Why is it so important to keep blood pressure in check? | Ethan Weiss & Peter Attia
Summary
TLDRThe transcript discusses the importance of blood pressure management for overall health, particularly in relation to kidney function. It emphasizes the kidney's sensitivity to high blood pressure and the need to maintain a blood pressure close to 120/80 mmHg throughout life, challenging the notion that higher blood pressure is a normal part of aging. The conversation highlights the significance of clinical trials in shaping current understanding and treatment approaches to hypertension.
Takeaways
- 🧐 The speaker expresses a growing interest in blood pressure and its impact on kidney health, highlighting the kidney's sensitivity to high blood pressure.
- 🌟 The importance of the kidney is emphasized, often overlooked, but it plays a crucial role in regulating blood pressure and is sensitive to changes in it.
- 🕰 The concept of 'bootstrapping' to live longer is introduced, suggesting that maintaining the health standards of a younger age group can contribute to longevity.
- 📉 The use of Systatin C over creatinine to measure glomerular filtration rate (GFR) is mentioned, indicating a shift in medical practice for more accurate kidney function assessment.
- 🚫 The speaker argues against the complacency of considering a GFR of 70 mL/min at age 55 as 'good enough', stressing that it's far from ideal for kidney health.
- 💡 The idea that even slight elevations in blood pressure can negatively affect long-term kidney, heart, and brain health is presented, advocating for normalization of blood pressure.
- 👨⚕️ The speaker acknowledges the neglect of the kidney in medical education and practice, sharing personal experiences teaching about hypertension and kidney pathology.
- 🔍 The impact of high blood pressure on the kidney's vasculature is discussed, suggesting the organ's small size and high blood flow make it particularly vulnerable to pressure changes.
- 📈 The speaker reflects on the variability of blood pressure throughout the day and the lack of awareness people have about their own blood pressure fluctuations.
- 🐘 A comparison is made to different animal species, questioning why humans share similar blood pressure levels with much smaller creatures, hinting at evolutionary conservation of the vascular system.
- 🛑 The notion that blood pressure naturally increases with age is challenged, with recent clinical trials suggesting that maintaining a blood pressure close to 120/80 mmHg is beneficial at any age.
Q & A
Why has the speaker become more interested in blood pressure over the past year?
-The speaker has become more interested in blood pressure due to its connection with kidney health, which has been a growing concern for them, especially when considering the long-term effects on kidney function and overall health.
What is the speaker's approach to aging and health?
-The speaker suggests a 'bootstrapping' approach to aging, where one should aim to maintain the health standards of a younger age group to potentially live an extra few years. This includes maintaining the health of the mind, body, coronary arteries, bone density, and kidneys.
What is the glomerular filtration rate (GFR) and why is it important?
-The glomerular filtration rate is a measure of how well the kidneys are functioning, indicating the rate at which the kidneys filter waste from the blood. It is important because it helps in assessing kidney health and is sensitive to high blood pressure.
Why has the use of creatinine been largely abandoned in measuring GFR?
-The use of creatinine has been largely abandoned because it has been replaced by cystatin C, which is a more accurate measure for estimating GFR, especially in elderly populations.
How does the speaker view the kidneys in relation to high blood pressure?
-The speaker views the kidneys as being exquisitely sensitive to high blood pressure due to their small size and the high volume of cardiac output they receive, making them vulnerable to damage from even slight elevations in blood pressure.
What is the speaker's perspective on the importance of normalizing blood pressure?
-The speaker believes that normalizing blood pressure is crucial for long-term health, particularly for the kidneys, heart, and brain, and that even minor elevations in blood pressure can interfere with these organs' health.
What does the speaker suggest about the standard blood pressure reading of 120 over 80 mmHg?
-The speaker suggests that while 120 over 80 mmHg is considered normal, it may not be optimal for maintaining long-term kidney, heart, and brain health, and that striving for a lower blood pressure could be beneficial.
How does the speaker's view on treating high blood pressure differ from past practices?
-The speaker's view differs from past practices in that they now believe that 120 over 80 mmHg should be the target for all ages, rather than accepting higher blood pressures as a normal part of aging.
What evidence does the speaker refer to that supports the idea that 120 over 80 mmHg is the normal blood pressure?
-The speaker refers to recent well-designed clinical trials that have shown that being closer to 120 over 80 mmHg impacts mortality rates and that permitting higher blood pressures can lead to significant health risks.
