What is blood pressure anyway? Blood pressure is a measure of the force of the blood against the walls of your arteries. Blood pressure readings include two numbers, such as 120/80 (say “120 over 80”). The first number is the systolic pressure and is the force of blood on the artery walls as the heart pumps. The second number is the diastolic pressure and is the force of blood on the artery walls between heartbeats, when the heart is at rest.
What is hypertension/high blood pressure? Your blood pressure normally goes up and down depending on what you are doing. You’ve probably heard that a normal blood pressure is less than 120/80 but it is normal for it to go up when you’re exercising or under stress. It’s normally higher for example when you’re exercising than when you’re sleeping. If you’re rushing to make it to your doctor’s appointment, it might be higher when it’s measured in the doctor’s office then when you’re relaxed right before you go to bed. Despite what a lot of people think, high blood pressure usually does not cause headaches or make you feel dizzy or lightheaded. It usually has no symptoms, but it does increase your risk for heat attack, stroke, kidney and eye damage. The higher your blood pressure, the more your risk increases. Your doctor will probably look at several variables when trying to determine whether your blood pressure is elevated abnormally and whether your blood pressure needs to be treated. If you have diabetes, kidney disease, an aneurism or if you’ve had a heart attack or a stroke we usually try to keep the blood pressure lower than for other patients because they are at higher risk of developing additional health related problems if their blood pressure is high.
If a patient is normally healthy without any health related problems, we usually don’t consider them to have hypertension unless their blood pressure is 130/80 or higher – stage 1 hypertension based on Guidelines released in November of 2017.
Guidelines released by the American Heart Association and American College of Cardiology in November of 2017 classify blood pressure in the following categories:
- Normal <120/80
- Elevated: Systolic between 120-129 and diastolic less than 80
- Stage 1: Systolic between 130-139 or diastolic between 80-89
- Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg
- Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
Why should you care if your blood pressure in high? Most of the time when people have high blood pressure they don’t have any symptoms so they aren’t even aware that it’s elevated! High blood pressure is sometimes called a “silent killer” because even though you don’t have symptoms from it being elevated, it can do damage to the arteries in the heart, brain, kidneys, eyes and other organs.
Men are often most interested to know that having hypertension can cause a form of sexual dysfunction called erectile dysfunction (ED). That’s right, if your blood pressure is elevated, your sex life may be negatively affected as a consequence. Read my article on male sexual dysfunction in men here.
It may take years to develop symptoms from this damage but it is usually permanent and can make patients more likely to have a heart attack or stroke, kidney damage (sometimes requiring dialysis), vision problems, and even lead to early death.
Some patients might not have thought about why they would want to stay healthy, so I usually ask them to make a list of what’s important in their life. For some people it’s important for them to be alive and healthy so they can spend time with their family members (wife/husband, children, siblings, pets, etc.) Some people enjoy traveling and they may not have considered that it’s much more difficult to travel if you have problems with your heart, brain, kidneys or eyes for example. I think it’s important to think about what your short term and long term goals are, and use this as motivation for keeping healthy.
Who is at risk? High blood pressure is a very common problem! Elevated blood pressure is more common as we get older but can affect anyone. Among people over age 60, hypertension occurs in 65 percent of African-American men, 80 percent of African-American women, 55 percent of white men, and 65 percent of white women.
I’ve had patients who are children with abnormally elevated blood pressures. Oftentimes high blood pressure runs in the family, so if your father, mother or siblings have hypertension it’s important to be aware that you are at higher risk of developing hypertension yourself. High blood pressure is also more common in people who have diabetes, drink more than two alcoholic drinks/day, are overweight, eat an unhealthy diet or don’t exercise regularly.
If you have sleep apnea, you are also at greater risk of high blood pressure. Until correcting the sleep apnea, it may be very difficult to control your blood pressure.
High Blood Pressure Treatment: There are certain lifestyle modifications that can help get your blood pressure in the normal range and also medications that your doctor might prescribe. Usually a combination of both medications and lifestyle changes achieves the greatest success in achieving a blood pressure that is within the healthy range for you.
1) Reducing the amount of salt in your diet
2) Losing weight if you are not at your goal
3) Avoiding excessive amounts of alcohol
4) If you smoke, decreasing or stopping
5) Exercising for at least 30 minutes on most days
Reducing sodium intake is important because with increased salt (or sodium chloride) intake from food that we eat, our bodies naturally absorb more wate. The increased water absorbed into the body then contributes to an increased amount of fluid in the blood vessels and heart and that in tern leads to hypertension. Diuretic medications (discussed below) work in almost an exact opposite way to decrease the amount of salt and water in the bodies and lower blood pressure.
Medications: If lifestyle changes alone are not successful in getting the blood pressure under control, your doctor may prescribe certain medications to help decrease the strain on the heart and arteries. The constant stress from the elevated blood pressure that may lead to organ damage if not treated adequately.
