Hypertension: Controlling the "silent killer"

| January 1, 2007

Hypertension: Controlling the "silent killer"

It is almost certain that you or someone you know has high blood pressure, known medically as hypertension. An alarming one in three American adults has this disorder. If you are among them, you can take steps today to protect yourself from the damage it causes.

Years ago, doctors didn't even treat high blood pressure in older people. They thought that hypertension was a normal part of aging, along with gray hair and creaky joints. That thinking changed in 1961, when investigators from the landmark Framingham Heart Study concluded that hypertension in fact increased risk for cardiovascular disease. In the years since, physicians discovered that high blood pressure can be prevented, controlled, and even reduced in many cases. Despite this understanding, more and more people began to develop hypertension and at younger ages. Today, 690 million people worldwide, including more than 65 million in the United States, are thought to have high blood pressure.

Part of the problem is that many people with hypertension don't even know they have it. Because hypertension has no symptoms or warning signs, yet can be so dangerous to your health and well-being, it has earned the nickname "the silent killer."

That's why it's crucial to identify the problem and get it under control sooner rather than later. To this end, a panel of government health experts is encouraging more aggressive treatment and a lower threshold for "normal" blood pressure. The result of these changes is that millions of people who were once told that their blood pressure was "normal" or "high-normal" now fall into a "prehypertension" category.

Archives of Internal Medicine, Fortunately, high blood pressure is easy to detect and treat. Sometimes people can keep blood pressure in a healthy range simply by making lifestyle changes, such as losing weight, increasing activity, and eating more healthfully. In other cases medication is necessary. Either way, reducing your blood pressure even a little bit can dramatically improve your health and life expectancy. According to research published in 1995 in the reducing diastolic blood pressure by just 2 mm Hg would result in a 6% reduction in the risk of coronary artery disease and a 15% reduction in risk of stroke and transient ischemic attacks.

This report lays out a step-by-step lifestyle program you can use to lower your blood pressure. It also covers blood pressure monitoring and medications. With the information available today, there is no need for hypertension to be a killer any longer.

Blood pressure basics

You can't see your blood pressure or feel it, so you may wonder why this simple reading is so important. The answer is that measuring your blood pressure gives your doctor a peek into the workings of your circulatory system. A high number means that your heart is working overtime to pump blood through your body. This extra work can result in a weaker heart muscle and potential organ damage down the road. Your arteries also suffer when your blood pressure is high. The relentless pounding of the blood against the arterial walls causes them to become hard and narrow, potentially setting you up for stroke, kidney failure, and cardiovascular disease.

Having your blood pressure measured is a familiar ritual at most visits to the doctor's office. The examiner inflates a cuff around your upper arm, listens through a stethoscope, watches a gauge while deflating the cuff, and then scribbles some numbers on your chart. You may be relieved if you learn your blood pressure is normal or alarmed if the examiner says "180 over 100." But what do these numbers actually mean?

Understanding the numbers

Blood pressure is recorded as millimeters of mercury (mm Hg) because the traditional measuring device, called a sphygmomanometer, uses a glass column that's filled with mercury (whose chemical symbol is Hg) and is marked in millimeters. A rubber tube connects the column to an arm cuff. As the cuff is inflated or deflated, mercury rises and falls within the column (see Figure 1). Although mercury gauges are still considered the gold standard for measuring blood pressure, newer mercury-free devices are available. Many modern instruments use a spring gauge with a round dial or a digital monitor, but even these are calibrated to give readings in millimeters of mercury.

Figure 1: Measuring blood pressure

Measuring blood pressure

A health care professional measures a patient's blood pressure using a stethoscope and a cuff that is inflated until the pressure it exerts is greater than the patient's systolic pressure (the pressure when the heart contracts). The cuff compresses the arm until the brachial artery is squeezed shut. At first, the artery walls will be closed, and the clinician will not hear anything through the stethoscope. As air is released from the cuff, he or she will hear a thump. This is the moment when the clinician records the systolic blood pressure the first and higher of the two numbers in a person's blood pressure. As the cuff pressure continues to drop below the level of systolic pressure, the artery will begin to open and close, and the clinician will hear a thumping noise. When the rhythmic sound disappears, he or she records the diastolic pressure the second, lower figure. As the cuff pressure declines below the diastolic pressure in the artery (the pressure between heartbeats), the vessel remains open, and no further sounds are heard.

The top number, or systolic pressure, reflects the amount of pressure during the heart's pumping phase, or systole. As the heart contracts with each beat, pressure in the arteries temporarily increases as blood is forced through them. The bottom number, or diastolic pressure, represents the pressure during the resting phase between heartbeats, or diastole. Hypertension is defined as having a systolic reading of at least 140 mm Hg or a diastolic reading of at least 90 mm Hg (see Table 1).

How high is high blood pressure? The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), a group of physicians and researchers from across the United States, developed these guidelines for classifying blood pressure in 2003. The figures are based on extensive reviews of the scientific literature and are updated periodically to keep pace with new research. To classify your blood pressure, a health professional averages two or more readings taken after you have been seated quietly for at least five minutes. For example, a patient with a measurement of 135/85 mm Hg on one occasion and 145/95 mm Hg on another has an average blood pressure of 140/90 mm Hg and is said to have stage 1 hypertension. When systolic and diastolic pressures fall into different categories, the JNC advises physicians to rate overall blood pressure by the higher category. For example, 150/85 mm Hg is classified as stage 1 hypertension, not prehypertension. This is also an example of systolic hypertension defined as a systolic pressure of 140 mm Hg or higher and a diastolic pressure below 90 mm Hg. The JNC notes that people in the normal category those with blood pressure below 120/80 mm Hg have the lowest risk of developing cardiovascular disease. Patients in the "prehypertension" category have a greatly increased risk of developing hypertension and should make changes in their lifestyle to reduce the risk. Patients with stage 1 hypertension generally require medication, although aggressive changes in lifestyle sometimes eliminate the need for medication.
Table 1: Current blood pressure categories
Category	Systolic blood pressure (mm Hg)		Diastolic blood pressure (mm Hg)
Normal	Less than 120	and	Less than 80
Prehypertension	120139	or	8089
Stage 1 hypertension	140159	or	9099
Stage 2 hypertension	160 or higher	or	100 or higher

What does blood pressure measure?

Blood pressure reflects both how hard your heart is working and what condition your arteries are in. The formula is as simple as ABC or actually, C A = B. That is, cardiac output times arterial resistance equals blood pressure.

