High Blood Pressure: Silent but Deadly

Hypertension is a very common disorder, affecting approximately 50 million Americans. The number of hypertensive Americans tends to increase significantly after the age of 70. No society or ethnic group is immune from hypertension. Hypertension is most common in blacks, affecting about one out of three, followed by whites and Mexican Americans. Hypertension is also more common in men than women in every ethnic group up to age of 50. Hypertension is also more common in obese individuals, in diabetics and in those with a familial history of high blood pressure High blood pressure is a silent disease and many individuals have no idea that they even have it. But being silent does not mean that the disorder is harmless. In fact, untreated blood pressure is associated with complications that are irreversible and can be fatal. Among the risks of untreated high blood pressure are a heart attack, loss of the kidneys, blindness, stroke and even death. Unfortunately because high blood pressure has no symptoms during the initial phase of the disease, most people do not even now if they have it. The disorder is so common that by the age of 65-75, most individuals will develop it. The reason for this is that the blood vessels harden and lose their elasticity with age, and thus, the blood pressure increases. The only good thing about high blood pressure is that it is easily treated with medications - which is a life long process. There are two types of blood pressure: systolic and diastolic blood pressures. Systolic blood pressure (a larger number in a blood pressure reading) is the number on top. Diastolic blood pressure (usually smaller reading) is the number on the bottom.

Unfortunately, the symptoms of high blood pressure are practically impossible to detect in the initial phase the disorder. Even individuals with extremely high blood pressure may not have any complaints. The few individuals who do develop high blood pressure symptoms may complain of - headaches - general malaise - visual blurring - frequent nose bleeds - dizziness

In more than 95% of individuals, the causes of high blood pressure are unknown and this is referred to as essential or primary hypertension. This type of blood pressure is usually a gradual process and is seen in after the 3-4 decade of life. The remaining causes of hypertension have an identifiable cause. This is known as secondary hypertension and there are a number of causes of it. The most common causes of secondary hypertension include a. disorders of the adrenal gland b. coarctation of the aorta (narrowing of the blood vessel) c. disorders of the pituitary gland d. kidney disorders e. use of medications — including birth control pills, cold remedies, decongestants. f. Use of illicit drugs, like cocaine and amphetamines g. Risk factors

There are some risk factors which may influence blood pressure and are either modifiable or non modifiable. Not Modifiable Risk Factors - Age: Blood pressure will occur once all individuals reach a certain age. In men high blood pressure occurs earlier than female. - Race: High blood pressure is particularly common among blacks, and occurs at a much earlier age compared to Caucasians. Serious complications, such as stroke and heart attack, also are more common in blacks. - Family history: High blood pressure is more common in families with a history of hypertension. Modifiable risk factors: - Obesity: if there is one risk factor which worsens hypertension, it is weight gain. The excess weight means that the heart has to work much harder to pump all the blood around the body. By decreasing weight, the blood pressure can be significantly decreased - Non active lifestyle: Individuals who are not active or couch potatoes generally tend to develop higher heart rates and high blood pressure. Physical inactivity also increase weight and is generally not a recommended life style goal. - Smoking: Smoking is the universal factor for most health problems. If people stopped smoking, more than 50% of the physicians would be out of a job. Smoking is bad not only for the blood vessels, but bad for health in general - Sodium intake: For some individuals too much intake of salt (sodium) may cause an increase in blood pressure. Salt causes water retention which in turn causes an increase in body fluids. - Stress: Stress is known to be associated with high blood pressure. Most individuals have different levels of stress and should try and avoid it. - Medical conditions: Certain chronic conditions also may increase your risk of high blood pressure, including high cholesterol, diabetes, kidney disease and sleep apnea. - Pregnancy: In some females the blood pressure may increase during the later part of the pregnancy (eclampsia). This is a serious condition which needs urgent treatment. The blood pressure resolves after delivery of the infant

There are some individuals with a history of blood pressure who suddenly present with symptoms. This may occur when the medications have been stopped abruptly. The individual may present with mental confusion, headaches, and seizures, loss of consciousness, blurred vision and lethargy. This lethal condition need immediate treatment in a hospital. The blood pressure in these individual is always above 200 systolic and 110 diastolic. If not treated, most of these individual are dead in 3-6 months. Urgent treatment is the key.