With such a variety of blood pressure medications available, medical providers try to make the best decisions based on the latest scientific research as well as an individual patient’s past medical history and other medical conditions. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment (JNC) has had seven publications that have been released based on scientific research about blood pressure since 1976. The guidelines are constantly changing as we acquire new data from scientific data.
Most blood pressure medications are tolerated well, but just like any medication, there is the possibility of side effects. I will discuss some of the possible side effects of the various classes of blood pressure medications. If you experience side effects, allergies or just don’t like the medication prescribed, I recommend discussing this with your doctor right away rather than just stopping the medication because there might be some reason (other than the medication) that could be causing an undesired effect. It’s also true that you might not notice an immediate drop in blood pressure right after starting some types of blood pressure medications. It can take a few days or even weeks to achieve the full effect with certain medications.
You should know that it often takes more than one blood pressure medication to get blood pressure under control. These medications are often used together and work in different ways to reduce blood pressure. We might use 1, but often use 2, 3 or 4 different blood pressure medications to achieve the blood pressure goal (less than 140/90 for example).
ACE (angiotensin converting enzyme) inhibitors block a hormone in the body that causes narrowing of the blood vessels. By allowing the blood vessels to widen, it lowers the blood pressure and improves the heart output. This is usually the first type of medication that is prescribed for someone who has high blood pressure because it usually works so well and because there are usually not many side effects. Some of the common ACE inhibitors are lisinopril, benazopril, enalopril, captopril and ramipril. There are many more ACE inhibitors available that are not named here. We also prescribe ACE inhibitors to patients who have chronic kidney disease, heart failure or diabetes. Usually these patients also have hypertension, but not always. If they don’t have high blood pressure, the ACE inhibitors are usually used because they protect the kidneys from damage due to elevated blood sugar.
Possible side effects: The most common complaint of patients who cannot tolerate an ACE inhibitor is a persistent, dry, hacking cough. About 10% of people who are prescribed an ACE inhibitor may experience a cough (that goes away after stopping the medication), and if that happens to you, we can use another similar medication – see ARB (angiotensin II receptor blocker) medications. A very small percentage of people can have an allergic reaction to ACE inhibitors that causes swelling of the lips/mouth (angioedema). If you develop swelling of the lips, tongue or mouth you shouldn’t take this medication and talk to your doctor right away. We don’t see it happen very often but severe allergic reactions to any medication can be life threatening so it’s important that if you have trouble breathing after taking any medication, you call 911 (an emergency/ambulance team) instead of trying to drive to a hospital yourself.
Angiotensin II Receptor Blockers (ARBs): These medications work similar to ACE inhibitors to reduce blood pressure but have their effect at a different site in the kidney than the ACE inhibitor. These are newer medications than ACE inhibitors and are generally more expensive. Since they work in a similar way to ACE inhibitors, we usually use these mostly in patients who cannot tolerate and ACE inhibitor or have chronic kidney disease. They also work to widen the blood vessels to lower the blood pressure. Some examples of ARBs include losartan, valsartan, and candesartan. Not all ARBs are mentioned here.
Possible side effects: The main difference between the ACE inhibitor and the ARB is that patients who cannot take the ACE inhibitor due to cough, can usually tolerate the ARB. Angioedema (allergy) is also less common in ARBs.
Diuretics: These medications lower your blood pressure by causing your kidney to produce more urine (which contains water, sodium and potassium). You might notice that you have to get up to go to the bathroom more frequently when you take a diuretic blood pressure medicine. Having less water/fluid in the blood vessels decrease the pressure inside the vessels (like having less volume of water running through a garden hose decreases the pressure inside of it). There are different classes of diuretic medications to discuss:
1) Thiazide diuretics: Usually these medications are taken once a day. Common examples are chlorthalidone and hydrochlorothiazide (HCTZ).
2) Potassium-sparing diuretics: Spironolactone, triamterene or amiloride are diuretics which do not cause as much loss of potassium in the urine as some of the other diuretics.
3) Loop diuretics: Lasix is an example of a stronger diuretic that lasts only 6 hours (so it has to be taken multiple times each day) but is used for patients who have high blood pressure and congestive heart failure. We don’t use loop diuretics as often with high blood pressure because they we have to be very careful to monitor the potassium closely in patients who take loop diuretics. This means that patients taking these medications may be asked to get blood work done fairly frequently.
Possible side effects: Diuretics are usually very well tolerated and the main complaint that I hear people complain about is having to urinate more frequently. I usually recommend taking a diuretic in the morning rather than the evening so that if they do have to urinate more frequently, they get most of the effect in the day when they’re awake. We need to check kidney function and electrolytes when patients take diuretics to make sure that the sodium and potassium do not get too low. People who have gout sometimes have more attacks if they take thiazide diuretics.
Calcium channel blockers: These medications reduce the amount of calcium that enters the cells of the heart thereby causing the cells of the heart to relax and dilate and reduce the pressure as well as reducing the force and rate of the heart. There are two categories of calcium channel blockers:
1) Dihydropyridine – examples include amlodipine, nifedipine, and felodipine. There are many others as well.
