Treatment of high blood pressure has improved vastly after the Second World War with the introduction of diuretic medication and the subsequent introduction of beta-blockers in the 1960’s. This lead a significant prolongation of the life expectancy in hypertensive patients throughout the world.
Further, with the introduction of home monitoring devices that allows a patient to adjust medication according to blood pressure readings, a patient can expect to add about 10 to 20 years of life over a lifetime. However, it is important to point out that despite that progress about 30% of patients do not know that they are hypertensive and as Ref. 2 stated only 25% get adequate anti hypertensive treatment.
The following recommendations will be useful for most of the patients with hypertension, but you should seek the advice of your physician to ensure that you will get optimal antihypertensive therapy with a minimum of side effects. The objective is bringing the blood pressure under control with the help of medication. Blood pressure therapy is an ongoing maintenance program, not a magic cure. Do not stop taking the medication without the advice of a doctor, or you run the risk of a sudden stroke or heart attack.
Steps for controlling blood pressure
Only very few people will be able to control their blood pressure by dietary changes, drastically reducing alcohol intake (less than 1 oz. per day) and restricting the sodium intake to less than 2 grams per day. It is safer to treat the high blood pressure with medication while changing life styles and habits and then reducing or phasing out the medication at a future date. I vividly remember a patient of mine who was in her 80’s, was sharp in her mind, but also was resistant to the advice of taking medicine. Within only 2 months she got a massive stroke, from which she died within three days. Life is too precious to risk a stroke or a heart attack!
Here is the standard approach to high blood pressure:
- You should buy a blood pressure cuff to monitor your blood pressure at home (thanks to www.health.harvard.edu/blog for this link). It does not matter whether it is an electronic machine or the old fashioned manual model. Learn how to use it properly. Bring it to the office and have the doctor check your technique. Alternatively have a nurse show you how to do it. You can also go to a blood pressure clinic with knowledgeable staff who can show you how to do it. Some prefer to follow the instruction booklet of the equipment and this will work also. Write down the value each time you measure the blood pressure. There is no point in measuring more often than once or twice a day in the beginning. When you are on maintenance medication it is sufficient to measure three times per week. Don’t forget to bring your booklet with the recorded values to the doctor. It is important for your care that the doctor sees how well the blood pressure is controlled at home.
- The treatment in the beginning is usually a diuretic for high blood pressure, such as hydrochlorothiazide (brand names: Esidrix ,Oretic, HydroDiuril) or chlorthalidone (brand name: Hygroton). Diuretics work by removing some of the excess sodium in the body and the extra fluid that had been accumulated. Other diuretics are the potassium sparing diuretics such as spironolactone (brand name: Aldactone), amiloride (brand name: Midamor) or triamterene (Dyrenium). There are a number of combination diuretics under the brand names Dyazide, Moduretic and Aldactazide, which combine hydrochlorothiazide with one of the potassium sparing diuretics to minimize the side-effects. It is used in low doses to minimize the side effects. Erectile dysfunction in males is a common side-effect.
- If this does not control the blood pressure (values below the 120/80 limit), a beta-blocker is added. Beta-blockers block the beta receptors of the arterial wall, which blocks the blood vessel constrictive effect of epinephrine and norepinephrine. The original one, propranolol (brand name: Inderal), is too sedating as a side-effect. Many newer beta-blockers have been developed with less side-effects. A few common ones are: atenolol (brand name: Tenormin), timolol (Brand name: Blocadren), pindolol (brand name: Visken), metoprolol (brand names: Lopresor, Toprol XL), nadolol (brand name: Corgard), labetalol (brand names: Normodyne, Trandate), acebutolol (brand name: Sectral). There are more beta-blockers as this is a lucrative market and various drug companies like to get a share of this business. About 85% to 90% of all hypertensive patients should be able to be controlled on the above regimen of either a diuretic alone or in combination with a beta-blocker, or a beta-blocker alone.
- If the blood pressure is still not controlled, the physician might want to think about more tests to rule out secondary hypertension as mentioned above. While this is being tested, the physician can either optimize therapy by adjusting the dose or change to another class of antihypertensive. The two more common other classes of medications available are: calcium blockers and ACE inhibitors. People with asthma, for instance, are not allowed to take beta-blockers as this can precipitate an asthma attack. Somebody with asthma should likely be started on a calcium blocker or ACE inhibitor.