Hypertension is never diagnosed on a single measurement. An accurate measurement of blood pressure is the key to diagnosis. Several determinations should be made over a period of several weeks to make a diagnosis. At any given visit, an average of 3 blood pressure readings taken 5 minutes apart is preferable. Blood pressure is measured in both the lying (supine) and sitting positions for accuracy. On the first visit, blood pressure should be checked in both arms and in one leg to avoid missing the diagnosis of coarctation of aorta. As the improper cuff size may influence blood pressure measurement, a wider cuff is preferable, particularly if the patient's arm circumference exceeds 30 cm. The patient should rest quietly for at least 5 minutes before each measurement.

In general, the diagnosis of primary hypertension is a diagnosis of exclusion and there is no identifiable cause. If a secondary cause of hypertensions is suspected, the physician will examine the pulses; order some blood tests including a lipid profile. For those suspected to have high blood pressure from a kidney disorders, imaging studies of the kidney may be obtained.

Because high blood pressure has no outward presentation, it is necessary that all individuals get a measurement of their blood pressure once a year, after the age of 50. If any symptoms are present, then the blood pressure must be evaluated frequently in the first few months to ensure that it is not elevated. The latest blood pressure guidelines, issued in 2003 by the National Heart, Lung, and Blood Institute, classify blood pressure measurements into four general categories: -Normal blood pressure: Your blood pressure is normal if it's below 120/80 mmHg. Once blood pressure rises above 140/80 mmHg, the risk of heart disease increases. -Prehypertension: Prehypertension is a systolic pressure ranging from 120 to 139 or a diastolic pressure ranging from 80 to 89. Prehypertension tends to get worse over time. Within four years of being diagnosed with Prehypertension, nearly one in three adults ages 35 to 64 and nearly one in two adults age 65 or older progress to definite high blood pressure. -Stage 1 hypertension: Stage 1 hypertension is a systolic pressure ranging from 140 to 159 or a diastolic pressure ranging from 90 to 99. -Stage 2 hypertension: The most severe hypertension, stage 2 hypertension is a systolic pressure of 160 or higher or a diastolic pressure of 100 or higher. Both numbers in a blood pressure reading are important. After the age of 50-60, the systolic reading is significant and remains a common cause if hypertension in the elderly.

If high blood pressure is untreated, severe complications can result. One can just imagine what can happen if the high blood continues to pound the smaller vessels in the eyes, brain and heart. The higher the blood pressure, the worse the complications which are not reversible. Complications include: - Damage to the blood vessels: the constant thumping of the fragile blood vessels due to high blood pressure leads to damage and severe trauma to the arteries. With time, these blood vessel will develop narrowing, thicken or may even rupture - Heart failure: With a high blood pressure, the heart has to work very hard to push the blood out into the circulation. With time, the heart become very think and enlarged. However, ultimately the heart can no longer maintain this function and heart failure develops - Brain hemorrhage: with the sustained blood pressure, the small blood vessels in the brain rupture and can lead to bleeding in the brain; thus leading to a stroke - Kidney failure: the continued pounding of the blood vessels to the kidney leads to severe damage to the kidney, which eventually fails. Next to diabetes, hypertension is the second most common cause of kidney failure - Eye: The eye has very fine blood vessels and with uncontrolled blood pressure, these vessels can rupture and vision loss can occur. - Dementia: when blood pressure is high for many years, the damage to the brain is quite pronounced. The dementia caused by high blood pressure is second next to Alzheimer’s as a cause of dementia

Once the diagnosis of blood pressure is made, it is important to start treatment even if one has no symptoms. Because there are no symptoms, many individuals delay treatment and then it is too late to reverse any of the complications. The treatment is life long. Blood pressure goals aren't the same for everyone. Although everyone should strive for blood pressure readings below 140/90, doctors recommend lower readings for people with certain conditions.