2) Nondihydropyridines – examples include diltiazem and verapamil
Possible side effects: Sometimes patients who take calcium channel blockers may develop headache, dizziness, flushing, nausea or swelling of the gum tissue (gingival hyperplasia). It the dose of medication is too strong, it can cause the heart rate to slow too much and lead to dizziness or falling.
Beta blockers: These medications lower the blood pressure by decreasing the rate and force of the heart when it pumps blood. Some examples of common beta blockers include metroprolol, atenolol, carvedilol and labetalol. The last two beta blockers listed here also cause relaxation of the blood vessels (alpha blocking effect).
Possible side effects: Beta blockers have a higher chance of causing side effects than some of the other blood pressure medications that are commonly prescribed so they are often reserved for patients who have resistant hypertension or have had a heart attack or heart failure. We often give beta blockers to patients who have migraine headache because the medication helps to reduce the frequency of migraine we believe by affecting the nervous system/blood vessels. People with panic disorder or anxiety may also benefit from taking beta blockers because patients often feel more relaxed while on this medicine, perhaps because of the effect on the sympathetic nervous system.
Patients who have asthma sometime get worsening symptoms from their asthma if they use beta blockers. We are careful with the use of beta blockers in patients who have diabetes (and who sometimes get low blood sugar from their insulin) because the beta blockers can sometimes make it difficult for patients with a low blood sugar to feel symptoms of it coming on. Beta blockers can also cause fatigue, dizziness, sleepiness, and decreased ability to exercise in some patients.
Alpha blockers: These medications relax the blood vessel s in the body and thus allow the diameter of the vessels to widen. Since vessels are wider, the pressure is decreased – think about how a nozzle works on a hose. If you widen the nozzle and amount of water that is able to go through the hose, the pressure will decrease. Some common alpha blockers are doxazosin, prazosin and terazosin.
Possible side effects: The most common side effect of alpha blockers is dizziness, especially when standing up quickly. We usually don’t use alpha blockers as a first medication for treating high blood pressure because of this possible side effect. Men with an enlarged prostate and high blood pressure however may benefit from one of these medications because they can help to shrink the prostate and help increase the urine flow and decrease blood pressure.
Direct vasodilators: We sometime prescribe medications that directly relax the blood vessels quickly, especially in patients who come into the hospital with severe hypertension. These medications are short acting and as they wear off they can lead to an increased heart rate so we usually only use these medications in combination with a medication such as a beta blocker. Common direct vasodilators include hydralazine or minoxidil.
Possible side effects: headache, weakness, nausea and rapid heartbeat or possible side effects. We also use minoxidil topically (Rogaine) for hair growth because it increases the blood flow to the hair follicles.
My recommendations: Patients who have high blood pressure and are motivated to get their blood pressure controlled can do so but it might take some time and effort on their part. After consulting with their primary physician and coming up with a treatment plan, I next recommend obtaining a blood pressure cuff and measure blood pressure twice a day. The first measurement should be done first thing in the morning after getting up and before having any coffee (or other caffeinated beverages). Write this number down and also record another blood pressure right before going to bed. It’s important to get your blood pressure less than 130/80 consistently.
I have a tendency to value the home blood pressure records more than what we measure in the office because there is often some stress with getting to the doctor’s office on time, parking , waiting in an exam room, etc. all of which may not be a pleasant experience. We can check your blood pressure cuff in the office and see how it compares to our cuff and ensure that it is accurate. If your blood pressure is consistently higher than it should be, we may make changes in your medications by adding additional medications or increasing the dosage of medications that you are already taking.
Again, do not stop taking your medications without telling your doctor. If you don’t take your medications, medical providers cannot help you with your blood pressure. We need to know if you cannot take them and we can even work with you to help you remember to take your medications if you forget.
Tips on checking your blood pressure at home:
1) Sit in a chair that supports your back. Rest your arm on a table so that your upper arm is at the same level as your heart.
2) Sit with your arm slightly bent with your palm up. Keep your feet flat on the floor and your legs uncrossed.
3) Use the same arm every time you check your blood pressure
4) Make sure that you can put the blood pressure cuff directly on the skin of your upper arm. You may need to remove any sweaters or pull up your sleeves. Be sure that your sleeves are not too tight around your arm.
5) Wrap the blood pressure cuff snugly around your upper arm, palm facing up. The lower edge of the cuff should be about 1 inch (2.5 cm) above the bend in your elbow.
6) Press the on/off button on the electronic monitor. Follow the manufacturer’s instructions for using the device.
7) The blood pressure cuff will automatically inflate to about 180mmHg (unless the monitor decides you need a higher number). Then the cuff will begin to delate automatically and the numbers on the screen will begin to drop.
8) Wait at least 5 minutes before taking another blood pressure readings working properly.
9) Look often at blood the blood pressure cuff and rubber tubing. Make sure that they are in good condition and do not have any holes or cracks.
9) When you purchase a blood pressure monitor, bring it to the doctor’s office to compare the reading you get with the reading that is taken in the office. They should be close. Repeat this check yearly to make sure your machine is working properly.
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO