Express valid concerns to physician

Dear Dr. Gott: My mother is 86 years old. She is in excellent health. The only medication she takes is 12.5 milligrams of HCTZ per day for isolated systolic hypertension. I consider this quite remarkable in this age of gross overmedication.

She suffers from “white coat” syndrome. I am her patient advocate, and I have trained her to take and record her in-home blood pressure readings periodically. We take these readings with us to any and all doctor appointments to avoid over medication by physicians who base their analysis solely on in-office blood pressure readings and/or physicians who have strict 120/80 mindsets without regard to the patient’s age and current physical condition.

Her new physician recently prescribed continuing the 12.5 milligrams of HCTZ per day, and, in addition, 25 milligrams of atenolol per day, all based on her higher in-office BP reading. I am very concerned about the J-curve in the elderly in whom lowering the diastolic has been shown to increase the incidence of stroke (not to mention the numerous side effects of medications).

Dear Reader: I wholeheartedly agree with you. Many authorities have recently concluded what you and I have known: In some patients, the office blood pressure is significantly higher than it is during home readings.

I suggest that you express your valid concerns to your mother’s physician and indicate your willingness to try a reasonable middle ground. Monitor her home blood pressure three or four times a week. Keep a diary that includes the blood pressure, date and time of day. I believe this information will confirm your belief that your mother’s blood pressure is predictably lower at home than it is in the doctor’s office, and continuation of her current treatment is sensible.

If, on the other hand, the blood pressure ranges consistently higher than 130-140/80-90 at home, I am incorrect and a change in medication (or dosage) is advisable, because some elderly people tend to have a slow rise in their blood pressure, and that rise can be dangerous unless treated. Atenolol, a beta-blocker, is certainly a reasonable next step.

I advise patients who change physicians to make an effort to develop trust and comfort with the new doctor. This includes open communication and a free exchange of ideas. For his or her part, the doctor should avoid being overly rigid in a health plan and must try to adapt so that the doctor-patient relationship becomes one of give and take.

For example, if I were you, I’d step back from the J curve issue. (The J curve refers to scientific findings that link heart attacks to both high and low blood pressure.) Let the doctor give you the benefits of his or her education and training.