Gettysburg Medical News
  The Clinical View
  by P. E. Hoffsten, MD
  24 August 2005

UPDATE ON HIGH BLOOD PRESSURE

Imagine a soft rubber hose carrying a liquid without much pressure on the hose.  Imagine this hose attached to your car, your washing machine, or your tractor in the same place, carrying the liquid for 40 years.  Imagine that of the hose would be carrying liquid that would be somewhat corrosive and the liquid would lay down deposits on the inside of the hose.  Usually such deposits are crusty and can get in the way of the hose being pliable and rubbery.  Now imagine the hose being alive and inside a human body developing deposits on the inside of the hose.  It now becomes a blood vessel.  The wall of the blood vessel being alive requires a blood supply.  That blood comes right through the wall of the blood vessel to nourish the inside of the blood vessel wall.  If a corrosive deposit coats the inside of the blood vessel not enough blood gets thru the wall to the muscle in the blood vessel wall with the result that the muscle becomes malnourished and eventually dies.  When this happens, calcium deposits replace the muscle and the hose is no longer pliable, soft, and elastic anymore.  Now it becomes a hard calcified pipe.  Before, when more blood was needed in an arm or a leg, the blood vessel could distend somewhat and carry more blood to the arm or the leg without really changing the blood pressure.  Now as that blood vessel is not distensible, it takes more pressure to carry more blood when if person were to crank up to run or walk fast.  Thus is born high blood pressure.  The body will naturally do what is necessary to get blood to the places where it is needed.  This includes the heart, brain, kidneys, arms, and the legs.  If the blood vessels don’t distend as easily as they do in youth, then a higher pressure is needed to force the amount of blood out to those areas where it is needed.  Now this poor blood vessel is not only not distensible, but it is being subjected to a higher pressure.  This may go on for another 20 years and then at about age 60, the blood vessel becomes so corroded that it can’t carry enough blood, even with high blood pressure.  That is when the person develops chest pain from the heart not getting enough blood, pain in his calves from his legs not getting enough blood, or begins to get memory problems because his brain doesn’t get enough blood.  One day the blood vessel may stop up altogether or spring a leak.  When that happens, it is called a stroke or a heart attack or the need to amputate a foot or a leg because the leg doesn’t get enough blood.  High blood pressure is a terrible thing.

            The deposits and corrosion that occur in the blood vessels are related to a number of factors.  The four most important factors by far in our population include diabetes, high blood cholesterols, smoking cigarettes and high blood pressure.  High blood pressure merely amplifies the adverse effects of these first three factors.  Fortunately, diabetes can be controlled, cholesterols can be effectively lowered, and cigarette smoking can be stopped.  If these three things were adequately controlled, almost 95% of the heart attacks and strokes that occur in the United States could be prevented.  High blood pressure can act alone to corrode blood vessels.  But more importantly it quite markedly accelerates the degenerative effects of high blood cholesterols, diabetes, and cigarette smoking.

            As I have indicated in these columns previously, people seem to think that health and well being is a God given privilege, or even right, that the person has no obligation to protect.  People believe that health is ”natural”.  They don’t seem to understand that bodies do wear out every bit the same as a tractor, a car, or a pair of shoes.  People seem to understand that maintenance for their possessions is important and useful, but it is so hard to convince people that preventive maintenance for their bodies is important too.

            The facts about blood pressure control are now much better recognized than in the past.  Previously, it was thought that a normal blood pressure was 140/90 mm Hg or less.  In the past 20 years, updated data have been collected from many sources showing that a normal blood pressure is 120/80 mm Hg or less.  An ideal blood pressure is 110/70 mm Hg.  The idea that 130 or 140 systolic blood pressures are okay is invalid.  There are definite degenerative changes that are occurring in a person’s body when blood pressures are persistently that high.

            Previously, it was thought that lifestyle changes would deal with blood pressures between 120 and 140 systolic.  Now we know that those values are simply too high and that lifestyle changes are very infrequently instituted to get blood pressures down without a medication.  Updated suggestions are to give a person two months for lifestyle change to get a pressure down in the normal range of 120 systolic or less.  If that can’t be achieved within two months, the person should start a medication.  If the blood pressure is 140 systolic or higher, it is now clear that starting two medications as a combination pill is an indicated step to get the blood pressure down.  When blood pressures exceed 160 mm Hg, aggressive treatment with as many medications as necessary to get the pressure down in the normal range is an appropriate step in care.

            Certain myths and wrong information need to be addressed.  First, there is no such thing as normal high blood pressure.  Many times patients will say that they feel better with their pressures higher.  If a person has had high blood pressure for an extended period of time and it is suddenly lowered, it is very believable that the person might not feel as good as they did when their pressure was higher.  Instead, blood pressure should be gently lowered over a month to two months.  There is no such thing as normal high blood pressure.

            In regard to medications used to lower blood pressures, there have been some very gratifying improvements in blood pressure medications over the last 20 years.  We now have a group of medications called the angiotensive receptor blockers that are very effective (Atacand, Avapro, Benicar, Cozaar, Diovan, Micardis, Tevetin).  They have a side effect profile that is not different from a placebo pill.  Unfortunately, these drugs are all still under patent protection and therefore more expensive.

            There is another group of drugs called the angiotensin converting enzyme inhibitors that have recognizable side effect.  The medication can be stopped if problems would develop.  There is a large group of drugs called beta blockers that have fringe benefit of protecting a person’s heart from irregular rhythms.  Beta blockers do have a tendency to slow one’s industry and ambition in some people, but not everyone.  If the beta blocker can be taken without side effects, it is an excellent choice.  The use of many other medications can be tailored to the individual person.  Some drugs work very well in one person and not so well in another.         Working with each individual patient to find a drug combination that will adequately control blood pressure is useful past lifesaving.  We like to save lives, but in addition, we are very conscious of the importance of preserving the quality of life.  Avoiding heart attacks and heart failure or strokes and paralysis is a really important way to protect the quality of a person’s life.  The healthcare providers at your local clinic are well aware of these considerations and can help an individual find a program that will control their blood pressure with the fewest side effects and the most fringe benefits.