What are the potential harms associated with treating high blood pressure too aggressively?
-The potential harms include side effects from medication, impacts on lifestyle, and serious health issues such as hyperkalemia or an increased risk of death.
How does the speaker connect the aging process with changes in blood pressure?
-The speaker connects the aging process with changes in blood pressure by suggesting that while blood pressure does increase with age, it may not be a normal part of aging but rather a consequence of underlying health issues such as decreased kidney function or increased vascular stiffness.
Outlines
🧬 The Importance of Blood Pressure and Kidney Health
The speaker expresses a growing interest in blood pressure and its impact on kidney health over the past couple of years. They emphasize the need to maintain blood pressure at a level that would be considered healthy for a younger individual, as part of a strategy to extend life. The speaker discusses the kidney's sensitivity to high blood pressure due to its unique vasculature and small size, which handles a large portion of cardiac output. They suggest that even slight increases in blood pressure can negatively affect long-term kidney health, as well as heart and brain health, advocating for the normalization of blood pressure to mitigate these risks.
🌡 Understanding Blood Pressure Variations and Aging
This paragraph delves into the dynamics of blood pressure throughout the day and how it changes under various conditions such as sleep, physical activity, and stress. The speaker ponders the concept of 'normal' blood pressure, questioning why humans share similar blood pressure levels with other species and why it increases with age. They challenge the traditional acceptance of higher blood pressure in the elderly, suggesting that it might not be a natural part of aging but rather a symptom of underlying health issues. The speaker reflects on the evolution of medical understanding, moving from a permissive attitude towards high blood pressure in the elderly to a more evidence-based approach that aims to lower blood pressure to levels considered normal for younger individuals, based on recent clinical trials.
📉 Blood Pressure and the Myth of 'Normal' Aging
The speaker continues the discussion on blood pressure, challenging the notion that elevated blood pressure is a natural part of the aging process. They argue that clinical trials have provided evidence that blood pressure levels drifting up to 125/130/135/140 mmHg in older individuals are pathological and not simply a consequence of aging. The speaker aligns with the idea that maintaining blood pressure closer to 120/80 mmHg is beneficial for health outcomes and impacts mortality rates. They acknowledge the potential risks of lowering blood pressure too much but emphasize the importance of striving for optimal levels without causing harm.
Mindmap
Keywords
💡Blood Pressure
💡Kidney
💡Glomerular Filtration Rate (GFR)
💡Creatinine
💡Kidney Pathologist
💡Hypertension
💡Aging
💡Clinical Trials
💡Epidemiological
💡Vascular System
💡Risk Factors
Highlights
The speaker expresses a growing interest in blood pressure and its impact on kidney health over the past two years.
The kidney is described as an underappreciated organ, crucial to maintaining overall health and longevity.
A 'bootstrapping approach' to living longer involves thinking of oneself as a younger version, including kidney health.
Glomerular filtration rate (GFR) is discussed as a critical measure of kidney function, with concerns about its adequacy in older individuals.
The sensitivity of the kidney's vasculature to high blood pressure is emphasized, highlighting its importance in overall health.
The speaker posits that even slight elevations in blood pressure can interfere with long-term kidney, heart, and brain health.
The importance of normalizing blood pressure to improve health outcomes is discussed.
The neglect of the kidney in medical education and practice is acknowledged.
The role of the kidney in regulating blood pressure and its genetic basis is explored.
The speaker discusses the variability of blood pressure throughout the day and its normal range in different situations.
The assumption that 120/80 mmHg is the standard for blood pressure across all ages is questioned.
The idea that blood pressure naturally increases with age is challenged, suggesting it may not be a normal part of aging.
Clinical trials are mentioned as evidence that blood pressure closer to 120/80 mmHg is beneficial for all ages.
The potential harms of treating blood pressure too low are acknowledged, such as side effects and lifestyle impacts.
The speaker's philosophy on blood pressure management is to aim for 120/80 mmHg without causing harm.
The reduction in GFR with age is compared to other age-related declines, suggesting it may not be an unavoidable part of aging.
The importance of clinical trials in guiding the understanding of what constitutes normal blood pressure is emphasized.
The speaker concludes that higher blood pressure in the elderly should not be accepted as a normal part of aging but actively managed.