Cardiac output is the amount of blood your heart pumps per minute. With each beat, your heart propels about 5 ounces of blood into the arteries. That adds up to about 4 to 5 quarts over the course of a minute of normal activity. During strenuous activity, your heart must pump considerably more blood to meet your body's increased demand for oxygen.

Arterial resistance is the pressure the walls of the arteries exert on the flowing blood. As blood pushes into the arteries with each heartbeat, it forces the artery walls to expand, much like an elastic waistband stretches to accommodate your body. When the blood flow ebbs, the vessel returns to its original shape. The less flexible the vessels are, the greater the arterial resistance. Narrowed, tightened, or inflexible vessels result in a higher pressure at any level of flow. As cardiac output or arterial resistance increases, so does blood pressure.

Types of hypertension

Physicians classify the different kinds of hypertension based on their causes and characteristics. Following are some of the most common types.

Essential hypertension

About 90%95% of people with high blood pressure have what's called essential hypertension or primary hypertension. This means the condition has no identifiable source. Most experts believe essential hypertension is caused by a variety of factors, many of them as yet unknown. If this hypothesis is correct, it may explain why certain treatments lower blood pressure in some people, but not in others. For example, people who are "salt sensitive" sometimes control their blood pressure with a low-sodium diet alone, while others find sodium intake has little or no influence on their hypertension.

A common problem

There are 690 million people throughout the world with hypertension. Even if you have normal blood pressure at age 55, you have a 90% chance of developing hypertension later in life.

Isolated systolic hypertension

As people age, their arteries tend to lose elasticity and become less able to accommodate blood surges. The damage created in the vessel lining when blood flows through the arteries at high pressure can accelerate plaque buildup. Eventually, plaque deposits lead to atherosclerosis (hardening of the arteries). Atherosclerosis can elevate systolic blood pressure, while diastolic pressure stays in the normal range. A systolic pressure of 140 or greater coupled with a diastolic reading of 89 or below is called isolated systolic hypertension. This is the most common form of high blood pressure in the elderly. The Framingham Heart Study, which has tracked the health of participants since the late 1940s, found that 65%75% of people over age 65 with elevated blood pressure had isolated systolic hypertension.

In the past, doctors considered isolated systolic hypertension to be normal in elderly patients and saw no reason to treat it. However, in 1991, the Systolic Hypertension in the Elderly Program (SHEP) study provided strong evidence to the contrary. SHEP tracked 4,736 patients with isolated systolic hypertension over five years. Half the participants were placed on drugs to reduce blood pressure, while the other half received a placebo. Those taking medication had significantly fewer strokes and heart attacks than the placebo group. The SHEP study has spurred doctors to treat isolated systolic hypertension more aggressively in older patients.

Secondary hypertension

As its name implies, secondary hypertension arises from some other, often treatable, condition.

White-coat hypertension

Stress can elevate blood pressure. For this reason, some people whose blood pressure is usually normal can become hypertensive in the doctor's office. This phenomenon is dubbed white-coat hypertension. In the past, doctors often dismissed these elevated readings as a reflection of the temporary anxiety many people experience at the clinic or hospital. But now some experts think white-coat hypertension is worth investigating because it might shed light on how stress influences blood pressure.

People who are habitually affected by stress whether from losing a job, feeling pressure at work, or simply getting stuck in traffic may develop temporary or longer-lasting hypertension that could inflict some of the same damage as full-time hypertension. By figuring out how these people's blood pressure varies throughout the day, doctors can determine how best to treat them if at all.

To get this information, patients take a portable device home with them and check their blood pressure periodically over the course of a week or two. Another option is a blood pressure monitor and cuff that you wear for 24 hours. The device automatically takes a blood pressure reading every 1530 minutes while you go about your daily activities. This technology may not be covered by insurers, although a Medicare advisory committee recommended in 2001 that Medicare pay for such monitoring for people who are believed to have white-coat hypertension (see "Monitoring blood pressure at home").

Labile hypertension

Labile means ever-changing, and in labile hypertension, blood pressure fluctuates far more than usual. Your blood pressure might soar from 119/76 mm Hg at 10 a.m. to 170/104 mm Hg at 4 p.m. These fluctuations can spring from a variety of sources, such as too much caffeine, anxiety attacks, or stress overload. Whatever the cause, these transient episodes of hypertension can be dangerous and should be treated. As with white-coat hypertension, home blood pressure monitoring over a 24-hour period helps determine the best treatment strategy (see "Monitoring blood pressure at home"). You're most likely to experience labile hypertension when you are in transition from normal to high blood pressure. Its duration can range from a few weeks to many years.

Resistant hypertension

Hypertension is often treated by adopting healthier habits and taking drugs to lower blood pressure, called antihypertensives. The first drug prescribed, however, doesn't always work. Your doctor may have to increase the dose, prescribe an additional drug, or substitute a different drug. Sometimes, though, your blood pressure remains persistently elevated in spite of these efforts.

In some instances, resistant hypertension results from drug interactions. For example, antihypertensive drugs may lose their effectiveness if you're also taking certain antidepressants or even some over-the-counter drugs, such as pain relievers, cold preparations, and diet aids. Use of caffeine, excessive alcohol, or too much licorice (either as candy or as found in some chewing tobaccos) can also contribute to persistently high blood pressure. Other causes include panic attacks, chronic pain, sleep apnea, fluid retention, kidney damage, weight gain, and inflammatory artery disease (arteritis).

Give your doctor as much information as possible about the medications you take, the foods and drinks you consume, and any conditions you may have. There are often simple ways to avoid the interactions that render blood pressure medications ineffective.

Malignant hypertension

Although rare, malignant hypertension is the most ominous form of high blood pressure. It's marked by an unusually sudden rise in blood pressure to dangerous levels, often with the diastolic reading reaching 130 mm Hg or higher. However, it may also occur at lower, seemingly more normal blood pressure levels if the rise is particularly abrupt. Unlike other kinds of hypertension, it's usually accompanied by dramatic symptoms such as severe headache, shortness of breath, chest pain, nausea and vomiting, blurred vision or even blindness, seizures, and loss of consciousness.

Malignant hypertension is a medical emergency. It places people at immediate risk for heart attack, stroke, heart failure, permanent kidney damage, and bleeding in the brain. Anyone who develops the condition must be hospitalized immediately.

