Focus on K2P Faculty: Dr. George Bakris
Dr. George Bakris is a member of K2P’s LEGENDS Series faculty and has provided an activity entitled “Our Evolving Understanding of Hypertension (Past, Present, and Future)” He also contributes to other K2P programs on hypertension.
Dr. Bakris is the director of the American Heart Association Comprehensive Hypertension Center within the Section of Endocrinology, Diabetes and Metabolism at the University of Chicago Medicine. He specializes in the diagnosis and management of resistant hypertension, particularly in complicated and refractory cases. He is also skilled in the treatment of kidney disease, with special expertise in diabetes-related kidney disease. His research is focused on understating the factors that influence kidney disease progression and the interactions between hypertension, diabetes, and kidney disease. He has published more than 900 articles and book chapters in the areas of kidney disease, hypertension, and progression of nephropathy, and edited more than 23 textbooks dealing with kidney disease, diabetes, and the role of hypertension in these conditions.
Dr. Bakris has been extensively involved as either a principal investigator or on the steering committees of national and international trials involving diabetic kidney disease progression and resistant hypertension. He has served on many guidelines committees over the past 20 years and the co-chair of the American Diabetes Association Blood Pressure Consensus Panel and is a member of the American Heart Association panel updating resistant hypertension guidelines. As well, Dr. Bakris was a member of the Cardio-Renal Advisory Board of the Food & Drug Administration. He received the Irvine Page and Alva Bradley Lifetime Achievement Award from the American Heart Association’s Council on Hypertension in 2019 to acknowledge his lifetime of outstanding achievements in the field of hypertension.
We sat down with Dr. Bakris to ask a few questions…
What would you like learners to take from your Legends talk on hypertension?
There are a couple of things. I would say number one, they really need to know that this is not just a numbers game. They need to understand that how you measure blood pressure is just as important as how you treat it, and if you don’t measure it correctly, then you will always make a mistake in treatment. There are many people with different types of hypertension, isolated, systolic, masked, and white coat hypertension, and what have you, and the treatments are similar but different. So, it really is important to know, number one, what medicines you’re going to start with and the proper dosage. Number two, what is the definition of hypertension for that particular person? And did
you measure the blood pressure per guidelines or did you just slap a cuff on and get a number? Because if you did that, there’s a great likelihood that you will be incorrect in making the diagnosis. Within these points, there are subtleties, of course. It is not simple.
Have there been any big advances in hypertension in the last 5 years?
There really have not been any major inroads in hypertension over the last five years. There are new drugs that are in development, new classes of drugs, but they will probably only be available in 2 to 5 years. There are the non-steroidal MRAs, like finerenone, although this is a different nonsteroidal MRA with unique blood pressure-lowering features, dual endothelin receptor antagonists, and also the aminopeptidase A inhibitors, which are less well known. The advantage of those drugs is they have unique mechanisms and they appear to have, at least so far from what I’ve seen, few side effects.
Can you explain briefly how to properly measure blood pressure?
Sure. Now, this is true for in-office, but it’s also true at home because you have to teach the patient how to measure blood pressure. First of all, what you don’t do is have the patient rush in and you slap the cuff around his shirt or blouse, check the pressure and you’re done. That is totally incorrect.
You need to have the patient come in and they need to rest a minimum of five minutes in a chair that has arm supports so that the patient can rest their arms on support, not using their muscles. You then take the shirt off, so that you’ve got a cuff that goes around the arm properly. You have to measure the circumference of the arm and you do it at the mid-bicep and the cuff is appropriate for the size of the arm. That’s important.
Then you put the cuff on and the patient sits there for a minimum of three to four minutes, ideally five minutes. Then you measure three blood pressures, one minute apart. You throw the first reading out and average the second and third reading and that’s your blood pressure. Doing this will take care of a lot of white coat hypertension and give you a more accurate reading. You will almost always see that the second reading is lower than the first.
I teach all my patients how to measure their blood pressures at home, because I know they’re going to measure them anyway, and I want them to do it properly. I expect a report card from them when they come to see me, and I would say 90% plus are
providing me with this data. When you measure properly, then you can use the right drugs to fit the occasion and you’ll see much better outcomes.
Besides measuring blood pressure properly, any other best practices for treating hypertension you can share?
There are 125 different approved anti-hypertensive medications, and although not all of them are available, the problem is that physicians are either scared to use them or don’t know how to use them. The dosing is very often wrong. For example, people are using ACE inhibitors and ARBs at much lower doses than they should be used at, lower than the doses they were tested at, and not doses that are likely to work.
Also, there are many single-pill combination medicines that are very effective and do not have more side effects than monotherapy, but they’re not being used. The most recent European guidelines cut to the chase on this and basically said, enough already, combination therapies are good, they’re effective, they have few side effects, and you’re getting two medicines for one. So, start with combination therapy and go from there. Since the average number of antihypertensive medications used in the general hypertension population is two, why don’t we just start with two medicines?
Another problem is that part of the reason why some medications appear to lack effectiveness or leave patients complaining of side effects is because physicians are not doing a good job explaining how to use the medications properly and the importance of reducing sodium intake. If you don’t control sodium, that will screw up any good blood pressure response that you’re going to get. This is not always a physician issue, but rather a policy and payer issue, but there is a lot of room for improvement in how we treat hypertension.
What career would you have chosen if you hadn’t chosen to become a physician?
Well, this may surprise you, but I was really into music and I played in a band. I played guitar and a bit of piano. This was back in the late sixties, early seventies, and I was seriously thinking about a music career. We cut a demo and we sent it to a couple of record companies just to see, you know, if we had a chance. Basically, the response was that we were good and they liked us, but we’d have to pay for our own studio time and if we managed to put out a hit, then great. The upfront cost at that time was about $5000. Amongst us all, we were lucky to have $300. So we just said forget it. I always liked science and medicine, so I went in that direction.