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Interviewer: Our emergency room physicians use vital signs to diagnose you. That's next on The Scope.

Announcer: This is from The Front Lines with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: One of the first things that will happen when you go to the emergency room as you will have your vital signs taken and what exactly does that do? I want to get a little insight from emergency room physician as to what that information can help with. Dr. Madsen, when you see somebody, do you see their vital signs before you actually ever see them?

Dr. Madsen: I do very often. And it's funny because vital signs, you hear that it sounds incredibly boring but in vital signs, they are vital.

Interviewer: Sure. Vital. How many vital signs are there?

Dr. Madsen: So there are four vital signs we use, blood pressure, heart rate, respiratory rate, so how fast you're breathing, and temperature. And those are the things I look at and 99% of the time, I see those before even walking to the room. A person comes to the ER, they go to the triage area, they check vital signs, and that's a big part of triage.

Someone comes in with a heart rate of 140, they're going to go back to a room a lot faster than someone who has completely normal vital signs. So it's a big part of what we do in the ER, it's a big part of my decision-making process of saying who do I need to see first versus okay, I've got five patients I need to see right now, who can wait?

Interviewer: Yeah. What's the worst case scenario of vital signs situation?

Dr. Madsen: Worst case?

Interviewer: Yeah. Like you look at the chart and you see this, you're like, "Bam, first on the list."

Dr. Madsen: The worst case scenario would be certainly no vital signs.

Interviewer: That is okay.

Dr. Madsen: That would be cardiac arrest.

Interviewer: Fair enough.

Dr. Madsen: But if I see someone who comes in, let's say they have a temperature of 104, heart rate of 120, blood pressure of 80/40, I'm thinking to myself, "This person is in sepsis. They have a severe infection. I need to get into that room right now. We need to get two IVs started, start fluids going, antibiotics going." We're jumping on it immediately. So it's a huge part of my decision-making processes as to where I'm going next as an ER doctor.

Interviewer: Give me a couple of other scenarios there, what the vital signs might tell you before you even see the patient.

Dr. Madsen: So another vital sign we might see, so let's just say I see a heart rate of 160, blood pressure again, 80/40, maybe they're not febrile, I'm thinking to myself, "This person is in an abnormal heart rhythm. They could have a supraventricular tachycardia or atrial fibrillation." Again, that's someone I'm going in the room immediately. It could be someone where we have to administer medication or shock their heart to get it back into a normal rhythm.

Interviewer: Got it. What about just a high fever? Everything else looks kind of okay.

Dr. Madsen: Okay. Yeah, and that's not an uncommon thing especially during flu season. Again, it's someone, I'm going to want to get in the room but I probably I'm paying more attention in that situation to their heart rate and blood pressure. It's someone where, again, if I had someone who had a low blood pressure versus the person with a temperature of 104, I'm going to be in the room with the blood pressure first.

Interviewer: Got it. So vital signs definitely are vital for what you do.

Dr. Madsen: They really are.

Interviewer: And then after you get in the room and you find out what happened, are there scenarios where you would combine all that information in a way that the average person wouldn't necessarily?

Dr. Madsen: Yeah. So I'm then going to combine that with the lab results so you've got to take the whole picture into account looking for infections. I'm going to look at vital signs or if are they febrile, what was their heart rate, I'm going to look at their white blood cell count. Those are all things I'm considering.

It also is a big decision part in terms of where they go from the ER. So if someone has abnormal vital signs, they may not go to a standard medical bed once they're admitted. They may go to the medical intensive care unit because they need closer monitoring. Those vital signs are telling me there's something wrong here that needs to be addressed and they can't just go to, again, a standard four bed where they may not get the attention they get in the intensive care unit.

Interviewer: So definitely vital signs is very important for you to do your job to try to figure out what's wrong with somebody but there's a lot of ways now that the common person can figure out their blood pressure at home, you've got home cuffs, we wear things on our wrists now that can tell us our pulse. Is that something we should be monitoring ourselves on a daily basis?

Dr. Madsen: So that's a great question because there is the flipside of this where I think sometimes we can pay so much attention to our own vital signs and it can become distracting. Occasionally, we'll see someone who has a home blood pressure monitor and they say, "Well, my blood pressure is usually 120. Today it was 140." There are always going to be just natural variations in blood pressure and heart rate. So I think you sometimes you can get a little overly concerned about blood pressure, or you can have heart rate monitors that maybe you're seeing your heart rate up around 100 at one point where normally it's 80.

Again, always going to be variations depending on stress level, just how you're feeling, exercise or not. All those things are going to affect your blood pressure or heart rate. But I wouldn't get overly concerned about things. But certainly, keep in mind that a significant variation there is something that raises concern for me.

Interviewer: When it comes to vital signs, what are the thresholds that you kind of look at? Like so say, for example, I maybe have a heart rate monitor, I feel my heart rate is starting to race all of a sudden and I'm just sitting there, right? I take my pulse or I look at my monitor, how do you know when it starts getting into abnormal?

Dr. Madsen: It depends what you're doing but I think for a person who's just sitting there, who's not exercising, if they have a heart rate greater than 100, that for me is concerning. And again, I just want to answer my mind, are they anxious, are they in pain, that's going to raise your heart rate or is there something else going on, an abnormal heart rhythm. That would prompt me to get an EKG, something to look at the electrical activity in their heart to make sure it's in a normal rhythm, that there's not something abnormal that's causing that.