Malignant hypertension develops in less than 1% of people who already have high blood pressure. In rare cases, the appearance of malignant hypertension is the first sign that a person has high blood pressure. While the cause of this condition is unknown, you should never stop taking antihypertensives without your doctor's supervision. Doing so might cause a precipitous increase in your blood pressure.

Hypertension during pregnancy

Pre-eclampsia, or hypertension during pregnancy, may appear as early as the 20th week of pregnancy and occasionally as late as one week after delivery. It occurs in about 5% to 8% of all pregnancies. Most cases of hypertension that develop during pregnancy disappear soon after the child's birth. Hypertension that persists is called pregnancy-induced hypertension.

The cause of pre-eclampsia is unknown. Signs of pre-eclampsia include swelling of the hands and face, blood-clotting abnormalities, and protein in the urine. For most women, pre-eclampsia never proceeds beyond the mild stage. For some women, though, the disease develops rapidly, moving from mild to severe in a matter of weeks or sometimes days. Doctors usually recommend bed rest. But if the problem remains or worsens, hospitalization and antihypertensive medications are often necessary to prevent pre-eclampsia from progressing to eclampsia, a serious medical condition. Eclampsia can cause dangerously high blood pressure, seizure, coma, and even the death of the mother, the fetus, or both. Since eclampsia frequently disappears once the baby is born, doctors often induce labor. They may also prescribe anticonvulsant medications. If the woman still has hypertension after giving birth, she may need medication. Little is known about the effects of antihypertensive agents in breast milk, however, so breast-fed infants must be closely monitored.

Are you at risk for hypertension?

Essential hypertension has no known cause. As a result, identifying clear risk factors is difficult. Researchers have discovered a few patterns, however. Some factors you have no control over for example, you can't alter your genes. But others, like smoking and heavy drinking, are habits you can change.

Risk factors you can't change

Even though you can't control these risks, that doesn't mean you can forget about them. Awareness of your risk factors can help you put your overall cardiovascular risk profile into perspective and may provide you with extra incentive to adopt healthier habits.

Controllable risk factors

Your health habits are key factors in determining your cardiovascular risk. In fact, you may be able to bring your blood pressure readings into a safe range simply by making changes in your lifestyle, such as quitting smoking and losing weight.

How hypertension damages your health

Hypertension operates with great stealth. Although it seldom produces symptoms, the intense pounding of blood gradually damages the artery walls. Small arteries are especially vulnerable. The walls respond by thickening and losing their elasticity and strength. As a result, less blood can pass through them, depriving surrounding tissues of oxygen and nutrients. The vessel walls are also more prone to rupture. Eventually, hypertension damages not just the blood vessels themselves, but also the heart, brain, kidneys, and eyes. These are the "target organs" of hypertension (see Figure 5) those most likely to be affected by the disease.

Figure 5: Danger zones

Danger zones

Hypertension can have far-reaching effects. High blood pressure not only harms your arteries and blood vessels, making them stiffer and more narrow, but it can also damage your heart, brain, eyes, and kidneys which, for this reason, are known as the "target organs" of hypertension.

The longer you have hypertension, the greater your chances of developing target-organ damage and, consequently, major diseases such as heart disease, stroke, kidney disease, and eye damage.

African Americans are particularly at risk: Not only are they more likely to develop hypertension, but they are also more apt to suffer from its complications. African Americans with hypertension have higher rates of stroke, heart disease, kidney disease, and diabetes compared with whites with hypertension. African Americans are also more likely to die as a result of hypertension than whites are.

Stroke

Untreated hypertension is the leading cause of stroke, which is the third leading killer in the United States. Two-thirds of people having a first stroke have blood pressures that are higher than 160/95 mm Hg.

An analysis of nine studies, involving a total of more than 420,000 participants, found that the people with the highest diastolic blood pressure (105 mm Hg) were 10 times more likely to have a stroke than those with the lowest diastolic pressure (76 mm Hg). If you have a blood pressure of 160/95 mm Hg, you're about four times more likely to have a stroke than someone with normal blood pressure.

Hypertension can lead to either of the two types of stroke: ischemic stroke, which is caused by a blockage of a brain artery, and hemorrhagic stroke, which occurs when a vessel in or near the brain ruptures.

More than 80% of strokes are ischemic in origin, and atherosclerosis plays an important role in most of these cases. Atherosclerosis is the thickening of the inner layer of artery walls from the buildup of debris such as fats, cholesterol, and dead cells from the bloodstream. This buildup narrows the passageway, diminishing or obstructing blood flow (see Figure 6). A stroke occurs when blood supply to part of the brain becomes cut off by either a clot that has developed on the walls of a brain artery (thrombosis) or a clot that has been swept into the brain artery from somewhere else in the body (embolism).

Figure 6: How plaque buildup narrows arteries

How plaque buildup narrows arteries

High blood pressure can lead to inflammation of the walls of your arteries, which in turn encourages fat to accumulate. This accumulation of fat is known as plaque. As this debris is deposited on artery walls, your arteries become narrower and blood flow is reduced. This thickening of artery walls is called atherosclerosis.

Hypertension is one cause of the initial damage that leads to atherosclerosis. Increased blood pressure damages the vessel walls, causing inflammation. This inflammation, in turn, encourages plaque buildup and narrowing of the arteries. In addition, Framingham Heart Study researchers found an association between high blood pressure and substances that make blood "sticky" and more apt to form stroke-causing clots.

In hemorrhagic stroke, the walls of small arteries become weakened and eventually burst, causing blood to leak into a portion of the brain, ultimately damaging or destroying it. Because hypertension is the most frequent cause of weakened vessel walls, hemorrhagic stroke is most likely to occur in people with high blood pressure. Although every stroke is dangerous, hemorrhagic events are often the most devastating.

A stroke's severity depends on which part of the brain is affected and how large the damaged area is. A mild stroke may cause few or no lasting problems. But approximately one-third of major strokes are fatal, and another third cause permanent damage, such as weakness or paralysis on one side of the body, vision disturbances, impaired speech, and diminished intellect.

Coronary artery disease

By making your blood vessel walls more susceptible to atherosclerosis, hypertension increases not only your likelihood of having a stroke, but also your risk of heart attack. When coronary arteries become completely blocked by a clump of platelets or by debris such as fats, cholesterol, and dead cells, a heart attack results.