- Calcium blockers(or calcium channel blockers) block the calcium channels in the arteries and thereby lower blood pressure. This has nothing to do with osteoporosis, there is no loss of calcium from the body. It does not damage the arteries either. I mention this just to dispel any misconceptions. The short-acting calcium channel blocker nifedipine ( brand name: Adalat)has earned a bad reputation through some studies showing that they can cause heart attacks in certain patients. However, it turned out later that this was due to the fact that there is an initial fast drop of blood pressure with the first dosage and in combination with a side effect of giving the heart muscle less contractility this can be enough in some patients with poor blood supply to the heart to cause a heart attack. In the meantime the short acting form of this medication is not used for treating high blood pressure, but is still an excellent medication for treating angina. The same medication in a slow release form (brand names: Adalat XL and Adalat PA) is still very useful as an antihypertensive. Other newer calcium blockers are: diltiazem, extended release (brand names: Tiazac, Cardizem CD, Dilacor XR); verapamil, sustained release (brand names: Isoptin SR, Covera-HS, Verelan, Calan SR). These medications cannot be used in patients with heart failure and also not in patients with heart blocks. Another group of newer channel blockers are the dihydropyridine derivatives. Some of these medications are: felodipine (brand name: Plendil), amlodipine (brand name: Norvasc), Nicardipine (brand name: Cardene), nisoldipine (brand name: Sular). Among some of the side effects of this group of calcium blockers is a reflex tachycardia (fast heart beat), which makes this medication not suitable for everybody. Your physician can determine the best medication for you.
- ACE inhibitors are relaxing the tension in the arteries by blocking the renin/angiotensin system and inhibiting the degradation of bradykinin. The end result is a lowering of the resistance of all of the blood vessels without a reflex tachycardia (fast heart beat). This medication has a low side-effect profile except for an annoying dry cough in 5 to 7% of patients. This type of medication seems to be the only one, which in males does not produce sexual dysfunction, like diuretics, beta-blockers and calcium blockers, which can be a source of frustration. ACE inhibitors improve kidney function in case of a diabetic nephropathy, but it would be contraindicated with renal artery stenosis. Some of these ACE inhibitors are: captopril (brand name: Capoten), enalapril (brand name: Vasotec), lisinopril (brand name: Zestril, Prinivil), fosinopril (brand name: Monopril), ramipril (brand name: Altace), benazepril (brand name: Lotensin).
- Other antihypertensive medications: There are a number of less common, but equally effective medications that can be used to lower blood pressure (see Ref.5).There are medications, which will block angiotensin II receptors. They are similar in action to the ACE inhibitors. Another group of medications are the adrenergic inhibitors, which work through a central action reducing the sympathetic outflow, but they have a side-effect of causing drowsiness, depression and lethargy. There are the postsynaptic adrenergic blockers, which work by blocking receptors right on the arteries and veins. This medication is also useful for benign prostatic gland enlargement in males. It also reduces LDL cholesterol (the bad cholesterol) at the same time. One of the brand names of this group is Hytrin.
Individualized blood pressure therapy
Ref.4 points out that physicians need to switch from “indiscriminate therapy” to “individualized therapy”. In other words every patient with high blood pressure has a right to the best therapy for his/her particular situation. We need to know about the side-effects, which are all listed in the physician’s desk reference book. The physician needs to balance the pros and cons and come up with the right combination, if necessary, to control the patient’s blood pressure and bring it down to below 120/80. In patients above the age of 80 years, the limit is 140/90.
The patient on the other hand does his/her part by watching the life style factors and doing the home blood pressure readings on a regular basis. There may be some weight loss necessary. Exercise may have to be introduced to improve the blood cholesterol levels. The physician will give you additional advice such as a low fat, low refined carbohydrate diet (DASH diet)and what to do and what to avoid. His advice is crucial, not only the medication (Ref. 9, p. 505). What counts is that you are comfortable taking care of your own blood pressure problem. You need all the help you can get, from the physician, from the medication, from your life style changes. It is for your life!
In this context it is interesting to note (mentioned in Ref. 10) that a group of Belgium cardiologists noticed that exercise alone could reduce blood pressure in people with hypertension by 7 points systolic and 5 points diastolic (7/5 reduction). Researchers at Duke University Medical Center added the DASH diet to exercise and there was a reduction of 16/10 (16 systolic and 10 diastolic). As Dr. Bryan points out, both exercise and the DASH diet are increasing nitric oxide in the blood, which dilates veins and arteries, just as the blood pressure medication does. The only difference is that eating beets, kale and green leave vegetables and doing regular moderate exercise will not have any undesirable side-effects, so try this first and add as little medication as you need on top of this.
It is time that not only 12.5 million, but all of the 50 million (100%) hypertensive Americans in the U.S. get treated adequately. The same type of reasoning applies to the rest of the world!
2. JS Trilling et al. Arch Fam Med 2000 Sep/Oct (9): 794-801.
3. DJ Hyman et al. Arch Intern Med 2000 Aug 160(15): 2281-2286.
4. CP Tifft Curr Hypertens Rep 2000 Jun (3): 243-246.
5. The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 199.
6. Noble: Textbook of Primary Care Medicine, 3rd ed.,2001, Mosby Inc.
7. Goroll: Primary Care Medicine, 4th ed., 2000, Lippincott Williams & Wilkins
8. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.
9. Rakel: Conn’s Current Therapy 2004, 56th ed., Copyright © 2004 Elsevier
10. Nathan S. Bryan, PHD and Janet Zand, OMD: “The nitric oxide (NO) solution. How to boost the body’s miracle molecule to prevent and reverse chronic disease”. Neogenis, published 2010.