Medical Associates Clinic

 Quality Care Close To Home

GETTYSBURG MEDICAL NEWS
The Clinical View
by P. E. Hoffsten, MD
26 July 2006

SOME RULES ABOUT HIGH BLOOD PRESSURE

            A recent survey of internal medicine doctors indicated that 15 percent of their time in office visits was devoted to problems with high blood pressure (hypertension).  Considering all of the many diseases that internal medicine doctors have to deal with, including heart disease, diabetes, cancer, and arthritis, by far the most common problem they had to deal with was high blood pressure.  Recently, a patient came to me for a second opinion regarding his high blood pressure.  He was a 61 -year-old executive who said he felt wonderful.  He took no medications.  On a recent screening done in his business office, it was seen that his blood pressure was 160/100 millimeters of mercury.  He said he had known it had been that high in the past.  He had taken a medication about 10 years ago.  It made his blood pressure “go down a little bit”, but he said he didn’t feel as good taking the medication and thought that the 160/100 blood pressure was “normal for him.”  The doctor he had gone to for years told him that he needed to change lifestyles and take a medication to get the blood pressure down, but the patient really hadn’t been impressed with this need.  He wanted a second opinion on how important blood pressure control was.  It took a full hour, or about 15 percent of my office time for that day, to explain the following rules.

            Rule number one: There is no such thing as normal high blood pressure.  A resting blood pressure should be 120/80 or less, ideally 110/70.  The standard of 140/90 that was established many years ago is now out of date and very clearly abnormally high; 160/100 is a heart attack or a stroke waiting to happen.

            Rule number two: Lifestyle is important.  It has been shown in multiple studies that exercise, weight control, adequate sleep, and techniques in stress management are all helpful to lower blood pressures.  Unfortunately, very few individuals are effective in utilizing these changes to adequately control blood pressure.  The most ineffective comment that I hear is “I am going to exercise more.”  It never seems to happen.

            Rule number three: A medication is almost always needed.  If the blood pressure is 140/90 or more, the person will probably need two different types of medication.  In today’s world, there are many combination pills that involve two different drugs that can be taken once a day as one pill.  For people with blood pressures greater than 140/90, the average number of medications to get blood pressures down into the normal range is three and a half.  That usually means taking two pills or more.

            Rule number four:  Medications should be tried for about six weeks before changes or adjustments in the drug program are made.  Most patients that are going to be controlled with a particular drug program will have the full effect of that program by about six weeks.  If the blood pressure isn’t in the normal range by that time, adjustments should be made.

            Rule number five: In spite of many patients’ claims to the contrary, a person cannot “feel their blood pressure.”  Just because a person “feels good” doesn’t mean their blood pressure is normal.

            Rule number six: Medication side effects have now been reduced quite substantially.  Older drugs had significant side effects, but the modern ones have very few.  It is almost always possible to tailor a drug program to fit the individual without side effects using today’s medications.

            Rule number seven: The consequences of untreated high blood pressure are very expensive and unforgiving.  Information continues to accumulate indicating that high blood pressure is a leading cause of heart failure in our society and a contributor to loss of brain function called dementia.  I have heard many patients say that they wouldn’t mind having a heart attack and being taken from this world in an instant.  That isn’t always the way high blood pressure works.  Very commonly, it leads to heart failure leaving the person short of breath and sitting in a chair the last few years of their life, or having a stroke with one side of their body that doesn’t work the last few years of their life, or developing dementia and not even knowing the last few years of their life.

            Rule number eight: The best way to control high blood pressure is to buy your own blood pressure cuff and measure your blood pressure yourself in your own world.  Many times, a patient comes to the office and feels that they have “white coat hypertension.”  They think that the only time their blood pressure is up is when they come to visit the doctor.  The best way to answer this question and to get a real answer regarding the blood pressure is to take it in their own world and make sure the medications they are taking do work to get the blood pressure at a 120/80 resting pressure.

            Rule number nine: There are certain medications and food products that can cause high blood pressure to be much more difficult to control.  Among these is a large amount of salt in the diet.  Salt restriction is important for those with high blood pressure and critical for some individuals.  The use of over-the-counter sinus medications can raise blood pressures a full 10 millimeters of mercury.  The use of nonsteroidal anti-inflammatory drug products such as Ibuprofen, Aleve, Aspirin, Ketorolac, etc., are salt retaining products that will raise high blood pressure.  Certain personal habits such as alcohol intake are a sore subject to talk about.  Excess alcohol is a very common cause of high blood pressure.  More than four alcoholic beverages per day raise blood pressure substantially.

            Rule number ten:  Just because the blood pressure comes down into the normal range with medication does not mean the medications can then be stopped.  Unless there is a major change in life style, medication programs are permanent.  When medications are stopped the blood pressure goes right back up again, usually within two to three months.

            Going through all of the above with the gentleman I described above took a full hour and I am not really sure he was convinced when we were through.  I did tell him that his private physician was giving him a very good advice and the control of his blood pressure was important.  I told him that he needed at least six weeks to have a drug program be demonstrated effective and without side effects.  I told him, most importantly, that if his high blood pressure didn’t get fixed it was very likely he was going to pay a terrible price with no hope of reneging on the debt.  Heart failure, strokes, and dementia do not go away when the patient says they now understand and want to control the blood pressure.  I hope the gentleman described above doesn’t have a “hearing defect” as so many people with high blood pressure do.   In the USA today only one person in three has their blood pressure effectively treated.