Fragments from these deposits, called emboli, can also break away from large blood vessels such as the aorta, travel through the bloodstream, and eventually block other vessels, such as those supplying the legs (causing circulatory problems) or the brain (causing stroke). Having high cholesterol in addition to hypertension only exacerbates this process and increases your risk of cardiovascular complications.

In addition to making atherosclerosis more likely, hypertension also forces the heart to work increasingly harder to drive blood through the body. As a result, the left ventricle, the heart's main pumping chamber, becomes thicker and more muscular in order to contract with greater force. This compensation known as left ventricular hypertrophy (LVH) eventually becomes counterproductive. As the heart muscle enlarges, it needs progressively more oxygen, but the arteries, which are also thickened and narrowed as a result of hypertension, become less able to deliver it. The lack of oxygen can cause angina (chest pain) and, if severe enough, a heart attack.

The combination of LVH and diseased coronary arteries spurred on by hypertension may also lead to congestive heart failure (the inability of your heart to pump blood efficiently throughout your body). In fact, if you have uncontrolled high blood pressure, you're twice as likely to develop heart failure as someone without hypertension.

Unlike your biceps, the thickness of your heart muscle doesn't translate into strength. With LVH, your heart muscle thickens, but your blood supply usually can't swell to the same degree, especially if your arteries are damaged. Without an adequate supply of blood, your heart weakens, and this in turn can lead to either of the two primary kinds of congestive heart failure systolic or diastolic. Systolic heart failure arises when your heart cannot pump forcefully enough to push a sufficient amount of blood into circulation. Diastolic heart failure occurs when your heart can't properly fill with blood because it's stiff and has trouble relaxing.

Symptoms of heart failure include weakness and fatigue (because your muscles aren't getting enough blood), shortness of breath, and the accumulation of fluid in your lungs, feet, ankles, and legs (known as edema).

Dementia

By accelerating atherosclerosis, hypertension can contribute to dementia. Atherosclerosis interferes with circulation, and a lack of blood supply can produce areas of dead tissue in the brain called small infarcts. Multi-infarct dementia, a well-recognized cause of memory loss in older people, is caused by a series of these tiny strokes. Each one affects such a small area of the brain that symptoms may not be apparent until a substantial amount of tissue has been destroyed.

The link between multi-infarct dementia and hypertension escaped attention for many years because people suffering from dementia often have normal or low blood pressure. But long-term studies now show that blood pressure in midlife may predict brain function years later. One example is the Honolulu-Asia Aging Study, which began in the mid-1960s and evaluated the health of Japanese American men over nearly three decades. The participants' average age was 53 at the beginning of the study and 78 at final evaluation. When the researchers compared performance on cognitive function tests and midlife blood pressure, they found a link between poor mental function late in life and high systolic pressure 25 years earlier. There was no link between mental function and diastolic pressure, a finding that underscores the importance of treating isolated systolic hypertension.

Kidney disease

The kidneys play a crucial role in the body's natural control of blood pressure by regulating the amount of water and sodium in circulation. When blood pressure rises, the kidneys excrete water and sodium. This action helps bring pressure back down by stimulating the loss of body fluids (through urination, for example), thereby reducing the volume of circulating blood. When blood pressure falls, the kidneys retain water and sodium to conserve blood volume and raise pressure.

Sustained high blood pressure damages the structures in the kidneys, called glomeruli, which filter waste products, sodium, and water from the bloodstream. Glomerular destruction due to hypertension is one of the most common causes of renal failure (loss of kidney function). People with renal failure become bloated with excessive fluid and weakened by the accumulation of toxic chemicals normally excreted by the kidneys. Uncontrolled hypertension is second only to diabetes as a cause of renal failure, accounting for about one in four new cases.

Eye damage

The eye works by focusing visual images onto the retina, a sheet of nerve tissue at the back of the eyeball. Immediately behind the retina lies a network of tiny blood vessels that keeps this tissue richly supplied with oxygen and nutrients. Hypertension can cause these arteries to narrow or break and bleed into the retina. It can also lead to swelling of the optic nerve, which carries images to the brain. In patients with longstanding, untreated hypertension, the result can be impaired vision and even blindness.

Hypertension and diabetes: A dangerous duo

It's not uncommon for people who have diabetes to also have hypertension. According to a report from the American Heart Association, hypertension is twice as common among people with diabetes as it is among people without. Although the two conditions seem to be linked, the mechanism by which they interact is unclear. Some experts theorize that the common denominator may be problems stemming from the body's production and use of insulin. Like hypertension, diabetes increases your chances of developing heart disease and stroke, as well as kidney disease and eye damage. Having both diabetes and hypertension raises these risks even more.

Over time, most people with diabetes develop cardiovascular problems. Although these are more common among people with type 1 diabetes, they also frequently occur among people with type 2 diabetes who develop the disease after age 40. For instance, atherosclerosis which can elevate systolic pressure (see "Isolated systolic hypertension") is almost 2.5 times more common in people with diabetes than in the general population. People whose diabetes goes untreated are also more likely to have hyperlipidemia (high blood fats).

Between 65% and 75% of people with diabetes will die from some type of cardiovascular disease a death rate that is two to four times that of people without diabetes. Thus, keeping blood pressure in check may be a vital factor in preventing heart disease and strokes among people with diabetes.

Making matters more complicated, diabetes can contribute to high blood pressure. People with both type 2 diabetes and coronary artery disease frequently have hyperinsulinemia, an excessive amount of circulating insulin. Excess insulin is thought to raise blood pressure in two different ways: by causing the kidneys to retain sodium and prompting the sympathetic nervous system to release neurotransmitters that constrict blood vessels.

Not only are diabetes and hypertension linked to cardiovascular disease, but they can also lead to kidney disease and eye damage. That makes careful control of these conditions even more crucial. Because of the marked increased risks associated with hypertension in someone with diabetes, the treatment goal is to lower blood pressure below 130/80 mm Hg. Blood sugar levels should be kept as close to normal as possible. By keeping your blood pressure and blood sugar levels within healthy ranges, you can go a long way toward preventing these complications.

Diagnosing hypertension

As experts have learned more about the causes and consequences of hypertension, their approach to diagnosing it has changed. Since the 1990s, doctors have come to regard systolic hypertension as more significant than previously thought.

