Every day I see patients in the Intensive Care Unit suffering from the consequences of high blood pressure. Coronary artery disease and stroke continue to contribute significantly to the population’s morbidity and mortality in the United States. Billions of dollars are spent each year acute and long-term care for these patients. One of the biggest risk factors for both conditions is hypertension or high blood pressure.

Hypertension is extremely common in the general population. Dietary indiscretions, including high salt intake, contribute to the development of hypertension. The maximum recommended sodium intake is about 2300mg/day. Yet, it is estimated that an average adult in the US consumes almost 4000mg/day.

It has been proven by multiple studies that diminished salt intake can lead to better blood pressure, decreasing the risk for both heart disease and stroke. It was also shown that it is possible to modify salt intake of the entire country’s population by reducing the sodium targets for specific food. The success of recent efforts in the United Kingdom to work with the food manufactures that lead to 9.5% decrease in nation’s sodium intake has sparked interest in population based strategies that can reduce the risk of heart disease and stroke.

A study published in the Annals of Internal Medicine examines two strategies for the reduction of sodium intake in the United States. The two strategies include reducing sodium targets for processed food and the implementation of a tax on sodium used for food production.

The authors assumed that based on the United Kingdom experience, it is possible to reduce the population's sodium intake by 9.5% by modifying salt content in processed food. The tax strategy assumes that a price increase of 40% on high sodium food would result in 6.0% reduction in sodium intake.

The conclusions of this study are quite impressive. It was estimated that a 9.5% reduction in sodium intake would result in only a 1.25mm Hg decrease in mean systolic blood pressure (for persons aged 40 to 85 years alive today in the US), yet it would prevent 513, 885 strokes and 480,358 MIs (myocardial infarction) The estimated savings of $32.1 billion in direct medical cost were also predicted from this strategy.

The tax strategy was less effective. A 6% decrease in sodium intake would result in a 0.93 mm Hg average blood pressure reduction preventing 327,892 strokes and 306,137 MIs. It would still save close to 22 billions over the lifetime of adults aged 40 to 85 years alive today.

The authors recognize the potential pitfalls of the population based strategies. For example, decreased sodium in processed food may lead to a compensatory increase in intake of sugar and fat rich food. The study is based on predictions from a mathematical model and those predictions might not quite work out in real life.

At the same time, the benefits of a reduced salt intake go beyond heart disease and stroke. Lower blood pressure will prevent many cases of end-stage renal disease and hypertensive (non-ischemic) heart failure, saving us many more billions of dollars.

In conclusion, it is a personal responsibility to maintain one’s health. Yet on a population-based level, effective strategies are available to control and prevent the spread of many diseases. And if this also prevents Medicare and Social Security from going broke, it is a welcome initiative.

When the patient with the symptoms of acute stroke is being evaluated in the Hospital, he or she is shown a picture from NIH (National Institute of Health) stroke scale to assess the patient’s judgment (Click on image above to see the picture) . As I am staring at this picture, while sitting in ER, I realized – as far as I am concerned, there is nothing wrong with this image. That exactly how my house looks when I am in charge of watching kids. This made me think that often we fail to consider the patient’s own perspective when administering treatment and medications. We are often concerned about the side effects and mechanism of action of any given medicine. It is that human factor not the side effect of the medications that often brings the patient back to the hospital. There are several ‘risk factors’ or what I call them ‘dysfunction factors’ that put the patient at the higher risk of side effects, complications and hospital readmission.
Here they are:

1.The patient has no idea what medications he is taking and why. Often I hear: “It’s all in my records” when I ask about medications. I have seen patients taking their diuretics and blood pressure meds, even though, they were already dehydrated with diarrhea or viral illness. Next thing you know that patient is in ER with the blood pressure in the 50’s.

2.There are more then twenty medications on the patient’s list. It would be a full time job just to keep track of those meds. Some medications are being taken two or three times a day which adds even more confusion.

3.The patient is ‘allergic’ to more then ten medications. Usually, it’s not a true allergy, but rather some side effects that the patient has experienced. It makes it difficult to treat an infection, for example, if the patient is ‘allergic’ to most of the antibiotics.

4.The patient is taking the same medication twice under different name. This happens rarely now due to electronic pharmacy records.

5.The patient is requesting a specific medication for pain. I often hear: “Only IV Dilaudid works for my pain”. This usually raises a red flag.

6.The patient is allergic to steroids (Prednisone). Prednisone is actually being used to treat allergy. Patients might have side effects to this medicine, but allergies are unlikely.

These are just a few things I came across in my practice. The list by no means is complete. Feel free to add things that I missed.

Few weeks ago I was called to admit a patient with “a likely stroke” He was having intermittent right-sided weakness, vision problems and impaired coordination. The Neurologist saw him in ER. The diagnosis of the posterior circulation stroke was made. The patient was started on tPA (thrombolytic, clot dissolving medicine). I saw him in ICU. He was awake and joking around – “Oh, this is nothing, Doc”. Few hours later he became less responsive and I had to intubate him. Repeat CT head showed no bleed; Extensive posterior-circulation ischemic changes were noted (see image above). Now the patient is unresponsive and prognosis for his recovery is quite poor. The family decided to withdraw care.
Stroke could be a devastating disease. Most patients survive, but left with motor deficits, weakness in their arms, legs or inability to speak or even understand human speech. What strikes me is how little we can do to treat this disease. Aspirin is commonly used to prevent further strokes. Clot dissolving medications (tPA in the case above) could improve your chances for survival and recovery. The problem is, a lot of the patients come to us too late for this medicine to be administered. And even when it’s given, it doesn’t work all the time and the complications could be even more disabling or lethal (bleed into brain). This could be very frustrating. In the case above the patient “was lucky” to be with a window of opportunity for the medication to be administered. Yet it did not work. The patient decompensated right in front of your eyes and there is not much you can do. Modern medicine can do wonders for our patients. Testing the limits of it is what makes this job difficult.