blood pressure is frequently referred to as the"silent
killer". Although elevated blood pressure causes no symptoms
in most people it directly kills 35,000 to 40,000 Americans
a year and is a major factor in the 400,000 plus deaths each
year from heart attacks, congestive heart failure, and stroke.
An estimated 50 million Americans (25% of all adults) have high
blood pressure. Two-thirds of the population will experience
at least mild high blood pressure before the age of 65. Although
the majority have mild hypertension, even this condition requires
medical attention. Only 20% of American adults have their blood
pressure under control. About one-third of patients with high
blood pressure are overweight. Anyone who is overweight has
a risk for hypertension that is 50% higher than people with
detection and treatment of high blood pressure can improve quality
of health and delay or prevent many premature deaths in people
pressure is produced by the pumping heart. Most people are familiar
with two separate numbers used in measuring blood pressure.
In laymen's terms these numbers are referred to as the"top"
and "bottom" numbers. Medically speaking blood pressure
has a systolic (top number ) measurement and a diastolic (bottom
number) measurement. Systolic pressure is the blood pressure
created while the heart is contracting (systole). Diastolic
pressure is the blood pressure measured when the heart is not
pressure measurements reflect the pressure within the artery
being measured. Pressure may be different in different arteries
of the body. The artery traditionally used for blood pressure
measurement is the brachial artery in the arm. Blood pressure
does not fall to zero in the arteries when the heart is not
contracting due to several factors. The main reason is due to
elastic stretch of the arteries. During systole arteries expand
slightly (much like a balloon inflates as you blow into it).
As the arteries relax (slightly deflate) they continue to propel
blood forward just as a deflating balloon releases air in a
continuous manner. During diastole the aortic valve closes preventing
the flow of blood back into the heart. The heart beats again
to repeat this cycle. Steady delivery of blood to body organs
is extremely important.
blood pressure is less than 120/80 mm Hg (systolic/diastolic).
Normal pressure is below 140/90. A person is considered to
have hypertension (high blood pressure) if their blood pressure
is above 140/90. Any blood pressure above normal should be
attended to with appropriate treatments.
is divided into four stages: mild (greater than 140/90 but
less than 160/100); moderate (less than 180/110); severe (less
than 210/120); very severe (greater than 210/120). When the
systolic and diastolic numbers are in different categories
the measurement in the higher category should be used to determine
the severity of hypertension. For example, if systolic pressure
is 165 (moderate) and diastolic is 92 (mild), the patient
would still be diagnosed with moderate hypertension.
A child's blood pressure is normally much lower than an adult's.
Children are at risk for hypertension if blood pressure is greater
for ages 3-5
for ages 6-9
for ages 10-12
for ages 13-15.
blood pressure is a very important risk factor for heart disease
(coronary artery disease). There are other major risk factors
as well including family history, smoking, diabetes, and high
cholesterol. The effects of these risk factors are additive.
A person with all of these risk factors, including high blood
pressure, is more likely to develop heart disease than another
person with the same blood pressure but no other risk factors.
The important point to remember is high blood pressure is
not the only risk factor for heart disease and stroke. How
a person's blood pressure is treated may depend on other factors
in addition to the blood pressure number.
National Heart Blood and Lung institute has recognized the
influence of other risk factors in addition to high blood
pressure. High blood pressure is now categorized by risk groups
A, B, and C. For example, group A has no risk factors for
heart disease or other medical problems; people in this risk
group who have mild hypertension would use diet and exercise
to try to reduce their blood pressure. Mild hypertension in
group C, which covers major risk factors for heart disease,
however, would probably require medication.
Blood pressure varies the same way throughout a given day.
It is usually highest at work and then drops a bit at home.
Pressure is lowest during sleep but suddenly increases at
Causes High Blood Pressure?
over 90% of patients with high blood pressure the physician
cannot find a specific cause. This is called essential,
or primary, hypertension. Several genetic factors regulating
important physiologic processes may interact with environmental
influences to produce essential high blood pressure.
studies are examining genes that affect a group of hormones
known as the angiotensin-renin system, which influences
all aspects of blood pressure control, including blood vessel
contraction, salt and water balance. Studies suggest that
some people with essential hypertension may inherit abnormalities
of the sympathetic nervous system, which controls heart
rate, blood pressure, and the diameter of the blood vessels.
Increased insulin resistance and low levels of a naturally
occurring vasodilator (nitric oxide) are also suspected
of playing a role in hypertension.
hypertension (less than 10% of people with high blood pressure)
has identifiable causes, which are usually treatable or reversible.
Medical conditions and medications may contribute to secondary
hypertension. Medical conditions include:
disorders causing excessive production of certain adrenal
apnea patients who have disordered breathing while sleeping
tend to have higher blood pressure and poorer responses to
high blood pressure medication.
prescription and over-the-counter drugs can cause temporary
high blood pressure. Medications contributing to secondary hypertension
Some prescription medications include cortisone, prednisone,
estrogen, and indomethacin.
contraceptives may increase the risk for high blood pressure,
but the risk is very small (41.5 cases per 10,000 people who
take birth control pills) and is highest in women using them
for more than 6 years.