Although both systolic and diastolic blood pressures tend to rise and fall together, especially in young and middle-aged adults, diastolic pressure fluctuates less. For this reason, doctors have traditionally focused on the diastolic reading. However, in 2003, the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) published a new classification of blood pressure for adults that states unequivocally that in people over 50, a systolic reading of more than 140 mm Hg is a much more significant factor in cardiovascular disease than the diastolic reading. This was based on a preponderance of research evidence highlighting the significance of systolic pressure. For example, the Framingham Heart Study showed that systolic blood pressure alone correctly identified 91% of those who needed treatment, while high diastolic pressure identified only 22% of individuals needing treatment. In addition, the Systolic Hypertension in the Elderly Program, or SHEP, trial found that drug treatment for high systolic pressure significantly reduced the risk of stroke by 36% and cut heart attack and heart failure rates. In light of these findings, the JNC recommends the following:

No matter what your age, strive to reduce systolic blood pressure to less than 140 mm Hg.
Systolic blood pressure should become the principal focus for the detection, evaluation, and treatment of hypertension, especially in middle-aged and older Americans.
Age-adjusted blood pressure targets are inappropriate. For instance, the general rule that it's acceptable for your systolic blood pressure to be 100 plus your age is incorrect.

Testing for hypertension

To determine whether you have hypertension, a medical professional will take a blood pressure reading. To prevent a false high reading, avoid caffeine, exercise, or smoking for at least 30 minutes and rest quietly for at least 5 minutes beforehand.

A diagnosis of hypertension is seldom based on a single reading, because blood pressure varies throughout the day. So your doctor will want to confirm high measurements on at least two occasions, usually within a few weeks of one another. The exception to this rule is a blood pressure of 180/110 mm Hg or higher, especially if there are symptoms of an underlying disease. A reading this high calls for prompt treatment.

In general, blood pressures between 160/100 and 179/109 mm Hg should be rechecked within two weeks, while measurements between 140/90 and 159/99 should be repeated within four weeks. People in the prehypertensive category (between 120/80 and 139/89 mm Hg) should be rechecked within four to six months, and those with a normal reading (less than 120/80 mm Hg) should be rechecked annually. However, your doctor may schedule a follow-up visit sooner if your previous blood pressure measurements were considerably lower, signs of target-organ damage are present, or you have other cardiovascular risk factors. Also, most doctors routinely check your blood pressure whenever you go in for an office visit.

Monitoring blood pressure at home

Stress, exercise, and even a few drinks the night before your doctor's appointment can push your blood pressure up. So it's often difficult to tell whether an unusually high reading at the doctor's office means you have hypertension or, if you already have high blood pressure, that it's worsening or if that work deadline has temporarily inflated your numbers.

To offset this problem, many doctors encourage people to monitor blood pressure on their own. Home monitoring is especially useful for people with white-coat hypertension or labile hypertension, as well as to track responses to exercise, medications, or changes in treatment.

Most pharmacies have machines that customers can use free of charge, but a home monitor is more practical for taking daily readings. It's possible to spend as much as $70$100 for a sleek machine with extra features you may not need, but if all you want is to track your blood pressure, most drugstores stock a basic unit for less. Your doctor may be able to lend you a blood pressure monitoring unit temporarily. If you need to purchase the equipment for long-term use, your insurance plan may cover the expense.

Treating high blood pressure: An overview

When you first look at them, your blood pressure readings may seem nothing more than a jumble of numbers. Yet your readings do more than indicate whether you have hypertension. They also help determine the course of action you and your doctor should take (see Table 3).

Guidelines released in May 2003 by the JNC, which are summarized here, offer formal guidance on who should be treated and what sort of treatment may be best. The guidelines emphasize the importance of tackling escalating blood pressure earlier rather than later, thereby heading off heart disease, stroke, and kidney damage.

But there's a simpler way to understand blood pressure control: Generally speaking, the lower the better. The consensus among hypertension specialists is that people should do whatever it takes to get their blood pressure numbers down to the healthy range. Whatever works for you is the right strategy to adopt, but it most likely will involve some combination of diet, exercise, stress reduction, and medication.

This report will discuss lifestyle modifications and antihypertensive medications in greater detail on the following pages. First, though, this section provides an overview of recommendations for what to do, depending on which blood pressure category you fall into.

Table 3: Quick guide to hypertension treatment
Category	Systolic blood pressure (top number)	Diastolic blood pressure (bottom number)	What you should do
Normal	Less than 120	Less than 80	Stick with a healthy lifestyle, including following a diet rich in fruits and vegetables and low in salt, using alcohol moderately, and maintaining a healthy weight.
Prehypertension	120139	8089	Change health habits. If you're heavy, lose weight. Reduce salt in your diet. Eat more fruits and vegetables, and get more exercise. Drink alcohol only in moderation. You do not need medication at this stage if you don't have other health conditions. If you have diabetes or kidney disease, begin drug therapy if your blood pressure is above 130/80.
Stage 1 hypertension	140159	9099	Change your health habits and take a blood pressure drug. Many people start with one medication, but may need to go to a second or third to find a treatment that works. If you have other health conditions, you may need a different drug or an additional one.
Stage 2 hypertension	160 or higher	100 or higher	Change your health habits. It's likely that you'll need to take at least two blood pressure medications.
Note: When systolic and diastolic pressures fall into different categories, physicians rate overall blood pressure by the higher category. For example, 150/85 mm Hg is classified as stage 1 hypertension, not prehypertension.

If your reading is normal

If your blood pressure is below 120/80 mm Hg, this is where you want it to stay. If you are already committed to a healthy lifestyle, keep it up. If you've managed to keep within the normal range without much thought about your health habits, you might want to think again. Data from the Framingham Heart Study suggest that even if your blood pressure is normal at age 55, you run a 90% risk of developing hypertension within your lifetime. But a combination of exercise, weight loss, limited salt intake, a diet rich in fruits and vegetables, and limits on alcohol consumption can prevent hypertension (see "Adopting healthier habits").

Prehypertension

You have prehypertension if your systolic blood pressure reading is between 120139, your diastolic pressure is between 8089, or both. The risk of cardiovascular disease begins climbing at pressures as low as 115/75 mm Hg, and it doubles for every 20-point increase in systolic pressure and each 10-point increase in diastolic pressure. If your blood pressure falls into the prehypertension category and you do not have any other risk factors, lifestyle changes are the recommended treatment at this stage.

If you have diabetes or chronic kidney disease, you should begin using antihypertensive medications beginning at pressures of 130/80 mm Hg.

