Hypertension, or high blood pressure, is blood pressure greater than 140/90. It is critical to diagnose and treat this adequately because it can remain without symptoms and cause a stroke, heart failure, heart attack, aneurysm, kidney disease and vision loss. It is one of the most common conditions treated in a doctor’s office, yet it is under-diagnosed and uncontrolled in over half the patients with serious consequences. The goal is to treat it with a blood pressure (BP) of less than 140/90 or even 120/ 80 if the patient can tolerate it.
It is important to have an annual blood pressure check for adults, but if there is a strong family history of hypertension, or if the blood pressure is close to upper limits of normal, then more frequently. Pre-hypertension is a term given to BP that is 120-139 / 80-89 and indicates a possibility of progression to hypertension.
When I see a patient whose BP is mildly elevated for the first time in the office, I recheck the BP, and instruct the patient on life style changes for controlling it and ask him/her to return in 1-2 weeks for recheck. I also ask the patient to check their BP at home and bring the record to the office. For home use an aneroid or digital BP apparatus with the cuff that fits around the upper arm is best. Occasionally the home apparatus should be brought to the clinic to verify proper functioning.
Correct measurement of BP is key. Patient should be seated quietly for a few minutes. The correct cuff size must be used as a regular cuff can give higher readings on a large person. The inflatable bladder in the cuff should encircle 80% of the arm, so larger persons will need a larger cuff. The arm should be supported while checking the BP.
If high blood pressure is confirmed, I do a full physical exam focusing on target organs such as eye, kidney and heart to detect any damage, blood and urine tests to detect other risk factors like diabetes or high cholesterol, and an EKG. Both arms are checked, and if the BP difference between the two sides is greater than 15 mm, I look for vascular disease. In elderly patients and if someone complains of dizziness, I check a standing BP after 1-2 minutes to ensure the BP does not fall too much upon standing as this can lead to falls.
Blood pressure is not static and changes throughout the day with the highest readings in the early mornings, progressively declining in the afternoon and evening, and reaching the lowest readings during sleep. BP can be checked morning and evening at home and sometimes medication can be given in divided doses for optimal BP control.
There are a large variety of drugs to treat hypertension and they are effective and well tolerated by most people. The selection of a drug frequently depends on the presence of co-morbid conditions like diabetes, heart disease or kidney disease. Two or more medications may be needed to control BP. Diuretics or “water pills “ are common first line agents that are time tested and effective but they can exacerbate gout.
It is key to educate patients about their medicines. Patients should inform their doctor of all medications, so duplicate or outdated medicines can be weeded out and medications should be monitored on a regular basis.
Life style changes are key for controlling established hypertension. Obesity is a major risk factor and losing even 10 pounds can lower systolic pressure (the top number) by 5 mm. Reducing salt intake is vital for controlling hypertension. Total daily intake of salt in older individuals and in hypertensive people should be about two thirds of a level teaspoon of salt or 1500 mg of sodium. Canned and processed foods have a high salt content. It is important to read the label for sodium “per serving” in processed foods. Many of the packaged Indian foods sold in stores, although convenient, have very high sodium content and have up to half the day’s sodium allowance in a single small serving.
Wash canned products such as beans to reduce salt content. Other high salt foods in common use are soups, salad dressings, pickles, soy sauce, cheeses, bagels and breads. Even if a product says “low sodium” it may still contain too much sodium, so it is important to read and understand the nutrition labels.
Exercise improves cardiovascular fitness, reduces weight, reduces blood sugar, and improves blood pressure. Moderate exercise like brisk walking for 30 minutes a day can help reduce blood pressure independent of weight loss.
Meditation, relaxation and deep breathing can alleviate stress and help with BP control.
Alcohol consumption may best be avoided since it adds calories and makes losing weight more difficult. A can of beer or 5 ounces of wine daily can pack 12-15 pounds a year. Even light beer has over 100 calories in a can. Moderate or heavy drinking can lead to severe elevations in BP. It is also important to control other cardiovascular risk factors such as diabetes, elevated lipids, and to quit smoking.
Isolated systolic hypertension is a condition which occurs in the elderly when only the top number or systolic BP is elevated due to stiffening of the large blood vessels, but it carries all the same cardiovascular risks, so has to be treated adequately.
Sometimes, BP may not be controlled even on multiple medications and is described as “Re-sistant Hypertension.” Frequently the cause is excess salt intake, missing medication doses, sleep apnea, obesity, decongestant use such as in cold medicine, pain medications called non- steroidal anti inflammatory drugs like ibuprofen or naproxen, too much alcohol consumption, and stress. If these causes of resistant blood pressure are ruled out, and BP remains high on multiple medications, referral to a specialist for further diagnosis and treatment is warranted.
Decades ago I used to see patients with massive cerebral hemorrhages, and many with bleeding and edema in their eyes from blood pressure crises. Fortunately they are less common now, but we still need to be vigorous in finding and treating this “silent killer.”
Padma Srinivasan is a physician practicing in the East Bay, and is Board certified in Internal Medicine and Nephrology. Besides medicine her other interests are Indian classical fine arts and traveling.