Long term use of nonsteroidal anti-inflammatory drugs (NSAIDs)
may cause kidney damage; these drugs can also interfere with
treatments for hypertension, including diuretics and beta
blockers. Such drugs include aspirin, ibuprofen (Advil, Motrin,
Nuprin), indomethacin (Indocin), naproxen (Anaprox, Naprosyn,
Aleve) and many others. Of these drugs, aspirin appears to
have the least detrimental effect on blood pressure.
Cold medicines containing pseudoephedrine have also been found
to increase blood pressure in hypertensive people, but they
seem to do no harm in people who have brought their blood
pressure under control.
high in salt may speed up hypertension in people as they age.
There have been conflicting view in the medical community on
how much a high salt diet contributes to hypertension. Between
30 - 50% of people with high blood pressure are salt-sensitive;
that is they are particularly vulnerable to the effects of salt
on blood pressure. People who are most likely to be very salt-sensitive
are overweight, older, and African American. High salt diets
in such people can also harm the kidney and brain, even independently
of high blood pressure.
estimated 10% of hypertension cases are caused by excessive
alcoholic intake. An analysis of a major study found that those
who drank more than three alcoholic drinks a day had higher
blood pressure than those who didn't, with heavier drinkers
having higher pressure. People who were binge-drinkers had higher
blood pressure than people who drank regularly. On the other
hand, mild to moderate drinking (one to two drinks a day) seems
to have certain benefits, including raising HDL cholesterol
levels (high levels of HDL cholesterol are considered good,
whereas high levels of LDL cholesterol are considered bad) and
reduced risk of heart disease.
Causes of Secondary High Blood Pressure
high blood pressure can result from stress, exercise, and long-term
consumption of large amounts of licorice. Exposure to even low
lead levels also appears to cause hypertension in adults.
Factors-Who Gets High Blood Pressure?
Age and Weight
estimated 50 million Americans (25% of all adults) have high
blood pressure. Two-thirds of Americans will experience at
least mild high blood pressure before the age of 65. Although
the majority have mild hypertension, even this condition requires
medical attention. Only 20% of American adults have their
blood pressure under control. About one-third of patients
with high blood pressure are overweight. Anyone who is overweight
has a risk for hypertension that is 50% more than people with
normal weight. In fact, the increase in blood pressure as
one ages may be due primarily to weight gain. (This is true
particularly in America; in other cultures old age does not
necessarily coincide with weight gain--or high blood pressure.)
Children and adolescents who are obese and babies who are
underweight at birth are at greater risk for high blood pressure
when they reach adulthood.
Gender and Ethnicity
under 60 are 50% to 75% less likely to have hypertension than
men of the same age. Between ages 50 and 60, 40% of white
men and 30% of white women have high blood pressure. In African
Americans of the same age groups over half of men and slightly
less than half of women have hypertension. After age 60, half
of white men and women have high blood pressure, but the rate
in African Americans is 60% in men and leaps to 80% in women.
Both whites and African Americans in the Southeast have a
higher incidence of hypertension and stroke than people living
in other parts of the country. African Americans tend to have
a greater sensitivity to salt than others, although researchers
have not found that this trait fully explains the higher incidence
for hypertension. The combination of high blood pressure and
insulin resistance (type II diabetes)is more common in African
Americans, Hispanics, and Pima Indians than in whites. It
should be noted that a recent study of African villagers whose
diets were high in fish had only a 3% rate of high blood pressure.
experts believe that essential hypertension may be inherited
in 30% to 60% of cases, although several genes, not just one,
are probably involved. It is difficult to differentiate between
genetic and environmental influences, even in studies of identical
40% of people with high blood pressure also have high cholesterol
levels, although any causal relationship remains unclear.
Stress may play a role in this association; in one study people
with high cholesterol levels experienced a steep increase
in high blood pressure when given a mental stress test; those
with normal cholesterol levels had only a modest increase.
When the high-risk group lowered their cholesterol intake,
their blood pressure dropped to normal levels during stressful
situations. This finding should encourage physicians to test
for heart disease risks, particularly unhealthy cholesterol
levels, in people with so-called white-coat hypertension--a
phenomenon that causes high blood pressure in the physician's
office despite normal blood pressure at home.
number of studies have linked chronic stress, depression,
and anxiety with high blood pressure in both men and women.
People who are anxious or depressed may have over twice the
risk for high blood pressure than those without these problems.
It is not clear whether these mood disorders contribute to
high blood pressure due to some physiologic effect on blood
vessels or if they may lead to behaviors, such as weight gain
or alcohol abuse, which are also risk factors for hypertension.
