Thursday, September 23, 2010

6.10 Secrets of High Blood Pressure Prevention & Treatment

Physician's Notebooks 6 - - See Homepage                 
10. Blood Pressure and Hypertension (Update 15 December 2018 with the JNC 8 guidelines)
   Table of headings for this chapter - use it by scroll down or search & find

The Blood Pressure Numbers
The mechanisms of high BP
What BP Number to use?
Factors Affecting Your BP Numbers
Approach to Hypertension
Anti-Hypertensive Medication
the Kempner Rice diet

This chapter advice uses the 8th Report of Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, published in Journal of the American Medical Association in Feb. 2014, the latest guidelines, and based on the results of many controlled studies of treatments and outcomes. The JNC 8 Guidelines make no changes in the definitions of hypertension based on the BP numbers as given below in this chapter. (The guideline lowers the generally advised blood pressure from, best to be below, 140/90 to be below 130/80) The changes in the JNC 8 Report are in its advice on treatments. Some doctors, nurses and paramedics are not aware of these guidelines, so you may notice your BP taking is not being done the standard way. If you are found to have “hypertension”, or “borderline hypertension” or “labile hypertension” or “white coat hypertension” based on measurements that did not completely follow the most recent standard, then request that the measurement be repeated according to it.
The Blood Pressure Numbers, “BP” is two numbers, eg, 120/80, that may determine the length and quality of your life. The numbers refer to millimeters of column of quicksilver mercury (mm Hg) such as you can see in a hospital's standing BP machine.
   The top number is “systolic” because its peak is the heart’s max instant of contraction, or systole, and is caused by the squeezing heart's left ventricle pushing a pulse of blood traveling forward from the top of aorta to the smallest-arterioles and can be felt at particular points on the body, like the wrist pulse.
   The bottom number is “diastolic,” because it coincides with the instant in the heart cycle of heart muscle max relax (diastole, or between systoles). Systole is peak and diastole, valley. Diastole has no element of heart contraction power; it reflects the elastic recoil of arteries plus the resistance of arterioles, the smallest artery branches. 
The mechanisms of high BP, or hypertension involve the heart (A too powerful heartbeat due to stress); the arteries from Atherosclerosis or hardening due to high cholesterol and calcium in large artery wall and also arteriosclerosis muscle hypertrophy in the smaller arteries or arterioles. Also the amount of fluid blood (Too much of it from eating too much salt) and the kidneys (Too little kidney tissue because you lost one kidney, you have aging kidneys or you got damaging kidney disease). High BP is a final result of a combination of heart, artery, arterioles, blood fluid and kidney damages caused by bad living, chief of which is overeating, unhealthy fats in diet, too much salt, too much sugar, and poor care of kidneys. 
What BP Numbers to use? A lot of decisions are made based on BP numbers. The data for decisions should be from the BP recorded by doctor or nurse in medical office according to the SOP of JNC 8.

What is high BP number and why? The BP number that defines high BP, or hypertension, has changed as our knowledge of the affects of the BP in the body grows. Two trends are seen: 1) The cut point between high and normal BP is dropping: Before 70 years ago it was either a systolic BP 160 or a diastolic BP 95, but since year 2000 the normal is both a systolic at or below 120 and a diastolic at or below 80, and 2) We no longer only consider BP number in decision about treatment; now we look also for sign of target organ damage (TOD) and risk factors like diabetes or kidney disease in deciding how to treat hypertension.
  The blood pressure taken under standard condition and procedure measured down to systolic 90 and diastolic 60 has no cut point between abnormally high BP and normal. Down to 90/60 the lower your BP the better your good health and long life expectancy. (This assumes a stable state in a person who feels healthy)

