Hypertension Essentials

High blood pressure (hypertension) affects nearly 1 in 2 people worldwide between the ages of 35 and 70 years old.  Hypertension is a leading risk factor for stroke, heart attack, death and disability. Hypertension is often called the silent killer, as there usually aren’t any symptoms until an adverse event occurs. Here are some essential points on hypertension.

How is hypertension defined?

Unless the blood pressure is dangerously high (greater than 210/120) or a patient is having symptoms (a heart attack, stroke or congestive heart failure), hypertension should be diagnosed after two to three measurements about one to two weeks apart.  In Stage I hypertension the blood pressure readings average 140/90 or greater. In Stage II hypertension, the readings average greater than 160/90.

What causes hypertension?

In the vast majority of patients with hypertension, 90%, there is no cause for the high blood pressure. This is called primary or essential hypertension. In approximately 10% of patients, high blood pressure may be secondary to another process and can occur with kidney or adrenal disease, a narrowing of the aorta, sleep apnea or taking medications known to increase blood pressure. Secondary hypertension usually occurs in a patient who has not had previous hypertension and who is very young (under age 35) or very old (over age 70).  These patients should undergo further testing to see if there is a reversible cause for the hypertension.

What is white coat hypertension?

White coat hypertension is defined as a blood pressure greater than 140/90 in a doctor’s office, but normal at home.  White coat hypertension occurs in about 10% of patients.  In patients with white coat hypertension as well as many other patients with essential hypertension, it is important to get accurate blood pressure readings at home, with the patient relaxed, in their own environment.  This may be accomplished in two ways. One is with an ambulatory blood pressure monitor, a device given to a patient in a doctor’s office. The patient wears the monitor for 24 hours, blood pressure readings are taken every hour and averaged, both during the day and at night. The other method is to have a patient take readings with a blood pressure monitor, usually purchased at a local pharmacy. Arm or wrist cuffs are best. For optimal results, patients are advised to sit quietly for 15-20 minutes before taking a reading, the arm should be bared and supported on a table or arm chair, the cuff should be at the level of the heart and they should refrain from coffee or cigarette smoking for at least 30 minutes. If blood pressure readings are still elevated on home readings, then therapy should be initiated.

How do we treat hypertension?

The first line of treatment for hypertension is life style modification.  This includes weight loss (if overweight), limiting the sodium (salt) content in the diet, starting an aerobic exercise program, limiting alcohol consumption and getting the proper amount of sleep. These interventions may lower the blood pressure by 5 to 20 points.  The DASH (Dietary Approaches to Stop Hypertension) diet is recommended for patients with high blood pressure.  The DASH diet is high in fruits, vegetables and low fat diary products and low in saturated and total fats (http://health.usnews.com/best-diet/dash-diet?int=9ff509). The DASH diet has been shown to reduce blood pressure by 11 to 15 points in hypertensive patients.  Once it is felt that medications are necessary to lower the blood pressure, the doctor and the patient must collaborate. All hypertension medications work, but to achieve the proper blood pressure lowering, the patient must be able to tolerate the medications, side effects should be minimal and the regimen must be as simple as possible (the goal is to take medications once or at most twice per day).

What is resistant hypertension?

Resistant hypertension is a blood pressure greater than 140/90 despite taking three different blood pressure medications for more than one month. The most common cause is the patient not taking the medications or not taking them correctly. Other factors which can cause resistant hypertension is taking certain over the counter medications (such as ibuprofen, Advil, Motrin, Aleve, nasal decongestants),  taking steroids or other medications known to raise blood pressure, sleep apnea (stopping breathing during the sleep cycle, not allowing the body to get the proper rest), excess alcohol, or developing one of the secondary causes of hypertension.

What is the goal of hypertension treatment? How low should the blood pressure go? The goal of treating high blood pressure is to reduce the risk for heart attack, congestive heart failure, stroke, kidney damage and death.  In 2014, the Eighth Joint National Committee issued recommendations based on the available medical literature. The goal for blood pressure control was less than 140/90 in patients under 60 years old and less than 150/90 in patients over 60 years old. The higher blood pressure target in older individuals recognized that these patients had a higher risk for complications with increasing medications, such as lightheadedness, dizziness, falls and fractures.  This month, the landmark SPRINT study was presented at the American Heart Association meeting. SPRINT is a trial which enrolled 9300 patients and compared two blood pressure goals, treating to under 140 and treating to under 120. The study was stopped early as the patients who were treated to under 120 had a significantly lower risk for congestive heart failure and cardiac death.  Those treated to under 120 were taking more medications and had a higher risk for low blood pressure, passing out and kidney injury.  While treating blood pressure to under 120 may be the new goal, certain caveats must be considered. The risks and benefits of taking more medications must be weighed on an individual basis. In addition, diabetic patients and patients with prior stroke were excluded from the SPRINT trial. Those patients should still be treated to a blood pressure under 140. Previous studies showed that diabetic patients had no benefit from further blood pressure reduction from 140 to 120. The SPRINT trial has generated a lot of controversy in the medical community. Most hypertension experts believe that the SPRINT trial will change, but not revolutionize, hypertension treatment. They don’t’ believe that the new goal for hypertension treatment should be lowered to 120 for all patients. However, in patients over 50 with a high risk for cardiovascular disease who have no diabetes or stroke, more aggressive blood pressure treatment is warranted.