Stress caused by discrimination may play a role in the high
rate of hypertension in African Americans; in one study, those
who experienced discrimination but did not report it suffered
higher blood pressure than those who challenged it. Anger
does not appear to predict high blood pressure.
who experience sleep apnea, a disorder in which breathing
halts briefly but repeatedly during sleep, also have a higher
incidence for hypertension. Many experts believe that a causal
relationship exists between the sleep disorder and high blood
pressure. Seasonal changes may influence variations in blood
pressure, with hypertension increasing during cold months
and declining during the summer. This seasonal effect is particularly
high in smokers. While cold may narrow blood vessels, another
study showed that lack of light was associated with higher
blood pressure. A recent study reported that people with normal
resting blood pressure that increases to abnormally high levels
during treadmill exercises may be at risk for essential hypertension.
Oral contraceptives, even low doses, may increase the risk
for high blood pressure in African American women.
Serious Is High Blood Pressure?
blood pressure killed over 35,000 Americans in 1992 and was
a major contributor to deaths from stroke, heart attack, and
heart failure. The death rate from hypertension declined by
8.6% between 1982 and 1992. However, it is still particularly
deadly in African Americans; an estimated 30% of deaths in
men and 20% of deaths per year in women who are African Americans
are attributed to hypertension.
can cause certain organs to deteriorate over time. People
who do not control their blood pressure die earlier than people
who control their blood pressure. High blood pressure contributes
to 75% of all strokes and heart attacks. Compared with normal
individuals, hypertensive people can have as high as ten times
the risk of stroke and five times the risk of a heart attack
depending on the severity of the hypertension. The risk for
developing congestive heart failure is also significantly
higher with high blood pressure. People whose high blood pressure
has caused left ventricular hypertrophy (a thickening of the
muscles on the left side of the heart causing enlargement)
remain at risk for strokes, heart attacks, sudden death, and
heart failure even after their blood pressure is under medical
control. High blood pressure causes 30% of all cases of kidney
failure that require dialysis and transplant operations. This
rate is second only to diabetes. African Americans with high
blood pressure are at even higher risk for kidney failure
than people in other population groups with hypertension.
form of sexual dysfunction occurs in 17% of hypertensive men.
It is often caused by medications that treat high blood pressure,
but there are indications that the disorder itself may impair
sexual function. Impotence related to hypertension is treatable.
A study found that women with high blood pressure, regardless
of medications, found it difficult to achieve sexual satisfaction
and had impaired vaginal lubrication.
blood pressure may accelerate age-related shrinkage of the
brain. Chronic high blood pressure is associated with mental
deterioration, especially short-term memory and attention.
A study has found that middle-age people with high systolic
blood pressure are at higher risk for poor mental function
in later life; the higher the blood pressure the greater the
risk. Increased blood pressure in elderly men is also associated
with a higher risk for Alzheimer's and dementia.
sudden high blood pressure in pregnant women caused by a condition
called preeclampsia can be very serious for both mother and
child. It occurs in up to 10% of all pregnancies, usually
in the third trimester (last three months) of a first pregnancy,
and resolves after delivery. Symptoms and signs of preeclampsia
include protein in the urine and swollen ankles. The reduced
supply of blood to the placenta can cause low birth weight
and eye or brain damage in the fetus. Severe cases of preeclampsia
can cause kidney damage, convulsion and coma in the mother
and can be lethal to both mother and child.
has been called the "silent killer", because it usually produces
no symptoms. It is important for anyone with risk factors
to have their blood pressure checked regularly and to make
appropriate lifestyle changes. Following these recommendations
is important for individuals who have overall high-normal
blood pressure, mild or above systolic pressure with normal
diastolic, family histories of hypertension, are overweight,
or are over forty years old.
Untreated hypertension increases slowly over the years. In
rare cases (fewer than one percent of hypertensive patients),
the blood pressure rises quickly (with diastolic pressure
usually rising to 130 or higher), resulting in malignant or
accelerated hypertension. This is a lifethreatening condition
and must be treated immediately.
confusion, headache, nausea, and loss of vision.
individuals should call a physician immediately if these symptoms
is High Blood Pressure Diagnosed?
hypertension is suspected, the physician should obtain the
and personal medical history, especially high blood pressure,
stroke, heart problems, kidney disease, or diabetes;
factors of heart disease and stroke, including tobacco use,
salt intake, obesity, physical inactivity, and unhealthy cholesterol
medications--both prescription and nonprescription--being
review of symptoms that might indicate secondary hypertension,
such as headache, heart palpitations, excessive sweating,
muscle cramps or weakness, or excessive urination; and
emotional or environmental factors that could affect blood
all physical exams include blood pressure measurement. An inflatable
cuff is placed around the arm, and the person taking the blood
pressure listens with a stethoscope over the artery. If high
blood pressure is present or suspected, the physician or health
professional should take two or more measurements separated
by two minutes with the patient sitting or lying down, as well
as one taken after the patient has been standing for two minutes.
Patients should not smoke or drink caffeinated beverages within
30 minutes of the measurement.
Although this test has been used for nearly 100 years, inaccurate
results can occur in certain situations. A person who has recently
exercised or a heavy smoker who has not smoked for awhile can
have a temporarily low pressure reading. Temporary high pressure
can result from an arm cuff that is too small, talking during
the test, or from having recently eaten foods that raise blood
pressure. Anxiety can cause a person's blood pressure to be
elevated in the doctor's office while it is normal at home.