Stage 1 hypertension

You have stage 1 hypertension if your systolic blood pressure is between 140 and159 or your diastolic pressure is between 90 and 99, or both. If you don't have any accompanying conditions such as heart disease, diabetes, kidney disease, or a history of stroke, you will usually start with lifestyle modifications and a single medication. Your doctor may let you try lifestyle modifications alone for two or three months to see if you may be able to avoid medication altogether, but many people find that they need to take some type of medication in order to reduce their blood pressure numbers to healthy levels. You may have to try several drugs to find a combination that works best.

The initial choice of drug may depend on whether you have other health problems such as diabetes, migraine headaches, or cardiac arrhythmias in addition to hypertension. The JNC guidelines also recommend that African Americans, who are at a higher than average risk for hypertension-related complications, start with a two-drug regimen if blood pressure readings top 145/90 mm Hg.

Stage 2 hypertension

You have stage 2 hypertension if your systolic pressure is at least 160 mm Hg, your diastolic pressure is at least 100 mm Hg, or both. In addition to lifestyle modifications, you will probably need to take at least two medications. If this course of action fails to bring your blood pressure down to your target level (below 140/90 for most individuals and below 130/80 for those with diabetes or chronic kidney disease), your doctor may add additional drugs to the mix.

Adopting healthier habits

Adopting a healthy lifestyle which means cutting back on salt, losing excess weight, not smoking, and maintaining a diet high in fruits, vegetables, and whole grains is the cornerstone for preventing and treating hypertension. If you don't have diabetes or damage to the heart, brain, kidneys, or eyes, lifestyle changes alone may be enough to bring a high blood pressure reading into the normal range.

The May 2003 JNC guidelines recommend lifestyle modifications as the best approach for bringing prehypertensive blood pressures (120/80139/89 mm Hg) into a healthy range. In addition, people with stage 1 hypertension (140/90159/99 mm Hg) who don't have any other health conditions can often try making lifestyle changes before resorting to medications. Studies have shown that by making a diligent effort to improve your diet and fitness, you can reduce your blood pressure numbers even without popping a pill (see Table 4).

Table 4: Keeping score
In many cases, studies have documented precisely how much of a reduction in systolic blood pressure you can gain from certain lifestyle changes. Estimates are listed below. Keep in mind, too, that the more lifestyle changes you make, the greater the reduction.
Lifestyle change	What to do	Potential reduction in systolic blood pressure
Lose weight	Reach and maintain a normal body mass index	520 mm Hg for every 22 pounds lost
Adopt the DASH diet	Eat plenty of fruits and vegetables, choose low-fat dairy products, and reduce total fat consumption	814 mm Hg
Reduce salt	Consume no more than 2,300 mg of sodium a day (about 6,000 mg of salt)	28 mm Hg
Exercise regularly	Get at least 30 minutes of moderate aerobic exercise on all or most days of the week	49 mm Hg
Limit alcohol	Have no more than two drinks per day if you're male, or one drink per day if you're female	24 mm Hg
Quit smoking	There is no safe amount of cigarette smoking; if you smoke, try to quit	28 mm Hg*
Source: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, May 2003. *Estimate based on clinical experience.

Journal of the American Medical Association A study published in the lends support to the emphasis on lifestyle changes. Researchers found that many people with hypertension were able to stop taking their blood pressure medications if they reduced their salt intake and lost weight. The trial included 975 volunteers, ages 60 to 80, who were taking blood pressure drugs. The 390 normal-weight participants received either counseling to reduce their salt intake or no dietary advice. The other 585 people, who were overweight, were divided into four equal groups. People in the first three groups were asked respectively to lose weight, reduce salt consumption, or do both. The fourth group received no special instructions. After three months, the researchers began to gradually withdraw the subjects from their blood pressure drugs.

More than two years later, the people assigned to both weight loss and salt reduction were only about half as likely to have high blood pressure, require an antihypertensive drug, or have cardiovascular problems as those who made no changes. People who only lost weight or reduced salt were each a third less likely to have high blood pressure, require an antihypertensive drug, or have cardiovascular problems than those who didn't make any lifestyle changes.

Even if you need to use antihypertensive drugs to control your blood pressure, you should still adopt healthy habits. The lifestyle changes described in the following pages can substantially improve your blood pressure. For example, diet and exercise are an essential part of treatment because they help medications control your blood pressure, making it possible for you to get good results with a lower dosage.

Tips for keeping your high blood pressure in check

Take your blood pressure medication as prescribed. If you experience side effects, talk to your doctor.
Try to maintain a healthy weight.
Increase your physical activity. Do at least 30 minutes of moderate aerobic activity, such as walking, on most days. You can split the session into three 10-minute segments during the day.
Eat foods low in sodium.
Read nutrition labels to determine how much sodium is in packaged foods.
Eat more fruits, vegetables, and whole grains, and choose low-fat dairy foods.
Include foods rich in potassium and calcium in your diet.
If you consume alcohol, do so moderately.
If you smoke, quit.
Reduce your stress.
Tell your family and friends you have high blood pressure, especially the person who prepares the meals.

Source: National Heart, Lung, and Blood Institute.

Eat well

Hypertension, stroke, and heart disease are common in the United States and most other Western industrialized nations. Epidemiologists attribute much of their prevalence to diet. After decades of research, scientists have concluded that the typical American diet is a recipe for hypertension and cardiovascular disease: too much salt, too much saturated fat, too many calories, and not enough fruits and vegetables. But the good news is that you can take an active role in preventing and controlling high blood pressure by watching what you eat.

Quit smoking

When it comes to heart disease and blood pressure, smoking packs a devastating wallop. Nicotine raises your blood pressure, lowers "good" HDL cholesterol, reduces your body's supply of oxygen, and makes blood clots more likely.

It is difficult to quit smoking, despite all the health reasons to do so, because this habit is psychologically and physically addictive. Smoking cessation programs primarily address the psychological facets of addiction by helping participants change ingrained behaviors. Nicotine replacement systems such as patches, chewing gum, and nasal sprays target physical craving by delivering the addictive substance in another form, allowing the user to taper off gradually and minimizing withdrawal symptoms. According to the American Lung Association, research has found that using a nicotine replacement product and participating in a smoking cessation program doubles your chances of successfully quitting.

Quitting isn't easy, but it offers enormous benefits. Within hours of stopping smoking, your heart rate and blood pressure decrease. Within a year of quitting, your heart disease risk is cut in half. Within 15 years of giving up smoking, your risk of heart disease is close to that of nonsmokers.