Transcripts
okay let's let's talk about blood
pressure because I I think this is one
of those areas that I've personally
become more and more interested in over
the past year
um
and it's actually become more of a
concern to Me Maybe over the past two
years through the lens of the kidney
so we have this organ that just doesn't
get much attention I'm trying to think
outside of my podcast with Chris Sonnen
day where we talked about kidney and
liver transplantation
I don't think I've got a single podcast
that deals with the kidney
um and it's a really special organ and I
sort of explained to my patients that
in our bootstrapping approach to
living an extra few years on this planet
a lot of it requires a phase shift in
time right so if you're 50 years old you
really need to be held to the standard
of a healthy 40 year old if you want to
live an extra 10 years that's the way
you want to think about it you want to
think about that in terms of your mind
you want to think about that in terms of
your body you want to think about that
in terms of your coronary arteries you
want to think about it in terms of your
bone density
but you got to think about it in terms
of your kidneys
and so when we look at a person and
estimate their glomerular filtration
rate which we use you know systatin C to
measure that we've largely abandoned a
creatinine
um
it's really tempting to say well you
know
this guy's 55 years old is egfr is 70
mils per minute that's good enough
but in reality it's not actually it's
far from good enough
and
the kidney is not uniquely but
exquisitely sensitive to high blood
pressure
again I'm not a nephrologist and I never
really I don't think I remember much
from Nephrology but I certainly remember
that something about its vasculature is
incredibly sensitive right it probably
has to do with the fact that it's such a
tiny organ that takes such a high amount
of our cardiac output
and I suspect just like the heart and
the Brain it's very sensitive to
pressure
um and so that really is the lens
through which I think about this first
and foremost with with the meaning even
the slightest amount of elevation in in
blood pressure is going to interfere
with long-term Kidney Health and also
with heart and brain health so so really
there's a win across the board if we
just normalize blood pressure so
I'll posit that and and have you just
kind of explain from the
um ascbd perspective the importance of
blood pressure and how it Stacks up with
smoking APO B and some of the other
heavy hitting risk factors
yeah so I I guess I just want to
acknowledge how strongly I agree with
you about the neglect how much we
neglect the kidney is in Oregon and
Nephrology as a sub-specialty of
medicine uh I actually used to give a
lecture on hypertension to the first
year medical students at UCSF and I did
that in conjunction with a kidney
pathologist who interestingly was
uh had been at Hopkins when I was a
medical student was my advisor very
interesting woman who's now retired
named Gene Olson and she she and I
co-game the lecture she gave the
pathology part and I gave the clinical
part and I learned so much about the
importance of the kidney and regulating
blood pressure
in that you know in giving that lecture
with her for however many years it was
10 years
um so it's it's uh it's both an
important cause of blood pressure and in
fact I think if you go back and look at
um you know Rick lifton who's sort of
one of the Premier human geneticists in
in you know history member of the
National Academy had it some probably
should win a Nobel Prize he
characterized all of the single gene
mutations that lead to extreme increases
or decreases in blood pressure
uh
you know I think at the time and this
was 20 years ago they were they were
like you know 10 each 10 10 Single gene
mutations that led to people who had
really really low blood pressure had to
constantly supplement salt and do things
like that and then 10 that led to
extremely high blood pressure and I
think like nine
or whatever it is 19 out of 20 of these
things were located in the same location
in the uh in the proximal collecting
doctor in the tubule it was it was like
you couldn't have picked a place that
was more important evolutionarily for
how we handle volume and and salt and
solute so it's an incredibly important
organ both as a cause of high blood
pressure
and also as a consequence and those
experiments you know Gene showed these
beautiful slides that I'll send along
sometime you know pictures of what
happens to to your kidney after it's
exposed to
low increased levels of blood pressure
over time so
um it was interesting because I was
giving this lecture as a cardiologist
during the kidney block it always felt
I fell out of place
so
most people kind of know that when they
go to their doctor and they get their
blood pressure checked normal is about
120 over 80 millimeters of mercury
um
what do we know about how much that
changes in a healthy person across the
course of the day
so when they're sleeping
when they're ambulatory and walking
around but not under stress I.E not
exercising when they are exercising
vigorously when they're you know under
stress physiologic stress psychological
stress
all of these different things that we do
every single day surely our blood
pressure must change and yet most of us
myself included have virtually no idea
of how our blood pressure is changing
under those situations even if under