This is known as "White Coat Hypertension". Home monitoring
is important to avoid unnecessary treatment in patients whose
pressure returns to normal after leaving the doctor's office.
Some people initially suspected of only having "White Coat
Hypertension" develop true hypertension. Persons with very
severe high blood pressure or those exhibiting any evidence
of organ damage due to hypertension should consider drug therapy
immediately. An individual with mild to moderate hypertension
found during a first examination and who has no evident organ
damage should be retested at least twice over several weeks.
An average of all the measurements will be considered in the
diagnosis of hypertension. People with normal blood pressure
should be rechecked every two years and those with high normal
pressure one year after. Anyone whose blood pressure is above
high normal should be evaluated as soon as possible for organ
damage and possible medications to reduce the pressure.
a physical examination indicates hypertension, additional laboratory
tests may determine whether it is secondary hypertension (high
blood pressure caused by another disorder) or essential hypertension
(no other disorder is present). The physician might also order
tests to uncover organ damage due to hypertension. These tests
include a complete blood count, urinalysis, and measurements
of potassium, blood urea nitrogen, fasting blood glucose, serum
cholesterol, and serum uric acid. An electrocardiogram (ECG)
may also be performed.
home tests are available for checking blood pressure between
doctor visits. Manual cuffs and stethoscopes are fairly accurate,
but they require practice to use, and the cuff must be the
right size (one size does not fit all). Devices that use a
digital readout and a cuff that can be electronically inflated
and deflated are as accurate as a stethoscope. A physician
may fit a patient with a portable unit that records blood
pressure during a full day's activity. This test, known as
ambulatory monitoring, is particularly useful for those who
experience wide blood pressure swings, including white-coat
hypertension, or show resistance to drug therapy. Some physicians
feel that such monitoring is not worth the expense and that
electronic home tests that print out a record for the doctor
are more cost effective and very reliable. Devices that take
the pressure from the finger can be very inaccurate.
gain seems to be a primary determinant in blood pressure
increase, and weight loss may be even more important than
salt restriction in controlling blood pressure.Many people
who are overweight and hypertensive can bring their blood
pressure to normal with only modest weight loss. Systolic
blood pressure may decrease by 1-2 points for each pound
lost while diastolic pressure may drop 1/2 to 1 point
for each pound lost. Weight loss is extremely difficult
for many people. It is important to realize that a 10
to 20 pound weight loss in a person who is 50 pounds overweight
may not make them "thin" but it may return their
blood pressure to normal. It is also important to realize
that not all people who are overweight or obese have high
A recent study found that a varied diet low in saturated
fat, rich in fruits and vegetables, and with modest amounts
of protein significantly lowered blood pressure; after
eight weeks, systolic pressure dropped by 11.4 mmHg and
diastolic by 5.5 mmHg. The diet, known as Dietary Approaches
to Stop Hypertension (DASH) is now recommended as an important
step in managing blood pressure. Such a dietary balance
is, in any case, important for fighting other health problems,
including coronary artery disease and cancer. Although
one study found that diets high in protein were associated
with lower blood pressure, it was not clear whether the
protein was derived from meat, fish, dairy, or vegetable
sources, and it should be noted that high protein diets
may put people with diabetes at risk for kidney disease.
Eating fish appears to benefit both blood pressure and
cholesterol levels. Vegetables are very important, with
those rich in magnesium and potassium of particular benefit
for patients with hypertension. Such foods include most
fruits, many vegetables (especially, carrots, spinach,
celery, alfalfa, mushrooms, lima beans, potatoes, avocados,
broccoli), chicken, liver, and milk. Many of these foods
are also high in fiber, which is protective against many
diseases. Garlic appears to benefit blood pressure, perhaps
by affecting mechanisms that keep blood vessels elastic
and healthy. It should be noted that grapefruit (but not
other citrus fruits) boosts the effects of calcium channel
blocking drugs used for hypertension.
restriction is important for reducing blood pressure in
those who are salt-sensitive and should be attempted in
all people with high blood pressure to detect those patients
who are salt sensitive. Salt restriction is important
for elderly people--even those whose blood pressure is
only in the upper normal range, which still puts them
at risk for stroke. Restricting salt also enhance the
benefits of certain antihypertensive drugs by reducing
potassium loss, and may help protect against kidney disease
in patients who are also taking calcium-blocker drugs.
People with hypertension should aim for a maximum of 2,000
mg salt intake; even people without hypertension should
reduce salt intake to 2,400 mg per day or less. Simply
eliminating table and cooking salt can be beneficial.
