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ypertension is the condition commonly known as high blood pressure. Where is the pressure? Our heart and arteries are muscular organs, and muscles basically do two things: they contract and they relax. In the heart and arteries, contraction is called systole (pronounced ‘sis-toe-lee’). Relaxation is called diastole (‘dye-as-toe-lee’).
Created by Christopher Green R.N. B.A.
When blood pressure (BP) is measured with a blood pressure cuff on your arm—a sphygmomanometer—two numbers are measured. The top number, the higher of the two, represents the pressure during systole, and the bottom is the pressure during
diastole. Normal pressure is considered to be less than or equal to 120/80 (read as “120 over 80”). Hypertension is diagnosed when pressure is consistently greater than 140/90, on at least three consecutive readings in a doctor’s office.
It is estimated that 55 million American adults have hypertension. Most of them, perhaps more than 95%, have “essential hypertension”. This means that the cause of the high pressure is unknown, and currently unknowable. Those few who have something else have “secondary hypertension”, and these conditions will be discussed in a separate article.
Why do we care about these numbers? High BP is one of the most important risk factors for developing coronary heart disease, congestive heart failure, kidney disease and kidney failure, and stroke. Thus, heart, kidney and brain are considered “target organs” for the damage of hypertension. Not only is high blood pressure a risk factor, it is a cause as well. Particularly in the case of kidney disease, the relationship is insidious, as kidney disease causes and aggravates hypertension, and hypertension causes and aggravates kidney disease.
What does a person feel when their BP is elevated? Usually nothing special. That is the danger. Damage to the heart and kidneys and arteries can progress silently to critical points before any symptoms occur. And the level of elevation of pressure does not have to be extreme for this damage and this progression to take place. Certain conditions aggravate the effect of high BP on the arteries and target organs. When BP is high and combined with high cholesterol, or with high blood sugar in diabetes, the effects are particularly dangerous.
ow is hypertension treated?
The first steps in treating high BP are not medications. There are lifestyle modifications. That is another way of saying that we are trying to change our own bodies by changing our lifestyle, in order to lower the pressures. Unless the situation is urgent, everyone deserves a reasonable trial of these measures, lasting perhaps for three to six months, depending on the individual.
There are several important ways in which modern life impacts us, raising blood pressure. Salt in our diet, too much too eat with even moderate degrees of overweight, stress and reduced level of physical activity are all factors that can lead to high blood pressure.
Reducing salt intake would benefit all of us, but especially those with hypertension. Fresh whole foods in their natural state contain all the salt we need. There is no need to put salt in food during cooking, and no need for the salt shaker on the table. In addition, pre-packaged, produced foods generally contain too much salt. We all need to learn how to read labels, and buy only low salt foods. For a large portion of people with hypertension, careful salt restriction can lower blood pressure as much as many medications.
Americans are overweight, and gaining more weight rapidly. We are becoming a nation of the obese, the morbidly obese, and—the newest category—the super obese. But losing weight can cause substantial reductions in blood pressure, as much as 5-20 points for every 5 kg (11 pounds) lost.
One of the best ways to lose weight is the DASH diet. DASH stands for Dietary Approaches to Stop Hypertension. This diet (*include on site*) emphasizes fresh vegetables and fruits. Whole grains are encouraged, and all cereal products should be from whole grains rather than from refined flours. Low fat dairy can be consumed in moderation. Animal protein can be eaten, but in lower amounts than we are used to in the
standard American diet, and must be very lean. Sugar of all descriptions is avoided. This diet has been shown in research to lower blood pressure as much as many medications. In addition, many health benefits can be ascribed to the DASH method—it is definitely a heart healthy diet.
Increasing physical activity lowers blood pressure in a number of ways. First, we burn more calories, so exercise enhances weight loss. Second, in the relaxation phase after exercise, the muscle tone of heart and blood vessels learn to relax, to lower their tone, and thus lower blood pressure. And over time, this “training effect” becomes conditioned into the arteries. How much exercise do we need? Current recommendations are for twenty minutes a day, five days a week. But there is no such thing as too much. And any amount is better than a lesser amount. The important thing is to start moving. That’s what our bodies were made to do.
We have long known that excessive alcohol intake can raise blood pressure. So moderation of alcohol intake is an important lifestyle change for some individuals.
A final lifestyle modification is often overlooked—
stress reduction
. Our modern American lifestyles are filled with stress. Our “fight or flight” hormones are always revved up, to a much greater extent than nature ever intended. These hormones were intended to raise our blood pressure for short bursts, so we could escape predators or defeat our enemies. But too many of us live with excessively high levels of these hormones, and our blood pressures are elevated as a result.
ow do we reduce stress?
There are many ways. They are as varied as hobbies, pets, yoga, tai chi, meditation, and prayer. There is no best way—the best way is the one that produces results for you.
What about medication?
Lifestyle modifications alone are not enough to control hypertension for most people. Medications are necessary. In fact, the average American with high blood pressure requires two to three medications to achieve good control.
There are several classes of blood pressure medications available. (*see table*)
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Diuretics are water pills. These can help get rid of excess salt and water to lower pressure.
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Some medications affect hormones from the kidneys and blood vessel that cause arteries to constrict. By
blocking these hormones, the arteries relax and your blood pressure goes down. These include ACE inhibitors
(angiotensin converting enzyme inhibitors) and ARB’s (angiotensin receptor blockers).
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Other medications block the neurologic reflexes that boost blood pressure. These are beta blockers and alpha
blockers.
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Calcium channel blockers allow arteries to relax by affecting the movement of calcium ions within the cells of the
arteries.
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Long acting nitrates are medications related to nitroglycerin, usually used for people with angina from coronary
heart disease. But they have proven to be useful for many patients with high BP, especially the elderly.
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Direct vasodilators are a group of miscellaneous medications that open arteries by relaxing the muscles within
them.
Why do we care?
Blood pressure control is one of the most effective things we can do to save lives. Lowering a person’s systolic pressure by 12 points over ten years will save one life for every eleven patients treated. There is very little else that doctors can do so efficiently and so effectively to save lives. The reward of achieving blood pressure control is worth it, because the reward is reduced risk of stroke, heart attack or kidney failure.
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Various guidelines have been developed on using these medications. The most widely used of these guidelines were developed by the Joint National Committee on the Detection and Treatment of Hypertension; and in 2003, the Joint National Committee published their seventh report (JNC 7). These are revised periodically because we simply don’t have all the right answers yet.
Medications should be started when your blood pressure is consistently greater than 140/90 after three readings, and after a reasonable trial of lifestyle modifications. But if pressures are much higher, greater than 160/100, medication should probably not be delayed. It may take weeks or months of working with your doctor to find the right combination of medications for good control.
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Dr. Samuel Snyder is Associate Professor and Chair of Internal Medicine at Nova Southeastern University College of Osteopathic Medicine. He is a Fellow of the American College of Physicians, the American Society of Nephrology, and the American College of Osteopathic Internists. He is board certified in both Internal Medicine and Nephrology. He writes scientific and popular articles and lectures widely on a wide range of medical subjects.
