The Silent Killer

Last week I asked a patient what her blood pressure (BP) runs on a regular basis.  I had noticed a continuing upward trend in her office readings and I know she owns an automated cuff.  “I don’t check it routinely,” she responded, “only when I feel it’s up.”

Her implication was that she has the ability to perceive whenever her BP drifts into elevated territory.  In explaining further she told me that she feels anxious and has a headache whenever her hypertension “acts up” and at those times her systolic level is typically over 180 mmHg.  All other times, she continued, her pressure is normal.

For years people have referred to hypertension as the silent killer.  The reasons for this are fairly obvious.  Contrary to what my patient believes (and I’ve had numerous people make the same claim) you don’t typically get symptoms when you become hypertensive, and even small increases in blood pressure over the course of years can lead to heart attack, stroke, congestive heart failure and kidney damage.  To make matters worse, a person’s resting BP tends to rise gradually as they age—someone whose pressure was normal 5 years ago may have now drifted into the hypertensive range.

There have been several research studies proving that people can’t perceive mild to moderate levels of BP elevation.  My patients who are convinced to the contrary are fooled by the fact that their own pressure is likely chronically elevated (so that it’s up anytime they have symptoms that lead them to check it) or by the fact that symptoms such as anxiety and headache can lead to transient rises in BP (rather than the other way around).

At Alegent Health we are currently in the process of trying to screen all our employees for modifiable risk factors such as obesity, high cholesterol, tobacco use and hypertension.  Last week I underwent my own screening and as the nurse checked my pressure I realized that I hadn’t been on the receiving end of a sphygmomanometer for years.  While my numbers were normal it occurred to me that I could very well have been among the many Americans who are ignorant about their own hypertensive status.

How many people are truly unaware of their BP?  Consider these facts:

• About a quarter of all Americans have hypertension.
• By the time you reach age 55 your likelihood of having this diagnosis rises to over 50%.
• About 30% of adults with high BP are unaware they have hypertension.
• Younger patients with hypertension tend to be less aware of their disease.
• Fewer than 50% of adults with hypertension treat their disease to an adequate level.
• A person with a BP of 135/85 is at twice the risk of stroke and heart attack as a person whose BP is 115/75

In other words, high BP tends to sneak up on you as you age and even those who are aware of it often do a poor job of treating it.  Compounding this problem is the fact that the prevalence of hypertension increases as our obesity epidemic worsens.  More and more young people are developing mild levels of hypertension along with the other maladies of widening girth: obstructive sleep apnea, type II diabetes, hyperlipidemia, etc.

Here are a few pearls of wisdom when it comes to hypertension:

• Check your own blood pressure periodically even if you don’t carry the diagnosis of hypertension; don’t just rely on your doctor to do it.  Your average should be below 135/85.  If you’re consistently above that level you should see your doctor about initiating therapy (by which I mean diet, exercise, weight loss; only if those don’t work do you start medication).
• I believe that anyone with hypertension should own their own home BP cuff.  Go to the local pharmacy and get their basic model.  If you don’t think you can afford one tell your family you want one as a birthday or Christmas gift.  If you still can’t get your hands on one come talk to us—we have a few loaner cuffs.  Start by checking your BP twice daily for a couple weeks just so you get a sense of what your numbers run.  Record the reading in a booklet every time you measure your pressure and bring your notebook with you to every doctor appointment.  Once your BP is under good control remember to check it at least weekly.
• Virtually everybody has a high degree of variability when it comes to BP measurements.  It’s not unusual for you to have large swings in BP throughout the course of the day.  This is why multiple measurements over the course of weeks are needed to provide the best assessment of BP control.
• Remain obsessively compliant with your medication.  A major drawback to some of our BP drugs is their relatively short life span; if you happen to miss a dose here or there your body will notice.  Worse, some drugs have a rebound effect and your BP will bounce even higher if you come off the pill temporarily.
• Cut as much salt from your diet as possible.  Not all people have hypertension that worsens with salt intake but most do.  Be particularly careful when you eat out.
• Don’t worry too much about isolated episodes of very high readings.  A single
  measurement of 180/100 is not particularly concerning.  On the other hand, even mild elevations, if allowed to persist over the course of years, can put you at great risk.  A systolic blood pressure chronically above 150 will more than quadruple your risk of stroke.
• Regular exercise will lower your BP to about the same degree as our most expensive prescription drug.
• The average number of medications it takes to control BP in most people is between 2 and 3. Don’t freak out if your doctor wants to add another drug to control your BP.  The way I look at it is this: most medications have relatively similar efficacy and drop your BP by about 10 points.  If your pre-treatment systolic pressure is 160 and you need to get to 130 you’ll need about 3 medications (3 x 10 = 30).
• We are fortunate to live in an age where BP in most patients can be controlled with medications that fulfill 3 important criteria: 1. Generic and affordable, 2. Once daily dosing, 3. Few (if any) side effects.  With the exception of people with very difficult-to-treat hypertension (those requiring more than 3 medications) we can generally provide adequate treatment and still stay within these parameters.
• The combination of two medications at low dose is more effective and produces fewer side effects than one medication at high dose.

I’m not quite sure how to handle patients like the lady in my opening paragraph.  It doesn’t help to try to convince her that she doesn’t have a sixth sense about blood pressure (any more than she could possibly sense her white blood cell count or serum c-reactive protein).  In the end I just asked her to humor me and bring in some readings from her cuff taken at regularly scheduled intervals.

On an unrelated note, I am pleased to see that therapeutic chocolate intake is again receiving positive press.  The British Medical Journal just published research showing that regular consumption of chocolate cuts the risk of cardiovascular disease by 37%.  I’ve previously written on the beneficial effect of chocolate and am always happy when science reaffirms the health benefits of something I’m addicted to anyway.  Now if only we could see some research touting the health benefits of pizza, diet Coke, and wasting time writing blogs.