Diagnosis Spotlight: High Blood Pressure

Answers to your questions about high blood pressure.


High blood pressure (or Hypertension) is one of the most common diagnoses I see.  It is one I address on a daily basis.  We hear about it all the time but don’t always understand what it is and why it is imperative to get it diagnosed and properly treated.  It’s been called the “silent killer,” but why? In this post I want to take some time to clear up any questions you may have about high blood pressure and impart some ways you can combat it.

What is Hypertension?

Simply put, hypertension is when there is excessive stress or pressure on the arteries in the body. There are two numbers in measuring blood pressure including the upper (systolic) and lower (diastolic) number.   The systolic pressure is the pressure exerted on the vessels when the heart is contracting pushing blood into the arteries.  The diastolic pressure is the relaxing pressure of the arteries caused by the elasticity within the arteries.  Both are important.  A normal blood pressure is under 140/90 when under 60 years of age and under 150/90 when over 60.  There are some conditions where we want to control your blood pressure tighter than this general rule of thumb including when also diagnosed with diabetes, chronic kidney disease and a few other conditions.  Hypertension is called the “silent killer” because it usually has no accompanying signs or symptoms.  The only way to discover it is to have it measured. According to the CDC, about 1 out of every 3 adults has high blood pressure and of these only about half have it under control.

Causes

It is normal for blood pressure to be variable and it can go up and down depending on certain situations.  When it is elevated for an extended period it can be dangerous and increase your risk for heart disease and stroke.  There are two types of hypertension: Primary and Secondary.  Primary or “essential” hypertension is where there is no underlying cause for the increased pressure and secondary hypertension is due to another cause.  About 95% of high blood pressure in the primary care office is primary hypertension.  For this post, we will focus on primary hypertension but if you do have high blood pressure, you should check with your doctor to make sure there is no treatable underlying cause

Risk Factors

There are a few things that can increase your risk for developing hypertension including certain health conditions, lifestyle and family history. The health conditions that can increase your risk include diabetes and prehypertension which is a blood pressure between 120 and 139 systolic and 80 to 89 diastolic.  Lifestyle choices that increase blood pressure include a diet with too much salt, lack of cardiovascular exercise, obesity, alcohol and tobacco use.  There are also things you can’t control that increase your risk including being over 60 and male.


Symptoms

As stated above, there are typically no symptoms with high blood pressure. However, if it is very elevated or goes untreated for a long time, a person can develop symptoms.  If the blood pressure is very high (over 180/110) there is a lot of pressure on the vessels and symptoms can develop including chest pain, headache, vision changes, nausea with vomiting, shortness of breath and passing out.  If these happen with the very elevated pressure, you need to go to an emergency room immediately.  Long term untreated high blood pressure can lead to heart failure (with symptoms of swelling and shortness of breath), stroke, kidney failure and blindness.  If blood pressure is controlled, these can be avoided.

Diagnosis

Diagnosis of hypertension is made by a doctor after elevated blood pressures are found on two separate occasions.  The blood pressure is measured using a sphygmamonometer (say that 10 times fast!) over the upper arm and listening to blood pulsations while slowly decreasing the pressure.  Diagnosis is made based on the numbers in the table below:

Blood Pressure Levels
Normal systolic: less than 120 mmHg
diastolic: less than 80mmHg
At risk (prehypertension) systolic: 120–139 mmHg
diastolic: 80–89 mmHg
High systolic: 140 mmHg or higher
diastolic: 90 mmHg or higher

White Coat hypertension, where the blood pressure is only elevated in the office, is no longer recognized as a true blood pressure issue.  If the blood pressure is elevated in the “stressful” office setting, it is usually going to be elevated in other stressful situations as well and needs to be controlled.  This being said, home blood pressures can be useful.  Here is a link to the home cuff I recommend: Omron 10 Series  (this is an affiliate link where I will receive a small kickback for any purchase).

Once hypertension is diagnosed, there should be blood and urine tests done to look at cholesterol levels, kidney function and an EKG should be done to look for any heart changes.  If the blood pressure is not being controlled with medication, other tests or cardiology referral may be needed.


Treatment

Treatment is initially through lifestyle changes.  This includes combating all of the risk factors stated above.  Thirty minutes of cardiovascular exercise should be done at least 5 days a week.  Proper diet includes adheing to the DASH (dietary approaches to stop hypertension) diet which includes plenty of fruits and vegetables and low salt along with avoid fatty and processed foods.  Men should limit their alcohol to 2 drinks per night and women to 1 drink per night (a “drink” is considered 12 ounces of beer, 8 ounces of wine or 4 ounces of hard liquor). Smoking should be completely stopped because it constricts and damages arteries. If overweight, you should work to lose weight.  Even small amounts of weight loss (5-10 lbs) can affect the blood pressure positively.

If lifestyle modification is not working and the blood pressure remains over 140/90, then medication is needed. Common medications fall into 4 major categories including: diuretics, RAAS (renin-angiotensin-aldosterone system) inhibitors, calcium channel blockers and beta blockers.  All of these can cause low blood pressure, dizziness and fatigue.

  • Diuretics typically include hydrochlorothiazide, chlorthalidone and triamterene and work to reduce the blood pressure by pulling off some fluid in the kidneys.  Common side effects include cramps, electrolyte abnormalities and kidney impairment.  
  • Calcium channel blockers include amlodipine, nifedipine (or anything else ending in -dipine), diltiazem and verapamil.  These work by relaxing the vessels directly and common side effects include constipation, leg swelling and slow heart rate
  • RAAS inhibitors include lisinopril, enalopril (or anything ending in -pril), losartan (or anything ending in -sartan) and aliskiren.  These work by inhibiting a feedback mechanism through the kidney to relax the blood vessels.  Common side effects include cough, elevated potassium, and kidney impairment.
  • Beta blockers include metoprolol, atenolol and anything else ending in -olol. These work by decreasing the rate and contractility of the heart.  Common side effects include slow heart rate, erectile dysfunction and difficulty exercising at higher exertion.
  • There are other medications beyond these but they are reserved for very difficult to control blood pressure.

I hope this was informative and able to answer any questions you have about high blood pressure.  If you have any further, please comment below. The most important thing when treating high blood pressure is to establish a trusting relationship with your primary care provider where you are both working together to meet your blood pressure goals.  

To see my  post on the updated blood pressure guidelines, click here.




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