For blood pressure, once you get that top number, the systolic number less than 90, that raises concern for me. Sometimes, you may have someone who just exercises a lot, who maybe their blood pressure is usually 95 and it drops to 85, that's not so concerning. But the average person, when it gets less than 90, that's also something for me that makes me a little more concerned.

Interviewer: And I think most of us can tell if we're breathing rapidly or . . .

Dr. Madsen: Yeah, breathing rapidly. A standard fever would be something greater than about 100.5 degrees, something getting up into the 100s there. Some people say, "Well, you know, my temperature runs a little cooler. My temperature is 99 now." Again, I usually don't get too concerned about that till it gets into the 100s.

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Interviewer: The current medical guidelines for systolic blood pressure are between 140 to 150 but new research indicates that reducing that to 120 can drastically reduce the chance of heart disease and death for adults 75 or older even if they are considered frail elderly. Dr. Mark Supiano is a geriatrician and the executive director of the University of Utah Center on Aging. This study, is this a new revelation that lower could be better with systolic blood pressure especially for elderly adults?

Dr. Supiano: Yes, Scott. This is exciting new information that came out of the systolic blood pressure intervention trial otherwise known as SPRINT. The trial ended late in 2015, earlier than anticipated because of these very dramatic benefits.

Interviewer: When it initially ended early, a lot of people speculated that that meant bad news but it actually meant quite the opposite.

Dr. Supiano: Yes and particularly for the 28% of the SPRINT subjects who are over the age of 75 there were some concerns, myself and other geriatricians, that the very intensive systolic blood pressure target of 120 might not be safe for older people. When we first got news of the trial ending early I first thought that it was possible that older people had more side effects or more injurious falls or other complications of the very low blood pressure and that was why the data safety monitoring board might have ended the study early. In fact, the results were just the opposite.

Interviewer: Like a revelation almost it seems like.

Dr. Supiano: It really was a surprise to be honest. Not so much as a surprise that the benefit but the surprise that the benefit was of this magnitude and that this occurred this early on on the trial.

Interviewer: So the current guidelines are between 140-150. This study points out that 120 can drastically reduce the chance of heart disease and death. How drastic are we talking?

Dr. Supiano: I'll focus on the population 75 and older as I said, this is 28% of the SPRINT cohort and in that group there was a 33% reduction in the cardiovascular outcomes. This is primarily a myocardial infarction or heart attack or congestive heart failure and stroke and then in addition overall reduction of 32% in mortality.

Interviewer: That's pretty substantial.

Dr. Supiano: It is. To be honest there are very few treatments I can recommend for people over the age 75 that can have this dramatic impact on those outcomes.

Interviewer: So if you're going to do one thing, according to the study so far, it would be try to get that blood pressure down to 120. Now, does that mean taking medication? Does that mean lifestyle changes?

Dr. Supiano: All of the above. On average, the people in the intensive group who are managed to a blood pressure of 120 or taking one additional anti-hyperintensive medication relative to people on the standard arm.

Interviewer: Of course your eyes looking at the risk benefits and something like this. So the benefits are tremendous. Are there risks?

Dr. Supiano: Absolutely. The good news was, and again focusing on those 75 and older population, our major concern would have been there were higher rates of injurious falls or what's called orthostatic blood pressure - a reduction of blood pressure when the people first stand up and get light headed or dizzy. First, there was no increase in serious adverse events between the intensive and the standard arm. Second, and again very reassuring, there was no high rate injurious falls in the intensive group, nor were there serious rates in the intensive group. The intensive group did have higher rates of low blood pressure, of electrolyte abnormalities, largely low sodium levels which was to be expected because of the medications that were used and some other adverse events. But when we weigh though over the benefit of preventing heart attack, stroke, heart failure and death, most believe that those benefits outweigh those risks.

Interviewer: That number of 120, can you go lower than that and get more benefits or is there a point where no?

Dr. Supiano: That would be another study. And it's important to point out the one on average for 75 and older group achieve of systolic blood pressure of just under 122. That meant that half the people had a systolic blood pressure above 122. So 120 maybe recommended as a target blood pressure. That doesn't mean everyone is going to get there. Nor does it mean that the benefit won't accrue if you don't get exactly to that target. I think the take home message is, it seems to be that the lower, the better.

Interviewer: So is this something that if somebody does fall under this group or somebody has a grandparent or parent that's in this group that you would recommend that they go to their doctor and say, "I would like to try for a blood pressure of 120"? Because this isn't the guideline yet.

Dr. Supiano: So important point, the guidelines are being written down or likely incorporate this new information but those guidelines won't be out until later this summer. Even with that guideline, like everything we do in medicine and particularly in geriatric medicine we have to be patient-centric. So we need to weigh someone's benefits and risk of their elevated blood pressure and incorporate that those at greater risk are likely to have greater benefit. So it needs to be an informed decision with patient who discussed the pros and cons and determine their level of interest in trying to achieve this lower target and recognize those benefits.

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Scot: New guidelines are out when to treat high blood pressure. The recommendations may surprise you. We'll explore that next on The Scope. Medical news, and research from University of Utah physicians, and specialists you can use for a happier, and healthier life. You're listening to The Scope.

We're with, Dr. Tom Miller, from the University of Utah Hospital. Dr. Tom, I understand that there are new guidelines for treatment of high blood pressure. What's going on?