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Reasons Why Your Blood Pressure Is Still High

Date: December 1, 2016      Publication: Bottom Line Health      Source:  Holly Kramer, MD, MPH, Loyola University Medical Center      Print:

New research shows how 100,000 lives could be saved each year…

When it comes to treating serious medical conditions, you would  think that high blood pressure (hypertension) would be one of the nation’s great success stories. Doctors test for it. Patients know the risks. And there are dozens of medications that treat it.

Yet the results are still disappointing. About one in every three American adults has hypertension…but only about half of them keep it under control.

Why are we still losing the battle against hypertension? Scientists now are discovering some of the traps that prevent people from adequately controlling their blood pressure. What you need to know…

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TRAP #1: Not treating soon enough. Even though normal blood pressure is defined as below 120/80 mmHg, researchers continue to debate optimal blood pressure targets. In reality, most doctors don’t consider treatment until readings reach 140/90 mmHg or above—the official definition of hypertension.

But recent research has shown us that is too late. The risks associated with hypertension—stroke, heart attack, kidney disease and vision loss, among others—start to rise at lower levels.

Important new finding: When researchers compared target blood pressure readings in more than 9,350 adults with hypertension and other cardiovascular risk factors, the results were striking. Those who got intensive treatment to lower their systolic (top number) pressure to below 120 mmHg were 27% less likely to die from any cause over a three-year period than those whose target was below 140 mmHg. In the study, diastolic (bottom number) pressure was not measured because it tends to decline as people get older.

Starting treatment earlier than 140 mmHg to achieve a normal reading could save more than 100,000 American lives a year, the researchers estimated.

My advice: If your systolic blood pressure is 120 mmHg or above (or your diastolic pressure is 90 mmHg or above), tell your doctor that you want to be treated. Note: If your systolic blood pressure is less than 150 mmHg, you may be able to avoid medication if you adopt healthier habits—not smoking…losing weight, if necessary…getting regular exercise…eating a well-balanced diet, etc. If these steps haven’t lowered your blood pressure after six months, you may need medication. If systolic pressure is above 150 mmHg, medications may be needed in addition to lifestyle changes.

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Caution: Intensive blood pressure treatment usually involves taking multiple blood pressure–lowering drugs, which increases risk for side effects, such as dizziness and light-headedness. Therefore, blood pressure should be checked frequently (see below) and regular tests should be given for potassium and electrolyte levels. Electrolytes and kidney function should be checked within one month of starting a diuretic or when a dose is increased. After that, levels should be checked every six to 12 months.

TRAP #2: Not testing at home. Don’t rely only on the blood pressure tests that you get at your doctor’s office. They can be too intermittent—and too rushed—to give accurate readings. Your pressure is likely to be artificially high…or artificially low, since people who are seeing a doctor often abstain from some of the things (such as drinking coffee) that raise it.

My advice: Buy a digital blood pressure monitor, and use it at home. Omron upper-arm blood pressure monitors (available at pharmacies and online for about $40 and up) are about as accurate as office monitors. A JAMA study found that 72% of people who tested at home had good blood pressure control versus 57% of volunteers who were tested only by their doctors. 

What to do: Every day, check your blood pressure in the morning before eating, exercising or taking medication…and again in the evening. (If your blood pressure is normal, test every few months.)

Before testing, empty your bladder (a full bladder will cause higher readings). Then sit with both feet on the floor, and relax for five minutes. Rest your arm, raised to the level of your heart, on a table, and place the cuff on bare skin.

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Do each reading twice: Measure your blood pressure once…wait a few minutes…then repeat—the second reading will be more accurate. Write down the readings, and share them with your doctor during your office visits.

TRAP #3: Taking the wrong drug. About 70% of patients with hypertension require two or more drugs to achieve good control. Many will be given prescriptions for one of the newer drugs, such as an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB). Some patients (such as those with heart failure) will need one of these drugs. Most people do not—at least not right away.

If you’ve recently been diagnosed with hypertension, consider a thiazide diuretic, such as chlorthalidone. It’s an older drug that is available as a generic. It costs pennies a day, and studies have shown that thiazide diuretics lower blood pressure as effectively as other drugs, with less risk for heart failure and stroke. Thiazide diuretics may be paired with an ARB or ACE inhibitor, since these drugs are synergistic (each drug increases the other’s effectiveness).

The caveats: Even though diuretics generally are safe, you’ll urinate more often (they’re known as “water pills” for a reason). Thiazide diuretics might also lower potassium levels in some patients—if so, your doctor may advise you to take potassium supplements. And diuretics can raise urate levels, triggering gout in some people.

TRAP #4: Not timing your medication. Most people take medications when it’s convenient—or at a set time, such as with their morning coffee. But blood pressure medication should be scheduled.

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It’s natural for blood pressure to vary by about 30 points at different times of the day. It almost always rises in the morning, which is why strokes and heart attacks are more common in the early hours. One study found that patients who took at least one of their blood pressure medications at night were about one-third less likely to have a heart attack or stroke than those who took all of their pills in the morning.

My advice: With your doctor’s OK, take at least one of your blood pressure medications (not a diuretic) at bedtime to help protect you from blood pressure increases in the morning. Diuretics should be taken in the morning so that frequent urination won’t interrupt sleep.

Source: Holly Kramer, MD, MPH, an associate professor in the department of public health sciences and the department of medicine, Division of Nephrology and Hypertension, at Loyola University Medical Center in Maywood, Illinois. She received the 2016 Garabed Eknoyan Award from the National Kidney Foundation.