime":442.64,"body":"most common cause of death in"},{"startTime":442.64,"endTime":444.94,"body":"the United States, and"},{"startTime":442.64,"endTime":444.94,"body":"we know that adherence"},{"startTime":444.94,"endTime":447.263,"body":"to oral medications like"},{"startTime":444.94,"endTime":447.263,"body":"you started to mention in"},{"startTime":447.263,"endTime":449.41,"body":"the outpatient setting can be challenging."},{"startTime":449.41,"endTime":451.89,"body":"How do you think we can"},{"startTime":449.41,"endTime":451.89,"body":"improve adherence with therapy?"},{"startTime":451.89,"endTime":454.262,"body":"And what do you see as"},{"startTime":451.89,"endTime":454.262,"body":"the major goals over"},{"startTime":454.262,"endTime":457.25,"body":"the next 10-20 years to"},{"startTime":454.262,"endTime":457.25,"body":"improve the mortality rate"},{"startTime":457.25,"endTime":459.14,"body":"from heart disease even further?"},{"startTime":459.14,"endTime":460.383,"body":"[Dr. Loscalzo] Thank you"},{"startTime":459.14,"endTime":460.383,"body":"for that question, Cathy,"},{"startTime":460.383,"endTime":461.67,"body":"I think the key is again,"},{"startTime":461.67,"endTime":465.67,"body":"establishing some kind of"},{"startTime":461.67,"endTime":465.67,"body":"working social structure that"},{"startTime":465.67,"endTime":467.784,"body":"supports a trusting relationship between"},{"startTime":467.784,"endTime":469.34,"body":"the patient and the caregiver."},{"startTime":469.34,"endTime":471.38,"body":"And there were a couple of"},{"startTime":469.34,"endTime":471.38,"body":"interesting studies that"},{"startTime":471.38,"endTime":472.45,"body":"highlighted this point,"},{"startTime":472.45,"endTime":474.9,"body":"that involved barbershops"},{"startTime":472.45,"endTime":474.9,"body":"in black neighborhoods,"},{"startTime":474.9,"endTime":476.24,"body":"beginning in Dallas."},{"startTime":476.24,"endTime":479.74,"body":"The BARBER-1 and BARBER-2"},{"startTime":476.24,"endTime":479.74,"body":"trials were quite intriguing"},{"startTime":479.74,"endTime":483.482,"body":"in that regard, barbershops"},{"startTime":479.74,"endTime":483.482,"body":"are sites of social gathering"},{"startTime":483.482,"endTime":484.99,"body":"in African-American communities,"},{"startTime":484.99,"endTime":486.62,"body":"more so than in white communities,"},{"startTime":486.62,"endTime":489.57,"body":"and the barber is a trusted"},{"startTime":486.62,"endTime":489.57,"body":"member of the community."},{"startTime":489.57,"endTime":491.44,"body":"Barber guidance, in this case"},{"startTime":491.44,"endTime":493.98,"body":"barbers were taught how to"},{"startTime":491.44,"endTime":493.98,"body":"take blood pressures properly"},{"startTime":493.98,"endTime":495.5,"body":"by a healthcare provider,"},{"startTime":495.5,"endTime":499.0,"body":"barber guidance almost"},{"startTime":495.5,"endTime":499.0,"body":"doubled blood pressure control"},{"startTime":499.0,"endTime":501.16,"body":"among patients who"},{"startTime":499.0,"endTime":501.16,"body":"participated in this trial"},{"startTime":501.16,"endTime":503.79,"body":"compared to those who weren't"},{"startTime":501.16,"endTime":503.79,"body":"guided by their barber."},{"startTime":503.79,"endTime":506.22,"body":"This is in BARBER-1, in BARBER-2,"},{"startTime":506.22,"endTime":509.26,"body":"there was an added element of"},{"startTime":506.22,"endTime":509.26,"body":"pharmacists guided algorithm"},{"startTime":509.26,"endTime":511.02,"body":"driven blood pressure control,"},{"startTime":511.02,"endTime":512.63,"body":"so that one could titrate drugs"},{"startTime":512.63,"endTime":514.58,"body":"or add second or third drugs."