Salt substitutes, such as Cardia, containing mixtures
of potassium, sodium, and magnesium are now available
but are costly. It should be noted that because about
75% of the salt in people's diets comes from processed
or commercial foods, the benefits of table-salt substitutes
are likely to be limited. Some sodium is essential to
protect the heart, but most experts agree that the amount
is significantly less than that found in the average American
Calcium, and Magnesium Studies
have indicated that potassium deficiencies, increase the
risk for high blood pressure, but it has not been clear
whether taking a potassium supplement would be useful
for preventing or treating high blood pressure. The recommended
goal is 3,500 mg of potassium a day. Excess potassium
level, however, can cause abdominal distress, muscle weakness,
and, in rare cases, dangerous heart events. Although some
people, such as those taking certain diuretics, may require
supplements, certain patients should be cautious about
potassium supplements, including those with conditions,
such as diabetes or kidney disease, that increase potassium
levels or who are taking medications, such as ACE inhibitors
or potassium-sparing diuretics, that limit the kidney's
ability to excrete potassium. Most people should obtain
this mineral from potassium-rich foods that include potatoes,
avocados, bananas, nonfat milk products, red beans, oranges,
prunes, and cantaloupes.
Calcium regulates the tone of the smooth muscles lining
blood vessels, and large studies have found that people
who have sufficient dietary calcium have lower blood pressure
than those who don't. Taking calcium tablets exceeding
the recommended daily allowance of 800 to 1,200 mg, however,
has very little additional effect on blood pressure in
women and African American men and none for white men.
Extra calcium appears to be useful for lowering blood
pressure only in people who are also salt-sensitive. A
1996 study suggested that calcium supplements might reduce
the risk for preeclampsia in pregnant women, but follow-up
studies did not confirm this benefit. (Pregnant and postmenopausal
women often need extra calcium, however, to prevent bone
One study has indicated that magnesium supplements help
to decrease blood pressure. It is important to remember,
though, that no major studies have been done on long-term
benefits or risks of magnesium supplements.
Intake, Alcohol, and Smoking Caffeine
causes a temporary increase in blood pressure, but is
not thought to be harmful, particularly in people with
normal blood pressure. Caffeine may, however, have a stronger
and longer-lasting effect on the blood pressure of people
with existing hypertension. Drinking coffee increases
excretion of calcium, which increases the risk for high
blood pressure, so anyone who drinks coffee should maintain
an adequate calcium intake. Smoking poses risks for a
wide range of diseases, and one study reported that smokers
have blood pressures up to 10 points higher than nonsmokers.
Although moderate drinking (one to two drinks per day)
of alcohol protects against unhealthy cholesterol, high
alcohol consumption raises blood pressure levels.
moderately intense physical activity can reduce blood pressure.
An additional benefit of exercise is weight loss, which is
a key factor in reducing blood pressure. Studies have shown
that regular activity, particularly aerobic exercises, helps
to reduce mild to moderate hypertension. In one study African-American
men with severe hypertension who engaged in moderately intense
aerobic exercise using a stationary bike three times a week
not only reduced their diastolic pressure but also reduced
left ventricle hypertrophy after about four months. One study
showed that even exercise that does not result in weight loss
or have any aerobic benefits still significantly reduces blood
pressure in postmenopausal women. As little as 35 minutes
of walking three times a week can help lower blood pressure,
but 20 to 30 minutes of daily brisk walking or other aerobic
exercise is more likely to help.
Intensive aerobic exercises, such as running or biking, may
lead to so-called athlete's heart, which, like hypertrophy
caused by high blood pressure, is muscular enlargement of
the heart. Unlike the disease-caused condition, however, this
muscular enlargement is not associated with heart problems
and regresses when training stops. Isometric workouts, such
as snow shoveling or weight lifting, tend to stress the heart
and raise blood pressure for a brief period. Such intense
isometrics can cause cardiac death, and one major study found
that sedentary people who throw themselves into a grueling
workout increase the risk of heart attack by 107 times. Two
small studies found that people with very mild hypertension
who exercised with a hand-grip device for a few weeks achieved
lower blood pressure, which increased after the subjects stopped
exercising. In all cases, but particularly before strenuous
exercise, it is very important to warm up in order to ease
the increase in blood pressure. No person with high blood
pressure should start an exercise program without consulting
a physician. Before exercising, no one with hypertension should
drink caffeinated beverages, which increase heart rate, the
workload of the heart, and blood pressure during physical
activity. Certain antihypertensive medications can interfere
with exercise capacity. Diuretics decrease body fluid and
may result in fluid imbalances, particularly in hot weather.
It is important to boost potassium intake if this type of
drug is being taken. Beta blockers inhibit adrenaline and
may cause fatigue and loss of endurance during exercise. ACE
inhibitors and calcium channel blockers are the best drugs
for active individuals. However, patients who must take drugs
that interfere somewhat with exercise capability should still
adhere to an exercise program and consult a physician on how
best to balance medications with exercise.
Stress Reduction and Psychologic Therapy
factors or psychologic stress are possible precursors to hypertension.
A recent study found that 73% of patients with mild to moderate
hypertension who had cognitive-behavioral therapy were able
to reduce their medication after 6 weeks; after 12 months,
55% required no medication. In another study, a technique
called transcendental meditation (TM), a simple relaxation
method that involves silent repetition of a single sound was
shown to be effective in reducing blood pressure .