Factors Affecting Your BP Numbers: You want to be sure your BP number is accurate in classifying you as normal or as abnormal. I would hate to be classified as hypertensive and having to suffer all that goes with it, merely because I drank a coffee in the doctor's waiting room 15 minutes before a nurse took my BP. Thus, before presenting self to doctor or nurse for BP measure, be well rested, calm, unstressed, no food or drink or tobacco or drug in previous hour but also not in hungry fasting state.
   You ought to know the standard in 2018 for measuring BP for the purpose of diagnosis. So here it is.
   BP Measurement should be in same condition and by same technique taken seated after at least 5 minutes rest and not within 30 minutes after food or drink, smoking, coffee/tea or other drug. Initially take BP in both arms (bare skin, no tight sleeve; if seated, elbow resting on desk at heart level) and, if difference of 10 or more systolic or 5 or more diastolic, then use the arm with the higher numbers. (Such difference should excite suspicion of heart or aortic deformity to be checked by echocardiogram) On initial visit, the arm BP ought to be measured with subject sitting, then standing and then reclining, all numbers recorded against position, and highest number used in considering diagnosis of hypertension. On later visits, a seated BP is usual. Also on initial visit, a BP measurement should also be made with BP cuff wrapped around a thigh and the subject reclining. High BP in arm and lower BP in thigh suggests coarctation of aorta, an important, treatable cause of secondary hypertension.
   Width of BP cuff should be at least 40% of mid arm circumference (11.5- to 13-cm-width cuff for normal adult). Fat persons require wider cuff (14- to 15-cm width) or the reading will be falsely high. Thigh blood pressure requires 18- to 19-cm-width cuff.
   To obtain accurate measurement, the cuff should be firmly wrapped about arm. (Note the "firmly" here. During a recent hospitalization, I noticed that the nurses taking my daily BP tended to carelessly wrap the BP cuff loosely about my arm or, even worse, to wrap it over my hospital gown sleeve. And always that gave incorrect, excessively high BP numbers. Insist on a firm wrap, direct on skin!) The cuff's lower border should be slightly more than 1 inch (2 1/2 cm) above elbow crease. The stethoscope head should be applied lightly just below but not touching lower edge of the BP cuff and slightly on inner side of arm so it is over the artery. (In 2019, more and more we rely on electronic digital BP measuring and so one may dispense with a stethoscope and use a digital electronic BP even though it is still standard, as described here)
   Examiner should determine the peak cuff inflation level just after wrapping cuff about arm but before applying stethoscope. This requires a finger on pulse at same-side wrist, inflating cuff by hand-pump action, and noting how high a mm Hg pressure it takes to disappear the pulse at the wrist. For the following BP measurement, the initial inflation should be 30-mm Hg higher than the pulse-disappearing pressure.
   In listening for the BP, the cuff is inflated 30-mm Hg above the estimated systolic blood pressure and, while listening by stethoscope, the column of Hg (fluid mercury) should be adjusted to fall at a rate of 2 to 3 mm per second. (Faster rate will underestimate BP)
Systolic BP and diastolic BP are estimated by changes from sounds of the artery pulse-beat heard by stethoscope applied over artery that runs down inner aspect of upper arm just above elbow with inflated cuff slowly deflating. Systolic BP is the number indicated by the Hg column at the instant of the 1st heard pulse beat over the artery as the cuff is slowly deflating. The diastolic BP number is the point where the heard pulse beat disappears. In rare case the pulse beat may be heard to continue to 0 mm Hg; In such case, the pulse beat sound will be heard to muffle (compared to its usual sharp tapping sound) at a certain point, and that first muffle point is taken as the diastolic BP number. 
Note that with an irregular heartbeat, only a mercury column BP carefully repeated several times should be recorded.
Calendar Time Point Reference for BP Measurements: I do not wish to create neurotics obsessed with BP, who take it every moment and talk of nothing but it. There is a time in life when you concentrate on getting your BP measured well, and then there is the rest of the time when you just enjoy life the better for having done the right thing for longevity and happy health.
   Each person, whenever it is they first become aware of BP, should get it checked properly. It means careful considering where, when and by whom. I have no pearl there; so long as the BP is checked by trained personnel according to SOP, OK. If you are a parent, then have your regular physician or a pediatrician check your children. (A child, depending on age & size needs smaller, usually 7.5- to 9-cm-width cuff) 
Once you get a BP check, it should either be determined to be normal or abnormal. Abnormal ought to be anything not stated as being normal. (“Borderline”, “labile”, “pre-”, “white coat-” are all abnormal)
   If you are told your BP is normal, and you are healthy, it ought to be rechecked once a year. If you are told your BP is normal and you have risk factor like diabetes or kidney disease, it should be rechecked more frequently. If you are feeling healthy and told your BP is anything other than below systolic 120 and diastolic 80 but still considered "not hypertension," you are in a category of “probable hypertension".