},{"startTime":514.58,"endTime":518.43,"body":"And this further improved"},{"startTime":514.58,"endTime":518.43,"body":"control greatly up to 84% versus"},{"startTime":518.43,"endTime":521.49,"body":"64% by conventional titration measures."},{"startTime":521.49,"endTime":524.43,"body":"So finding a socially acceptable strategy,"},{"startTime":524.43,"endTime":528.3,"body":"barbershops, churches,"},{"startTime":524.43,"endTime":528.3,"body":"other social gathering sites"},{"startTime":528.3,"endTime":532.1,"body":"is one approach that I think"},{"startTime":528.3,"endTime":532.1,"body":"has gathered lots of interest"},{"startTime":532.1,"endTime":534.48,"body":"and may have some real traction."},{"startTime":534.48,"endTime":535.8,"body":"Now, as you point out,"},{"startTime":535.8,"endTime":538.53,"body":"hypertension and cardiovascular"},{"startTime":535.8,"endTime":538.53,"body":"disease in general"},{"startTime":538.53,"endTime":540.78,"body":"continue to plague our society in general"},{"startTime":540.78,"endTime":544.0,"body":"and the African-American"},{"startTime":540.78,"endTime":544.0,"body":"community in particular."},{"startTime":544.0,"endTime":547.83,"body":"Globally, cardiovascular diseases"},{"startTime":544.0,"endTime":547.83,"body":"account for more than half"},{"startTime":547.83,"endTime":550.84,"body":"of all non-communicable disease mortality,"},{"startTime":550.84,"endTime":553.98,"body":"18 million out of 35 or so million."},{"startTime":553.98,"endTime":555.27,"body":"And the American Heart Association"},{"startTime":555.27,"endTime":557.68,"body":"and the United Nations and"},{"startTime":555.27,"endTime":557.68,"body":"World Health Organization"},{"startTime":557.68,"endTime":560.22,"body":"have as a goal a decrease in the risk"},{"startTime":560.22,"endTime":563.017,"body":"of non-communicable diseases"},{"startTime":560.22,"endTime":563.017,"body":"by 25% between 2025 and 2030."},{"startTime":563.017,"endTime":565.908,"body":"of non-communicable diseases"},{"startTime":563.017,"endTime":565.908,"body":"by 25% between 2025 and 2030."},{"startTime":565.908,"endTime":567.94,"body":"Things got a little"},{"startTime":565.908,"endTime":567.94,"body":"delayed with the pandemic."},{"startTime":567.94,"endTime":570.02,"body":"And I think that's an"},{"startTime":567.94,"endTime":570.02,"body":"admirable goal that is"},{"startTime":570.02,"endTime":572.81,"body":"potentially achievable,"},{"startTime":570.02,"endTime":572.81,"body":"and the emphasis should,"},{"startTime":572.81,"endTime":574.9,"body":"of course, not just be on"},{"startTime":572.81,"endTime":574.9,"body":"treatment and adherence,"},{"startTime":574.9,"endTime":578.72,"body":"but also prevention, which"},{"startTime":574.9,"endTime":578.72,"body":"could be region specific,"},{"startTime":578.72,"endTime":582.09,"body":"must involve implementation"},{"startTime":578.72,"endTime":582.09,"body":"of cost-effective strategies"},{"startTime":582.09,"endTime":584.83,"body":"by country and culture,"},{"startTime":582.09,"endTime":584.83,"body":"and most importantly,"},{"startTime":584.83,"endTime":587.45,"body":"collaboration in"},{"startTime":584.83,"endTime":587.45,"body":"public-private partnerships"},{"startTime":587.45,"endTime":589.87,"body":"across multiple social sectors."