Are the Drug Treatments for High Blood Pressure?
General Guidelines for Drug Therapy
now suggests that aggressive drug treatment of long-term
high blood pressure can significantly reduce the incidence
of death from heart disease and other causes in both men
and women. If patients have mild hypertension and no heart
problems, then lifestyle changes may suffice if carried
out with determination. For more severe hypertension or
for mild cases that do not respond to changes in diet and
lifestyle within a year, drug treatment is usually necessary.
All drugs used have side effects, some distressing, and
ongoing compliance is difficult. A major study found, however,
that people taking blood pressure drugs did not experience
any greater decline in the general quality of life or daily
functioning over five years than did people who were not
on blood pressure medication. In all cases, healthy lifestyle
changes must accompany any drug treatment.
A single-drug regimen can often control mild to moderate
hypertension. More severe hypertension often requires a
combination of two or more drugs. Prolonged-release drugs
are being developed so that they are most effective during
early morning periods, when patients are at highest risk
for heart attack or stroke.
One study showed that to reduce mortality rates, the goal
of treatment should be a systolic pressure of less than
134 mm Hg for men and less than 149 for women and a diastolic
pressure of less than 95 for both. It should be noted, though,
that when people with moderate to severe diastolic hypertension
reduce their blood pressure to 90 or less using drugs, they
appear to have a higher risk for heart problems. Those with
naturally low diastolic pressures do not have this risk.
Dozens of antihypertensive drugs are available. They
usually fall into the following categories:
Diuretics, which cause the body to excrete water and salt;
ACE inhibitors, which reduce the production of angiotensin,
a chemical that causes arteries to constrict;
Beta-blockers, which block the effects of adrenaline, thus
easing the heart's pumping action and widening blood vessels;
Vasodilators, which expand blood vessels; and
channel blockers, which help decrease the contractions of
the heart and widen blood vessels.
As first-line treatment experts recommend beta blockers
or diuretics, which are inexpensive, safe, and effective,
for most people with hypertension without complicating problems.
drugs or combinations are now recommended for specific problems:
inhibitors should be used as the first-line treatment
for people with diabetes and kidney damage.
attack survivors are usually given beta blockers and sometimes
ACE inhibitors to prevent a second attack.
with heart failure should be given ACE inhibitors and
diuretics; specific drugs in these classes may be particularly
beneficial for these patients because they reduce left
ventricle hypertrophy. One study showed that diuretics
are effective for preventing heart failure after a heart
they have a higher risk for salt sensitivity, African
Americans are usually prescribed diuretics. Isolated high
systolic pressure is treated with a diuretic; one study
found that when a beta blocker was added the risk of heart
failure was cut by half in patients with this condition.
also now warn against taking short-acting calcium channel
blockers, which may increase the risk of heart problems
and even death. Some studies are also suggesting that
calcium channel blockers increase the risk for certain cancers,
including breast cancer, and also for bleeding during surgery.
Some physicians have also been concerned about the long-term
effects of antihypertensive drugs on mental processes.
decades, diuretics, which cause reduction of water and sodium,
have been the mainstays of antihypertensive therapy. Diuretics
have reduced the incidence of stroke by a significant 40%
and, to a lesser degree (about 16%), the incidence of hypertension-related
heart attacks. They also may protect against blood clots.
Diuretics come in many brands and are generally inexpensive.
Some need to be taken once a day, some twice a day. A diuretic
used as initial single therapy is particularly effective
in elderly and African-American patients. Diuretics may
also help reduce the rate of fractures in elderly people
who have taken them for a long time. It has been thought
that long-term use of diuretics can be harmful to patients
with diabetes; one large study, however, reported that a
low-dose diuretic reduced the risk of major heart disease
with few adverse effects in older patients who had type
2 diabetes and isolated systolic hypertension. Experts believe
that diuretics should be the first line of therapy for such
Three primary types of diuretics exist:
often serve as the basis for high blood pressure treatment,
either taken alone for mild to moderate hypertension or
used in combination with other types of drugs. There are
many thiazides and thiazide-related drugs; some common ones
are chlorothiazide Diuril), chlorthalidone (Hygroton), and
hydrochlorothiazide (Esidrix, HydroDiuril).
Loop diuretics block sodium transport in parts of the kidney;
they act faster than thiazides and have a great diuretic
effect. It is important therefore to control the medication
and avoid dehydration and potassium loss. Loop diuretics
include burmetanide (Bumex), furosemide (Lasix), and ethacrynic
acid (Edecrin). The loop and thiazide diuretics deplete
the body's supply of potassium, which can cause arrhythmias--heart
rhythm disturbances that can, in rare instances, lead to
cardiac arrest. In such cases, physicians will either prescribe
lower doses of the current diuretic, recommend potassium
supplements, or use potassium-sparing diuretics either alone
or in combination with a thiazide.
diuretics include amiloride (Midamor), spironolactone (Aldactone),
and triamterene (Dyrenium). Studies indicate that people
who take a potassium-sparing diuretic with a low-dose thiazide
have a lower risk for cardiac arrest than those taking either
a beta-blocker or thiazide alone. Potassium-sparing drug
have their own risks, which include dangerously high levels
of potassium in people with damaged kidneys or who have
a high potassium intake from other sources.