Cut back on alcohol

Heavy drinking increases blood pressure and interferes with blood pressure medication. Drinking has dietary drawbacks, too. For people battling their weight, alcohol adds "empty" calories with no nutritional value. A bottle of beer contains 146 calories (100 calories if it's light beer), and a glass of wine has 123 calories. Some mixed drinks add fat and cholesterol, too. Eggnog with brandy, for example, serves up 288 calories with 6 grams of saturated fat, 11 grams of total fat, and 84 mg of cholesterol.

On the other hand, modest alcohol consumption has different effects. Numerous studies have shown that people who drink in moderation are at significantly lower risk for coronary artery disease than those who don't drink. Moderate alcohol use for men is defined as no more than 1 ounce of alcohol (two drinks) a day. However, women absorb more alcohol than men and should limit their daily intake to half an ounce (one drink). Small or underweight people are more susceptible to the effects of alcohol than heavier people and should consume no more than half an ounce daily (see "How much alcohol is in your drink?").

How much alcohol is in your drink?

The following drinks each contain about an ounce of alcohol:

1 ounce of 100-proof liquor
1½ ounces (a jigger) of 80-proof liquor (bourbon, gin, rum, scotch, tequila, vodka, or whiskey)
3 ounces of fortified wine (sherry, port, marsala, or Madeira)
4 to 5 ounces of table wine
12 ounces of regular or light beer

Be active

Not only does regular exercise help prevent high blood pressure (see "Sedentary lifestyle"), but it's also a proven treatment for existing hypertension.

The American College of Sports Medicine reviewed 40 studies on the effect of exercise on blood pressure. With regular aerobic exercise, participants were able to reduce their systolic and diastolic pressures an average of 11 and 9 mm Hg, respectively. Although many studies focused on high-intensity exercises like running, several evaluated the impact of moderate activities such as walking. Surprisingly, moderate-intensity training provided the same or even better blood pressurelowering benefits. Exercise is also beneficial to people with hypertension because it may prevent plaque buildup in the arteries and makes clots less likely. Furthermore, exercise helps strengthen muscles and bones, control weight, and improve mood and mental functioning.

Need more reasons to get up and moving? In a study of severely hypertensive African American men, 10 of the 14 who rode a stationary bike for 45 minutes three times a week were able to lower their dosage of antihypertensive drugs at the end of the 32-week trial. In addition, echocardiograms showed that thickness of the heart wall had diminished in all the men who exercised. A thickened heart wall, known as left ventricular hypertrophy, raises your risk of stroke, abnormal heart rhythm, and heart attack.

Study after study has shown that aerobic exercise walking briskly, running, or cycling provides a host of other health benefits, including weight loss and reduced cholesterol levels.

While aerobic activity is most commonly associated with cardiovascular health, strength training exercises, such as lifting weights and doing resistance-band workouts, is also great for your heart and overall health. In the past, doctors were hesitant to recommend strength training for hypertensive patients because this type of exercise elicits a short-term spike in blood pressure. But information from the American Heart Association suggests that moderate, comfortable resistance exercises are safe and beneficial.

You can start to do strength training exercises by using resistance bands, small hand weights, weight machines, or even your body's own weight. Generally speaking, you should aim to perform one or two sets of 8 to 12 repetitions of each exercise find a weight that's challenging but manageable.

Experts recommend that you get at least 30 minutes of moderate physical activity on all or most days of the week. Longer sessions can yield even greater health rewards. But it's important to start any exercise program slowly and to gradually build up the intensity level and length of sessions. People with heart disease or other health problems should consult their doctors before starting an exercise program.

Attain a healthy weight

Not only can being overweight raise your blood pressure (see "Obesity"), but it can also increase your risk for diabetes, arthritis, sleep apnea, and some cancers. Achieving and maintaining a healthy weight is an important step in fighting these and many other illnesses.

People with hypertension who are more than 10% over their ideal weight may be able to reduce their blood pressure by weight loss alone. According to the JNC report, you can reduce your systolic blood pressure by 5 to 20 mm Hg for every 22 pounds you lose (see Table 4). A smaller weight loss can have an effect, too. Losing as few as 10 pounds can reduce your blood pressure.

Stress less

Even though it's vital to survival, stress has a bad reputation. When you perceive stress, your sympathetic nervous system triggers the "fight or flight" response to prepare your body for action. A release of hormones quickens your heart rate and breathing, and extra blood is pumped to your muscles and organs to provide them with a burst of energy. Stress keeps drivers alert, helps students excel, and spurs competitors to win. But ongoing stress has harmful long-term effects, including raising your blood pressure.

If you are often tense, the following stress reduction strategies can help.

Get enough sleep. Lack of sound sleep can affect your mood, mental alertness, energy level, and physical health.

Exercise. Physical activity alleviates stress and reduces your risk of becoming depressed.

Learn relaxation techniques. Meditation, progressive muscle relaxation, guided imagery, deep breathing exercises, and yoga are the mainstays of stress relief. Your local hospital may offer meditation or yoga classes, or you can learn about these techniques from books or videotapes. To get started, try a quick relaxation exercise (see "Quick stress relief exercises").

Quick stress relief exercises

When you've got one minute. Place your hand just beneath your navel so you can feel the gentle rise and fall of your belly as you breathe. Breathe in. Pause for a count of three. Breathe out. Pause for a count of three. Continue to breathe deeply for one minute, pausing for a count of three after each inhalation and exhalation.

When you've got three minutes. While sitting down, take a break from whatever you're doing and check your body for tension. Relax your facial muscles and allow your jaw to fall open slightly. Let your shoulders drop. Let your arms fall to your sides. Allow your hands to loosen so that there are spaces between your fingers. Uncross your legs or ankles. Feel your thighs sink into your chair, letting your legs fall comfortably apart. Feel your shins and calves become heavier and your feet grow roots into the floor. Now breathe in slowly and breathe out slowly. Each time you breathe out, try to relax even more.

When you've got 10 minutes. Try imagery. Start by sitting comfortably in a quiet room. Breathe deeply and evenly for a few minutes. Now picture yourself in a special place. Choose an image that conjures up good memories. What do you smell the heavy scent of roses on a hot day, crisp fall air, the aroma of baking bread? What do you hear? Drink in the colors and shapes that surround you. Focus on sensory pleasures: the swoosh of a gentle wind, the soft cool grass tickling your feet. Passively observe intrusive thoughts and then gently disengage from them to return to the world you've created.