},{"startTime":589.87,"endTime":592.44,"body":"[Dr. Wiener] Joe, I love the"},{"startTime":589.87,"endTime":592.44,"body":"fact that you're highlighting"},{"startTime":592.44,"endTime":594.75,"body":"the interaction between"},{"startTime":592.44,"endTime":594.75,"body":"the social determinants"},{"startTime":594.75,"endTime":597.24,"body":"of effective therapy,"},{"startTime":594.75,"endTime":597.24,"body":"adherence to therapy,"},{"startTime":597.24,"endTime":599.29,"body":"which obviously are"},{"startTime":597.24,"endTime":599.29,"body":"going to be very variable"},{"startTime":599.29,"endTime":601.15,"body":"by community and individual,"},{"startTime":601.15,"endTime":603.21,"body":"and as we broaden that internationally,"},{"startTime":603.21,"endTime":605.98,"body":"it's going to be different"},{"startTime":603.21,"endTime":605.98,"body":"in every different country."},{"startTime":605.98,"endTime":608.31,"body":"But if you wouldn't mind"},{"startTime":605.98,"endTime":608.31,"body":"stepping back and talk to us"},{"startTime":608.31,"endTime":612.24,"body":"a little bit about the biological"},{"startTime":608.31,"endTime":612.24,"body":"basis of how you approach"},{"startTime":612.24,"endTime":614.78,"body":"treatment for hypertension"},{"startTime":612.24,"endTime":614.78,"body":"in individual patients,"},{"startTime":614.78,"endTime":617.86,"body":"and also what future translational"},{"startTime":614.78,"endTime":617.86,"body":"or mechanistic research"},{"startTime":617.86,"endTime":621.65,"body":"do you think is going to impact"},{"startTime":617.86,"endTime":621.65,"body":"how we control hypertension"},{"startTime":621.65,"endTime":623.46,"body":"separate from the question of adherence,"},{"startTime":623.46,"endTime":626.56,"body":"which obviously is vitally important?"},{"startTime":626.56,"endTime":628.48,"body":"[Dr. Loscalzo] That's a"},{"startTime":626.56,"endTime":628.48,"body":"critical issue in the management"},{"startTime":628.48,"endTime":630.64,"body":"of any of our patients,"},{"startTime":628.48,"endTime":630.64,"body":"and the first point to make"},{"startTime":630.64,"endTime":634.03,"body":"is that hypertension is really"},{"startTime":630.64,"endTime":634.03,"body":"a terrible phenotype, right?"},{"startTime":634.03,"endTime":635.21,"body":"Just think about how we measure it."},{"startTime":635.21,"endTime":637.63,"body":"We listen to these"},{"startTime":635.21,"endTime":637.63,"body":"Korotkoff sounds that appear"},{"startTime":637.63,"endTime":640.09,"body":"and then disappear, and"},{"startTime":637.63,"endTime":640.09,"body":"there are varying levels"},{"startTime":640.09,"endTime":642.43,"body":"of sensitivity in the"},{"startTime":640.09,"endTime":642.43,"body":"way one picks them up."},{"startTime":642.43,"endTime":644.92,"body":"There's the notion of"},{"startTime":642.43,"endTime":644.92,"body":"white coat hypertension,"},{"startTime":644.92,"endTime":648.35,"body":"there's the effects of routine"},{"startTime":644.92,"endTime":648.35,"body":"caffeine and tobacco use,"},{"startTime":648.35,"endTime":650.88,"body":"there's the pseudohypertension"},{"startTime":648.35,"endTime":650.88,"body":"of the elderly with stiff"},{"startTime":650.88,"endTime":653.58,"body":"pipes that suggest there's"},{"startTime":650.88,"endTime":653.58,"body":"a wide pulse pressure,"},{"startTime":653.58,"endTime":655.53,"body":"but if one measures central pressures,"},{"startTime":655.53,"endTime":659.09,"body":"patients aren't truly"},{"startTime":655.53,"endTime":659.09,"body":"hypertensive in the same way."},{"startTime":659.09,"endTime":662.15,"body":"So we have that problem of"},{"startTime":659.09,"endTime":662.15,"body":"how you define hypertension"},{"startTime":662.15,"endTime":663.83,"body":"and most important, of course,"},{"startTime":663.83,"endTime":666.31,"body":"is how does blood pressure"},{"startTime":663.83,"endTime":666.31,"body":"vary as a function of time"},{"startTime":666.31,"endTime":667.62,"body":"throughout the day?"