It is important to stress that, in general, all diuretics
are more beneficial than harmful. (Arrhythmias can also occur
as an interaction between diuretics and certain drugs, including
some antidepressants, antiarrhythmic drugs themselves, and
digitalis.) Common side effects of diuretics are fatigue,
depression, irritability, urinary incontinence, loss of sexual
drive, breast swelling in men, and allergic reactions. Diuretics
can trigger attacks of gout and may raise cholesterol level;
they have no effect on heart size.
and Alpha Blockers
blockers prevent certain receptors in the heart from taking
up chemicals (adrenaline type) responsible for the force and
frequency of heart beats. As a result they ease the workload
of the heart, and reduce pressure. They are very effective,
and currently recommended along with or instead of diuretics
as initial treatment. In studies, beta blockers have been
associated with a lower risk for a second heart attack or
sudden death after a first heart attack. These drugs are not
as effective as ACE inhibitors in people with or at risk for
kidney disease. Because they can narrow bronchial airways
and constrict blood vessels, patients with asthma should avoid
them whenever possible. Many beta blockers are now available,
including propranolol (Inderal), acebutolol (Sectral), atenolol
(Tenormin), betaxolol (Kerlone), carteolol (Cartrol), metoprolol
(Lopressor), nadolol (Corgard), penbutolol (Levatol), pindolol
(Visken), and timolol (Biocadren). The drugs may differ in
their effects and benefits. Carvedilol (Coreg), which is a
mild beta blocker with some vasodilating properties has been
found to improve very severe heart failure. It also appears
a better effect on insulin sensitivity than other beta blockers
and so may prove to be a good choice for people with diabetes.
A similar drug, bucindol, is in development. Atenolol has
been found to reduce left ventricular hypertrophy and, when
used with the diuretic chlorthalidone, was found to significantly
reduce the risk for heart failure, particular in patients
at high risk for it.
Some beta blockers tend to lower HDL cholesterol (the beneficial
cholesterol) by about 10%; the effect is most marked in smokers.
Fatigue and lethargy are the most common psychologic side
effects. Some people experience vivid dreams and nightmares,
depression, and memory loss. Exercise capacity may be reduced.
Other side effects may include cold extremities, asthma, decreased
heart function, gastrointestinal problems, and impotence.
If side effects occur, the patient should call a physician,
but it is extremely important not to stop the drug abruptly.
Angina, heart attack, and even sudden death have occurred
in patients who discontinued treatment without gradual withdrawal.
Converting Enzyme Inhibitors
converting enzyme (ACE) inhibitors have successfully battled
all types of hypertension. Many brands are available that
are similar in efficacy and safety, as well as in price, which,
unfortunately, is high. ACE inhibitors include captopril (Capoten),
enalapril (Vasotec), quinipril (Accupril), benezepril, and
lisinopril (Prinivil, Zestril). ACE inhibitors are recommended
as first-line treatment for people with diabetes and kidney
damage, for some heart attack survivors, and for patients
with heart failure when taken with diuretics. Captopril has
also been found to reduce left ventricular hypertrophy. African-American
patients usually do not respond well to ACE inhibitors unless
they are combined with diuretics. Although these drugs are
expensive, one study demonstrated that enalapril decreased
the risk of death by 18% and reduced hospital visits, saving
over $1,500 per patient over a 40-month period. Side effects
are uncommon but may include an irritating cough, excessive
drops in blood pressure, and allergic reactions. A recent
study found that the drug picotamide can help reduce the frequency
of coughs. Although ACE inhibitors can protect against kidney
disease, they also cause the kidneys to retain potassium,
which can cause cardiac arrest if levels become too high.
Because of this action, they are not generally given with
potassium-sparing diuretics or potassium supplements. One
rare but severe side effect--granulocytopenia--has been observed,
which is an extreme reduction in white blood cells; this can
be minimized with lower dosages.
which widen blood vessels, are often used in combination with
a diuretic or a beta blocker. Representative vasodilators
include hydralazine (Apresoline), prazosin (Minipress), clonidine
(Catapres--available in tablets or as a skin patch), and Minoxidil
(Loniten). These drugs should be used with caution or not
at all in people with angina or who have had a heart attack.
spite of a number of studies indicating severe problems with
certain calcium channel blockers and that other drugs, particularly
beta blockers, are equally or more effective, prescriptions
for calcium channel blockers continue to increase. Calcium
channel blockers include diltiazem (Cardizem, Dilacor), amlodipine
(Norvasc), verapamil (Calan, Verelan), nisoldipine (Sular),
nicardipine (Cardene), nifedipine (Adalat, Procardia), isradipine
(DynaCirc), mibefradil (Posicor), lercanidipine (Zanidip),
felodipine (Plendil), and nitrendipine. These drugs are expensive
but may be useful for people who cannot take beta blockers
and for people with heart rhythm disorders. Sustained-release
calcium channel blockers provide stable and persistent lower
blood pressure. Side effects vary among different preparations,
and may include fluid accumulation in the feet, constipation,
fatigue, impotence, gingivitis, flushing, and allergic symptoms.