Approach to Hypertension: The focus here is on persons who fall within the earliest stage of the BP numbers indicating risk for hypertension. It is important to keep in mind that a BP number does not denote a diagnosis or a disease; rather, it denotes degree of risk of target organ damage (TOD).
In a group of apparently healthy persons with systolic below 120 or diastolic below 80 there is a very low risk of TOD.
If you go for initial BP evaluation and are told your systolic is between 120 and 139, or diastolic 80 and 89,
your BP range is placing you at slightly increased risk of TOD that may lead to serious illness at an earlier older age. If you decide it worthwhile to make an effort at lifestyle modification, then study what needs doing, seek expert consultation and do it well.
  What Lifestyle Modification? The data reveal that 1) Adopting a diet that emphasizes fruit, vegetable and low-fat dairy; that includes whole grain, poultry, fish and nut; that contains only small amounts of - or even better, no - red meat, sweets, sugar-added beverage; and little or no total & saturated fat and very little cholesterol; that kind of diet will lower BP in persons with hypertension as compared with a typical North American diet and 2) reducing the dietary intake of sodium from the usual ad lib salt shaker and salty foods by half or more (Stop adding salt to all foods including cooking) will lower your BP. Using the combined diet and low-salt approach, the average systolic BP lowering has been c.10 mm Hg and the diastolic c.7 mm Hg 
The data also show that the most effective non-drug approach to lowering BP is to lose weight to BMI <25 with a maximal effect achieved down to BMI 20.
Anyone motivated to lifestyle modification should stop smoking (includes marijuana), stop cocaine or other stimulants and reduce alcohol to 2 or less standard drinks a day. Otherwise: increase potassium (K+) and magnesium (Mg2+; almond nuts will up it), eat more garlic and reduce stress (1/2 to 1 hour repose lying flat). Also, functional exercise, meaning walking instead of using vehicles and mechanical instead of using electrical devices, will give lowest BP.
  If you cannot get a systolic below 150 or a diastolic below 90 by life modification alone, add medication under your doctor's advice.
   My advice for anyone with BP systolic 150 or diastolic 90 is to first get to a world-beater hypertension expert. A person with BP >150/>90 should get tested for degree of TOD and for secondary causes of hypertension. These tests should be done initially at the time a person is discovered to be high BP, and in major medical center. Once TOD degree has been determined and secondary cause of hypertension ruled out, the decision of medication is made.

Anti-Hypertensive Medication:
  The evidence is strong that if you are age 60 or younger (Age over 60 also benefits but the evidence is not as strong) and have a systolic BP of 150 or higher or a diastolic BP of 90 or higher, the lowering of your systolic BP or your diastolic BP, and even better, the lowering of both systolic and diastolic, by medication, reduces the kidney, heart and brain damage of aging, and will improve the quality and length of your life. 
The advised first-line medications are a thiazide diuretic, a calcium channel blocker (CCB) or an angiotensin-converting-enzyme inhibitor (ACE-I, or in case you cannot tolerate ACE-I, an angiotensin II receptor blocker). The thiazide as initial treatment in mild to moderate essential hypertension with minimal TOD is chlorthalidone starting in daily dose 12.5 mg. Results based on hard data show the 3 types of first-line medications, each taken alone, give equal results except in cases where heart failure is a complication, and in those cases the thiazide proved the superior for first-use, the ACE-I was next best and the CCB was least good for first use. If heart failure is not a problem, the choice of which of the 3 first-use types to start on will be based on personal patient factors and physician preference.
   Opinion on beta-blockers: Beta-blocker medication has been proven less than ideal as a first-line anti-hypertensive because of one study that showed a combined higher rate of cerebrovascular, heart failure and other cardiovascular bad outcomes. This should not suggest that beta-blockers are dangerous treatment; it only applies to them as first-line against high blood pressure. Beta-blockers can be useful as added-on treatment, especially for limiting rapid resting heart rates. (Also beta blockers are useful as part of a healthy longevity program where the focus is not on treatment of hypertension but on prevention of too rapid heartbeat)