},{"startTime":667.62,"endTime":669.79,"body":"And newer methods for looking at 24-hour"},{"startTime":669.79,"endTime":671.96,"body":"ambulatory blood pressure measurements"},{"startTime":671.96,"endTime":674.512,"body":"are an important strategy"},{"startTime":671.96,"endTime":674.512,"body":"for getting a better sense of"},{"startTime":674.512,"endTime":677.3,"body":"the hypertensive burden"},{"startTime":674.512,"endTime":677.3,"body":"as a function of time,"},{"startTime":677.3,"endTime":679.52,"body":"but those have their problems as well."},{"startTime":679.52,"endTime":682.19,"body":"There's the sort of Pavlovian response"},{"startTime":682.19,"endTime":684.7,"body":"to an increase in blood pressure"},{"startTime":682.19,"endTime":684.7,"body":"as a consequence of feeling"},{"startTime":684.7,"endTime":686.94,"body":"that the blood pressure"},{"startTime":684.7,"endTime":686.94,"body":"cuff's being inflated."},{"startTime":686.94,"endTime":688.74,"body":"There are some new technologies, in fact,"},{"startTime":688.74,"endTime":691.62,"body":"one that was just published"},{"startTime":688.74,"endTime":691.62,"body":"this year by Forten"},{"startTime":691.62,"endTime":693.39,"body":"in Nature Communications,"},{"startTime":693.39,"endTime":695.44,"body":"in which they developed a non-invasive,"},{"startTime":695.44,"endTime":698.68,"body":"real-time monitoring device"},{"startTime":695.44,"endTime":698.68,"body":"that uses a combination of"},{"startTime":698.68,"endTime":700.87,"body":"oscillometry, an old-fashioned method"},{"startTime":700.87,"endTime":702.14,"body":"for looking at blood pressure"},{"startTime":702.14,"endTime":706.2,"body":"and photoplethysmography built"},{"startTime":702.14,"endTime":706.2,"body":"into a tiny fingertip device."},{"startTime":706.2,"endTime":709.37,"body":"It doesn't involve any detectable"},{"startTime":706.2,"endTime":709.37,"body":"change in pressure around"},{"startTime":709.37,"endTime":711.89,"body":"the fingertip that you could"},{"startTime":709.37,"endTime":711.89,"body":"use throughout the day."},{"startTime":711.89,"endTime":713.798,"body":"I think devices like"},{"startTime":711.89,"endTime":713.798,"body":"that, and there are others"},{"startTime":713.798,"endTime":715.912,"body":"that folks have been"},{"startTime":713.798,"endTime":715.912,"body":"working on for a while,"},{"startTime":715.912,"endTime":717.25,"body":"will give us a better sense of"},{"startTime":717.25,"endTime":718.95,"body":"really what blood pressure variation"},{"startTime":718.95,"endTime":720.78,"body":"is like throughout the"},{"startTime":718.95,"endTime":720.78,"body":"day, and a better sense of"},{"startTime":720.78,"endTime":722.8,"body":"what our blood pressure targets should be."},{"startTime":722.8,"endTime":725.48,"body":"So once we make the"},{"startTime":722.8,"endTime":725.48,"body":"diagnosis of blood pressure,"},{"startTime":725.48,"endTime":728.082,"body":"I really try to define"},{"startTime":725.48,"endTime":728.082,"body":"it in the context of"},{"startTime":728.082,"endTime":731.06,"body":"what are the medical"},{"startTime":728.082,"endTime":731.06,"body":"problems the patient has?"},{"startTime":731.06,"endTime":733.97,"body":"Is the patient anxious? Does"},{"startTime":731.06,"endTime":733.97,"body":"the patient seem to have"},{"startTime":733.97,"endTime":736.76,"body":"a sort of hyper-sympathetic"},{"startTime":733.97,"endTime":736.76,"body":"response to stress?"},{"startTime":736.76,"endTime":738.91,"body":"Is the patient in heart failure?"},{"startTime":738.91,"endTime":741.21,"body":"Does the patient have"},{"startTime":738.91,"endTime":741.21,"body":"ischemic heart disease?"