Grapefruit juice appears to boost the effects of these drugs
in some people. Newer drugs, such as lercanidipine may reduce
or avoid many of these side effects.
A number of serious questions have been raised over the use
of calcium channel blockers. Of major concern is an increased
risk of death and serious heart events from abrupt drops in
blood pressure in people taking short-acting forms (those
taken three times a day) of the calcium channel blocker nifedipine.
Experts now recommend that short-acting nifedipine be taken
with great caution, if at all. Although most studies on long-acting
forms of calcium channel blockers or other short acting forms,
including diltiazem, do not report an increased risk for heart
events, a recent study found that patients with type 2 diabetes
who took nisoldipine, a long-acting calcium channel blocker,
had a significantly higher number of heart attacks than those
on an ACE inhibitor. Other worrisome studies have pointed
to a higher rate of cancer in those taking calcium channel
blockers compared to people taking other antihypertensive
medications. One reported more than double the risk for breast
cancer in women taking calcium channel blockers, particularly
if they were taking short-acting forms along with estrogen
therapy. Studies have found a significantly increased risk
for blood loss during surgery in patients taking these drugs.
Another study found changes in brain tissue on scans of people
who had taken calcium channel blockers. No one currently taking
any calcium channel blocker should stop taking it abruptly,
because such action could dangerously increase the risk of
high blood pressure. Patients who are concerned should consult
with their physician about alternative medications. Even long-acting
calcium channel blockers should be used with caution or not
at all by people who have had a recent heart attack, who have
unstable angina, or who have or at risk for congestive heart
failure. Of some encouragement are studies that have found
that the negative effects of calcium channel blockers, even
nifedipine, are reduced when they are taken with a beta blocker
known as angiotensin II receptor antagonists, including losartan,
candesartan cilexetil, and valsartan (Diovan), have benefits
similar to ACE inhibitors and may have fewer or less severe
side effects, including coughing. They may also have positive
effects on blood vessels. Labetalol (Normodyne, Trandate)
is an alpha-beta blocker and is useful for hypertensive patients
who also have angina. Alpha blockers, which include terazosin
(Hytrin) and doxazosin (Cardura), are also effective against
high blood pressure, particularly in men who also have benign
prostatic hyperplasia. Doxazoin reduces systolic pressure
and may improve cholesterol levels.
women who develop high blood pressure only during pregnancy
(gestational hypertension) are at low risk for preeclampsia
and require no treatment other than monitoring. Treating pregnant
women who have chronic, mild hypertension is probably not
necessary, although no large studies have been done to confirm
this. Those with more severe hypertension, however, should
be treated, usually with methyldopa or labetolol. Many of
the standard antihypertensive drugs, particularly ACE inhibitors,
have potentially harmful effects to a fetus. Women who have
taken ACE inhibitors before pregnancy will not endanger the
fetus if they discontinue therapy during the first trimester.
Atenolol is also associated with adverse effects on the fetus;
studies on other beta blockers are conflicting. No significant
or long-term studies have been conducted on pregnant women
using calcium channel blockers. Treatment for preeclampsia
ranges from monitoring to emergency treatments, depending
on severity. It does not respond well to standard drug treatments.
Preventive treatment using magnesium sulfate during labor
is recommended by some experts.
Effects of Hypertension Treatment
of the most difficult issues that hypertensive patients face,
particularly those with primary hypertension, is that the
treatment may make them feel worse than the disease, which
is almost always symptomless. Patients face a lifelong prospect
of taking drugs with unpleasant side effects, reducing their
salt intake, exercising, and watching their diet. Many drugs
that treat high blood pressure impair sexual function, for
example, although this is immediately reversible once the
drug is stopped. Whatever the difficulties, compliance with
a drug and lifestyle program is worth the effort and the cost.
Sources of Information About High Blood Pressure?
Heart, Lung, and Blood Institute Information Center
P.O. Box 30105 Bethesda, MD 20824-0105
The web site also includes the DASH diet.
7272 Greenville Ave..- Dallas, Texas 75231-4596
214-373-6300 or 800-242-8721
This is a primary source of information for heart problems.
They are very responsible and will send free pamphlets and
reading material, including useful diet information and
locations of local representatives.
2323 Colorado Ave. , Turlock, CA 95380
This organization provides bracelets or neck chain emblems
with critical personal medical information. Also keep computerized
medical records (call 800-432-5378).
(New York Online Access to Health)
A joint effort between various public New York institutions
NOAH seeks to provide high quality full-text health information
for consumers that is accurate, timely, relevant and unbiased.
NOAH currently supports English and Spanish. Covers lots of
Site dedicated to high blood pressure (http://www.bloodpressure.com)
Well written, easy to understand. Some promotion of commercial
Corner INternet Group, Inc. 1997-2004