140/90 for the healthy adult 130/80 for those with chronic kidney disease, diabetes or heart disease 120/80 for those with a weak heart

The treatment of hypertension is straightforward, unless your doctor is incompetent. Over the last 3 decades various guidelines have been established. There are numerous types of drugs used to treat hypertension and which drug the physician selects is based on experience and use. For most individual, a single drug may be required, and in others multiple drugs may be required to control the blood pressure. The major types of medication used to control high blood pressure include: - Thiazide diuretics: These water pills act by removing the excess water and salt from the body. These drugs are the first line for treatment of high blood pressure, they are cheap , effective and have minimal side effects - Beta blockers: These medications act by decreasing the work of the heart and dilating (opening) up the blood vessels. They have been around for more than 50 years. Unfortunately they are not very effective in black individuals but otherwise work in all ethnic groups. The side effects include decreased libido and glucose intolerance. - Angiotensin-converting enzyme (ACE) inhibitors: These drugs have today become the gold standard and are very effective in the treatment of high blood pressure. They also protect the heart and are useful in all groups of patients. They are useful in individuals with diabetes, heart failure or those who have angina. They are readily available but are expensive and some of them have a tendency to produce a persistent dry cough. - Angiotensin II receptor blockers: These latest medications open up the blood vessels and decrease the blood pressure. However they are very expensive and are not first line treatment. They are to be used in individuals who do not respond to the other drug treatments. If any physician starts this drug as a first line drug, then either the physician has a financial interest in the drug or is dating the beautiful drug representative. - Calcium channel blockers: These drugs have been around for many years and work well in blacks. They are very effective in the treatment of blood pressure. They are reasonably priced but should not be used in patients with a weak heart. They do tend to cause swelling in the feet. - Renin inhibitors: These are the latest drugs available to treat blood pressure. They act by inhibiting a chemical which is known to cause high blood pressure. The new drug, Tekturna (aliskiren) is a renin inhibitor. The drug is very expensive and is not a first line drug. The drug is most effective when used in combination with other drugs. - Alpha blockers: These medications have been around for decades but are rarely used to treat high blood pressure because of their side effects - Central-acting agents: There are some medications which act in the brain to decrease the nerve impulses to the blood vessel. They are quite effective in decreasing blood pressure and widely used - Vasodilators: There are a variety of medications which can open up narrowed blood vessels and decrease blood pressure. These medications are often used intravenously in the ICU for emergent use in the treatment of hypertension. Once your blood pressure is under control, your doctor may add aspirin and/or a medication to lower your cholesterol to your regimen to further decrease the risk of a heart attack.

In some cases, the blood pressure may be resistant to a single drug and a combination of 2-3 drugs may be required. Most of this combination therapy is done on a trial and error basis. In some cases, the individual will be referred to a heart specialist who deals with blood pressure treatment.

The major problem in the treatment of hypertension is that because individual has no symptoms, he/she refuses to take the medications. Compliance with blood pressure medications is a difficult problem and it is important for the individual to understand the importance of treatment. One may skip a day, but routine skipping of blood pressure medications is only waiting for a disaster to happen.

Changes in lifestyle are not only a key to improving blood pressure, but are important for general good health. In addition to losing weight, one should make efforts to control the blood sugar, stop smoking, live an active life style and eat well. -Eat healthy: One should eat healthy and change the diet from eating too much meat to a more vegetable oriented diet. Limiting salt may help some individuals in the control of blood pressure. -Maintain a healthy weight: Make efforts to lose weight. Obesity is associated with other problems besides hypertension also. -Exercise: “Couch potatoes” better move along. Inactivity leads to higher blood pressure and worsens obesity. -Don't smoke: This is the ultimate taboo for many medical disorders. One should try to stop quitting. There are no magical drugs- just cold turkey is the key. -Avoid stress: For those with high stressors, one should try and avoid or decrease the stress levels. Rest, relax and exercise.

There is no cure for high blood pressure and thus life long treatment is required. To help cope with the management of blood pressures, one should do the following: - Home blood pressure monitoring: This is useful tool for home use and one can monitor the treatment and see if the medications are working. -Take the medications regularly: Do not skip medications, sometimes rebound hypertension can occur. -See the doctor regularly: At least one a year, see your physician and get your blood pressure measured and make sure that it is well controlled. Medicine loses it fun when there are a lot of Dos and Don’ts, especially when one deals a disorder with no symptoms and yet requires life long treatment. However, on the plus side, well controlled blood pressure will add years to your life. On the negative side, one may end up with one eye, no kidney and be demented- the choice is very simple - you better take the medications as prescribed and stop whining.