perfect optimal conditions I.E sitting
down legs uncross for five minutes it
reads 120 over 80. so what do we know
about the rest of the time
so I guess it's it we don't I don't want
to get too distracted but I think it's
fascinating I've thought about this a
lot and the question of what's normal is
you know we all assume 120 over 80 is
normal
if you look at blood pressures across
different animal species
it's mostly in that range there are some
that are outliers obviously a giraffe is
is the best example of an outlier
species with much higher blood pressure
that it needs to have to be able to pump
blood up to that very hit that head
that's sitting way up high
it is weird to me from an evolutionary
evolutionary perspective why we would
have the same blood pressure as a mouse
right it's a little tiny creature who
walks around on four legs why should we
have the same blood pressure it speaks I
think to the conservation of the sort of
vascular system that we have
I think most people when I was a medical
student I'm sure you were the same we're
taught that 120 over 80 is normal that
that's just normal whether you're uh you
know 7 17 or 75
I don't think we have a good
understanding of well we have an
understanding of what is
epidemiologically normal as we age and
so we know that blood pressure does go
up with each decade of life
if I had access to that lecture I used
to give I could show you what happens
but but certainly with each decade of
Life your blood pressure goes up on
average if you're looking at a
population of people is that normal is
that part of normal healthy aging or is
that just a function of pathology is it
a function of something going wrong over
time to your point is it's something
about decreased kidney function or maybe
as an increased vascular stiffness over
over time I think all those things are
possible and probably probably probable
so for a long time
it was assumed that a blood pressure
that was normal for somebody in their
20s and 30s
was
probably too low and not normal for
somebody who was in their 60s 70s and
80s and so we let had sort of had this
permissive hypertension
in elderly people because we thought
well gosh they
required it's just part of
the aging process and it really hasn't
been until the past really 10 plus years
that we've begun to ask specifically
in really well-designed clinical trials
is that the case and is it the case when
it comes to looking at an important
clinical outcomes and I think uh you
know my take on this now is different
than it was 15 years ago and that is
that 120 over 80 is normal no matter
where you are in life and that anything
above that is abnormal and you know just
to kind of get to the punch line what I
tell patients is that my aspiration is
that we can get you as close to 120 over
80 as we can without harming you because
there are certainly potential harms that
are associated with treating people to
these low numbers they can be in the
form of
side effects or impacts on lifestyle
they can be in the form of real toxicity
you know hyperkalemia have risk of death
I mean there's all kinds of potential
issues that it's not just a simple
intervention
like treating LDL or apob lower and
lower lower there's really no
consequence at all there is a
consequence of lowering blood pressure
too low in this case so that's my
overall kind of philosophy of how to
think about blood pressure is I do think
there's now evidence from good clinical
trials that 120 over 80 is normal and
that we should try to get there as best
we can without making a mess
so through that lens basically we're
saying that the amount of float that we
see in blood pressure again we're all
we're talking about blood pressure in a
very narrow instance which is seated
resting Etc oh yeah yeah we'll come back
to the other point but just to build off
that that when that drifts up to 125 130
135 140 in an aging population
we're actually calling that pathologic
in the same way that I think we would
all agree that the reduction in
glomerular filtration rate the reduction
in ejection fraction the reduction in
pulmonary function
okay yes that occurs with aging but that
doesn't mean that it's not part of an
aging process and therefore part of
something we want to minimize correct
that's right we lose muscle mass as we
age is that something we want to accept
and that's normal or do we want to try
to do it again to preserve the muscle
mass that we had it younger in life and
again I think here the the crutch that
we fall back on and
is good high quality
well done clinical trials and in this
case we have now have them and it's not
just sort of an opinion based thing that
says oh we'll really get closer to 120
over 80. we actually have evidence that
being closer to 120 over 80 impacts
mortality and uh and that permitting
people to run higher to a level that we
used to consider to be just basically
pre-hypertension or just normal even an
older person 140 over 90 that leads to a
significant increase in risk of dieting
so to me I think uh we've learned a lot
and I don't I don't consider it to be a
normal function of Aging I think
there may be a process there's obviously
a process that goes along with aging
that there's a decrease in function of a
lot of different things that combines to
lead to this increase in blood pressure
but I don't leave it alone
foreign
[Music]
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