  Opinion of variation of medication based on African-American versus non African-American patients: The above advice applies to the non African-American patients. A difference in choice of first-line medication for African-Americans is that thiazide is best, CCB is next best, and ACE-I is least good. Note that in non African-American there is no difference in first-use choice except if heart failure is present in which case the order of best, better, good is thiazide>ACE-I >CCB. Further note that no matter your race or ethnicity, the presence of heart failure takes precedence in choice of first-use medication.
  The principle of treatment is interactive with your BP number. Here is the place to use electronic digital home BP measurement because it is easy, quick, simple, and relatively accurate assuming you calibrate your machine with your doctor's mercury column BP machine. You start on the lowest daily dose of your initial medication. (With chlorthalidone 25-mg pill, cut to 1/2 pill a day) Before starting medication you get baseline BP daily under standard measurement conditions once a day for a week. Then you give it 2 weeks daily dosing, measuring your BP response twice a day in standardized way. You have endpoint goal BP below 150//90. At end of initial 2 weeks of treatment, if no response, you step up your dose (12.5 to 25 mg a day) and continue to track your BP at home. When you reach max dose of a particular initial medication or start running into side effect, and if you have not yet achieved your BP goal, your doctor should put you on a second anti-hypertensive. This second drug will either be a CCB, an ACE inhibitor or receptor blocker (ARB) based on TOD risk and other factors (Diabetics should start with ACE-I, but kidney failure patients should not use ACE-I unless each has had careful renal evaluation to rule out renovascular disease). The same principle will follow each added medication – step up dose and monitor response by BP. If the BP goal is not achieved by two medications, and if your doctor thinks it is important that it should be achieved, then he may start third type. In rare case 4 types of medication may be advised.
   Note, the order of using medications starts with one of the 3 advised types of  first-line medications - thiazide, CCB, ACE-I or ARB. Then if needed you add on another first-line, and then if needed, another. Once you run out of those options, the 2nd-line like beta blockers, alpha adrenergic blockers and others are used according to your doctor's choice based on particulars of your case. Also note that either ACE-I  or ARB is used, never both. Generally ACE-I is chosen and ARB may be substituted if ACE-I gives its bothersome side effect - cough - that ARB does not have. But the choice is up to your doctor and you.

Final note on race. If you are in doubt about your racial status, non African-American is the default mode for medication use. Also TOD organ indications for a particular medicine is more important than racial category. If a kidney condition calls for ACE I, yet that is not considered best for a African-American but he has the kidney condition, he should use the ACE-I
  The above paragraph is book l’arnin’ advice. Now let me give you my personal experience as an example of someone without hypertension but at now age 86 striving for healthy longevity. Several years ago I found myself with usual BP 130 to 140 systolic over 80 to 85 diastolic; normal BP's by standards that I learned in medical school but a little high now. More worrisome was a resting heart rate between 80 and 85 beats per minute (bpm). The heart rate was probably a combination of my hyper personality and use of other medication. I realized that this combination of borderline high BP and rapid resting heartbeat would not give the healthy longevity that Physician’s Notebooks defines as passing age 80 on one’s feet with wit and wits. After consulting my physician, I started low-dose beta blocker with the idea to neutralize my natural stress hormone and slow the heart rate and decrease the force of the heartbeat. Then I added low-dose ACE-I to lower BP even more. And, finally with medication, each day I take one or more pravastatin pill to lower my LDL cholesterol,  and a standard 325 mg aspirin under tongue to prevent blood clot thrombosis that causes deep vein thrombosis in calves or brain stroke or coronary artery blockage in heart. As part of this program, I avoid salt shaker, add no salt to my cooking, take few soft drinks (which are salt loaded) and also no obviously salted foods. And I try to drink at least an extra liter of water a day. I also do repose/meditation (in chair or lying down and thinking good thoughts) for up to an hour several times a day.  I have been clocking my BP whenever I visit the hospital to see my doctor and not too long ago I got a best 105/55 with heart rate 65 to 70 bpm. The point of my relating this hands-on experience is it is a practical approach for persons who may not have hypertension but are on the high side in BP and heart rate because of various stresses they may be undergoing or of medications they may be taking. I am fairly certain the max 30 mm Hg reduction in systolic (from 135 down to 105) and max diastolic BP (85 to 55) I achieved will give me extra years of useful, happy life now.
    End Note: the Kempner Rice diet was developed in 1939 as acute treatment for severe hypertension, end-stage renal failure, weight loss and heart failure. I have had personal experience using it in a modified fashion. Ignore what you see on internet; keep it simple. Three to 4 meals (depending on appetite) in the 24 hours centered on cooking 1/2 cup dried rice per meal as main dish without added salt. Add as much fresh fruit (but limit to one banana a day if any) and vegetables as you like; also boiled eggplant, mushroom and zucchini. The diet should be strict for 2 to 4 weeks using your BP as feedback. Its max use is 4 weeks and stop and check blood test to be sure no vitamin or mineral deficiency. My experience saw a very severe hypertensive (210/150, which is immediately life threatening) bring her BP down to 120/80 after 2 weeks on the rice diet and she felt better for it. It is a temporary stopgap of death or target organ damage and a way to get body weight and kidney function back to normal. It is best on a patient frightened of impending death from hypertension, overweight, kidney failure or heart failure.
       END OF CHAPTER. To read next now, click 6.(11-14) Drug/Exercise/Diabetes/Collapse, CPR & A...

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