},{"startTime":741.21,"endTime":742.32,"body":"Each of these, of course,"},{"startTime":742.32,"endTime":745.59,"body":"would govern the choice or"},{"startTime":742.32,"endTime":745.59,"body":"help me decide about the choice"},{"startTime":745.59,"endTime":748.07,"body":"of types of antihypertensives I might use."},{"startTime":748.07,"endTime":750.92,"body":"In contrast to someone who comes"},{"startTime":748.07,"endTime":750.92,"body":"in completely asymptomatic,"},{"startTime":750.92,"endTime":754.07,"body":"who winds up having significantly"},{"startTime":750.92,"endTime":754.07,"body":"elevated blood pressures,"},{"startTime":754.07,"endTime":756.723,"body":"in which case you might"},{"startTime":754.07,"endTime":756.723,"body":"begin in the standard way,"},{"startTime":756.723,"endTime":760.02,"body":"as recommended by the AHA, in"},{"startTime":756.723,"endTime":760.02,"body":"standard way with one of the"},{"startTime":760.02,"endTime":763.58,"body":"simplest classes including"},{"startTime":760.02,"endTime":763.58,"body":"thiazide diuretics,"},{"startTime":763.58,"endTime":766.47,"body":"including ACE inhibitors"},{"startTime":763.58,"endTime":766.47,"body":"depending upon renal function,"},{"startTime":766.47,"endTime":767.95,"body":"including calcium channel blockers"},{"startTime":767.95,"endTime":769.8,"body":"depending upon the patient's age."},{"startTime":769.8,"endTime":772.77,"body":"So those are sort of the"},{"startTime":769.8,"endTime":772.77,"body":"three principle subtypes"},{"startTime":772.77,"endTime":775.73,"body":"of antihypertensives that I"},{"startTime":772.77,"endTime":775.73,"body":"use for asymptomatic patients"},{"startTime":775.73,"endTime":777.06,"body":"initially, depending upon"},{"startTime":777.06,"endTime":779.96,"body":"the other demographic"},{"startTime":777.06,"endTime":779.96,"body":"parameters that I mentioned."},{"startTime":779.96,"endTime":781.62,"body":"[Dr. Handy] Thank you so"},{"startTime":779.96,"endTime":781.62,"body":"much, and thank you so much"},{"startTime":781.62,"endTime":784.79,"body":"for joining us today and your"},{"startTime":781.62,"endTime":784.79,"body":"insight into hypertension,"},{"startTime":784.79,"endTime":787.65,"body":"and also how we think about"},{"startTime":784.79,"endTime":787.65,"body":"some of these epidemiology"},{"startTime":787.65,"endTime":791.49,"body":"studies, and how really we need"},{"startTime":787.65,"endTime":791.49,"body":"to change our model of care"},{"startTime":791.49,"endTime":793.5,"body":"to reach patients where they are"},{"startTime":793.5,"endTime":795.25,"body":"in order to get the best outcomes."},{"startTime":795.25,"endTime":797.53,"body":"So we look forward to"},{"startTime":795.25,"endTime":797.53,"body":"talking with you again soon,"},{"startTime":797.53,"endTime":799.52,"body":"and for our audience, if"},{"startTime":797.53,"endTime":799.52,"body":"you want to learn more,"},{"startTime":799.52,"endTime":801.82,"body":"you can go to Harrison's"},{"startTime":799.52,"endTime":801.82,"body":"chapter on hypertension."},{"startTime":801.82,"endTime":806.645,"body":"[outro music]"},{"startTime":806.645,"endTime":809.63,"body":"[Mr. Shanahan] This is Jim"},{"startTime":806.645,"endTime":809.63,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":809.63,"endTime":811.25,"body":"Harrison's Podclass is brought to you"},{"startTime":811.25,"endTime":813.23,"body":"by McGraw Hill's Access Medicine,"},{"startTime":813.23,"endTime":816.22,"body":"the online medical resource"},{"startTime":813.23,"endTime":816.22,"body":"that delivers the latest trusted"},{"startTime":816.22,"endTime":818.55,"body":"content from the best minds in medicine."},{"startTime":818.55,"endTime":821.113,"body":"Go to accessmedicine.com to learn more."}]}