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A: You're
on the right track. There are a few more measures to try -- including
patience -- but first some background.
A device to measure blood pressure
was first invented in the late nineteenth century and was given the
unfortunate, unpronounceable name of sphygmomanometer. By the early
twentieth century measurement of blood pressure was becoming a routine
"vital sign." Now it is hard to pass through a doctor's office or
hospital without getting your blood pressure measured, and usually one
cannot walk through a mall or pharmacy, grocery store or WalMart without
finding an opportunity to have one's blood pressure checked. A blood
pressure reading has two numbers. The first number measures the systolic
pressure, or the peak force of blood as it is actually being pumped by
the heart. The second number, the diastolic pressure, measures the force
of blood as the heart is filling for the next beat.
Why all the interest in blood
pressure?
Well, for starters,
high blood pressure is very common. Depending on how it is defined,
somewhere around 15 to 25 percent of all adults in the United States
have high blood pressure, or hypertension, most of it being mild
(defined as systolic pressures of 140 - 160 and/or diastolic pressures
of 90 - 100.) However, in spite of all the opportunities to measure
blood pressure, we are not reaching everybody who has it. Many people
don't even know they have it, since it usually causes no symptoms.
Despite the lack of symptoms, hypertension is a leading cause of death
and disability. The two most important complications of an elevation in
either systolic or diastolic pressure are
stroke
and
heart attacks. Fortunately, risk
of both of these dreaded complications can be significantly reduced when
hypertension is properly treated.
In general, hypertension is a risk
factor for hardening of the arteries, also known as atherosclerosis. In
addition to damaging the brain and heart, atherosclerosis can also cause
blocked circulatory problems elsewhere in the body, most notably the
legs and kidneys. However, the main reason hypertension must be treated
is to reduce the risk of heart attacks and stroke.
So when is treatment appropriate?
That turns out to be a challenging question. The treatment of
hypertension is more complicated now than in the past. The old guideline
of treating any patient with sustained pressures over 140/90 is no
longer used, although that number still provides something of a
benchmark. The definition of hypertension by the Joint National
Commission on Hypertension has been changed to acknowledge the fact that
evidence shows no simple cut-off point for high blood pressure. If you
look at whole populations of people, you can measure a gradually
increasing risk of cardiovascular complications right through the normal
range on up to severe elevations in blood pressure: the higher the blood
pressure, the greater the risk of complications. Thus, a natural blood
pressure of 110/70 is better than 125/85 which in turn is better than
138/90, all the way up to 200/115 and beyond.
We can also say that the higher your
blood pressure, the more likely you are to benefit from treatment. This
makes the decision to treat very easy in severe hypertension. However,
in mild hypertension, there is a dilemma for practitioners, patients and
public health officials, since the cost of treatment is quite high, the
benefits small, and everyone would like to avoid drug side effects and
cost. So, for example, one study (called the MRC trial) of patients with
mild hypertension (defined as diastolic pressures between 90 - 100) and
no other cardiovascular risk factors, showed that you would have to
treat 262 patients for five years in order to prevent one cardiovascular
complication. That means 261 patients took the drug (or drugs) and
received no benefit during that five-year interval. Unfortunately, when
treatment is begun, no one knows who that one person will be and most
will take the medication "for nothing."
So back to your mild hypertension:
There are several things you need to do. The first is to be patient and
follow your blood pressure over a longer period of time. Many people
have fluctuations in their blood pressure, perhaps brought on by stress
or perhaps because they are slowly approaching a time when they will
actually have sustained hypertension. Often, after a half-dozen
pressures obtained over several months, the pressure looks better and
there is no need for medication. Secondly, a decision about treatment is
critically dependent upon whether or not you have other cardiovascular
risk factors. Other risk factors include smoking, older age, obesity,
high cholesterol, diabetes, African-American ancestry and a history of
cardiovascular disease complications. The more risk factors you have,
the more compelling the need to treat aggressively.
Once this assessment has been made,
and I would advise you to do it in consultation with a doctor, you will
probably want to continue to do whatever you can in terms of lifestyle
and diet -- avoiding medications -- to prevent worsening hypertension.
Actual weight loss if you are obese, aerobic exercise if you are
sedentary, and a reduction of alcohol to less than 2 ounces per day will
all help. Salt restriction will help some patients but it must be strict
(i.e. less than 2 grams per day). There is some data that people with
diets high in calcium or potassium and high in fish oils will have lower
blood pressure, and these may soon become standard recommendations.
Stress reduction can be helpful in some patients. Neither habitual
caffeine use nor smoking elevates blood pressure per se.
Finally, I would encourage you to
reduce or eliminate other cardiovascular risk factors. Whether or not
you develop blood pressure high enough to warrant treatment with
medications, it's good for you to eat better, lose weight and exercise.
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