Harvard Medical School Guide to Lowering Your Blood Pressure You may also want to explore a more integrative approach to stress management known as the "relaxation response," a term coined by Dr. Herbert Benson of the Mind/Body Medical Institute. The relaxation response is the opposite of the stress-induced fight or flight response, and it is elicited by daily practice of relaxation and meditation. As its name implies, the relaxation response is characterized by a slowing of the breathing and heart rates, lowering of blood pressure, and a calm state of mind. It is so effective at reducing blood pressure over the long term that a one study even suggests that it may help some patients reduce or even eliminate their need for antihypertensive medications (see "Can you reduce your need for medication?"). For more information on the relaxation response, refer to the (see "Resources").

Strengthen your social network. Studies show that social ties significantly protect health and well-being. Try to connect with others by taking a class, joining an organization, or participating in a support group.

Learn time-management skills. These skills can help you juggle work and family demands.

Confront stressful situations head-on. Don't let stressful situations fester. Hold family problem-solving sessions and use negotiation skills at work.

Nurture yourself. Treat yourself to a massage. Truly savor an experience: Eat slowly, focusing on each bite of that orange, or soak up the warm rays of the sun or the scent of blooming flowers during a walk outdoors. Take a nap. Enjoy the sounds of music you find calming.

Talk to your doctor. If stress and anxiety persist, talk to your doctor about whether anti-anxiety medications could be helpful.

Acupuncture for hypertension?

Acupuncture is one of the oldest known forms of health treatment. Believed to have originated in Asia more than 2,500 years ago, acupuncture involves inserting fine needles into the skin at various points along what are believed to be pathways ("meridians") for a form of energy known as "chi." According to acupuncture theory, health problems are the result of blocked chi flow, and inserting the acupuncture needles helps to restore the flow and restore health.

Some small studies and anecdotal reports have suggested that acupuncture might be helpful for people with hypertension. Now the results of a pilot clinical trial are in and the outcome may disappoint proponents of acupuncture.

Hypertension, The SHARP (Stop Hypertension with the Acupuncture Research Program) trial involved 192 participants whose untreated blood pressure was between 140/90 mm Hg and 179/109 mm Hg. Participants first had their medications reduced and eliminated, and were then randomly assigned to one of three groups: two that received different forms of acupuncture treatment, and one that received the acupuncture equivalent of a placebo ("sham acupuncture"). The participants received up to 12 treatments over six to eight weeks. At the end of that time, reported the investigators in 2006 in the journal there was no significant change in blood pressure between those who received sham acupuncture and those who received the real version.

www.medicalacupuncture.org Even so, there may be a role for acupuncture in helping some people with hypertension. Studies have shown that acupuncture is effective for treating some forms of chronic pain and depression, both of which can have a negative effect on blood pressure and overall health. In this way acupuncture may be an effective "back-door" treatment. Before you consider integrating acupuncture, make sure you find a qualified, experienced practitioner. The American Academy of Medical Acupuncture () keeps a directory of qualified acupuncturists by location.

Medications for treating hypertension

Doctors once hesitated to prescribe medication for patients with blood pressure below 159/99 mm Hg, which was once deemed "mild hypertension," because they didn't consider that level dangerous. Many doctors worried that the drugs' potential side effects might outweigh their benefits. Both of these perceptions turned out to be false. Research has firmly established the value of treating stage 1 hypertension (140/90 to 159/99 mm Hg) with drugs, if necessary.

For those with diabetes or kidney disease, medications may be necessary at pressures as low as 130/80. And today, blood pressure can be controlled with lower doses of medications, meaning there is less chance of side effects.

Doctors can choose from an abundant selection of antihypertensive medications, including many preparations that combine one or more drugs. Many newer antihypertensive drugs have a slightly different chemical structure from older drugs but produce nearly identical effects in the body. Others act in entirely different ways. Doctors can tailor treatment to the individual patient and can often prescribe a drug that controls blood pressure, produces few or no side effects, and, hopefully, protects against complications. In addition, it's often possible to use a single medication to treat both the hypertension and accompanying medical problems, like congestive heart failure.

It's also important to understand that no single drug is "superior" to the others. Blood pressure control is ultimately a numbers game: The value of any antihypertensive drug is judged on an individual basis, depending on how significantly the medication reduces blood pressure for the person who takes it.

Experts recommend starting any antihypertensive drug at the lowest possible dose and gradually increasing it until blood pressure sinks to a normal level. If the drug causes troublesome side effects, it should be replaced with a different medication.

The usual course of treatment for stage 1 hypertension is to begin with one drug and add a second if your blood pressure does not fall to desired levels (usually less than 140/90 mm Hg; less than 130/80 mm Hg for those with diabetes or chronic kidney disease). You may have to try several medications before you find a drug, or a combination, that works. The treatment for stage 2 hypertension often begins with a two-drug combination. Additional drugs may be added if your blood pressure doesn't drop to an acceptable level. With all stages of hypertension, and even prehypertension, lifestyle changes are also an important component of treatment.

The JNC found that blood pressure can be adequately controlled in most people with hypertension, but many individuals will need two or more medications to get their blood pressure in check. Poor blood pressure control can result if the doctor doesn't encourage lifestyle changes, prescribe adequate doses of medications, or add additional medications as needed.

Fast fact

In the United States, 71% of adults with hypertension don't have their blood pressure under control.

Classes of hypertension drugs

Doctors can choose from several classes of antihypertensive drugs: diuretics, anti-adrenergics, direct-acting vasodilators, calcium-channel blockers, angiotensin-convertingenzyme (ACE) inhibitors, and angiotensin II receptor blockers. In addition, researchers are testing three potent classes: direct renin inhibitors, endothelin receptor antagonists, and vasopeptidase inhibitors. With so many choices available, which medication should you and your doctor choose? The JNC recommends that most people with hypertension start with diuretics, but many experts disagree with this advice (see "The right drug for the right person"). In light of the controversy, it's wise to talk to your doctor about which medications are best for you.

The right drug for the right person

If you can't control your blood pressure by adopting healthier habits such as limiting salt, increasing exercise, and quitting smoking then it's time for medications. Although the JNC recommended thiazide diuretics as the first medications to try, several studies have provided evidence that other drugs might be better choices, especially if you have other health conditions. For instance, diabetes and heart disease often accompany hypertension, and newer drugs, such as ACE inhibitors or angiotensin receptor blockers, perform double duty by helping to treat these conditions while lowering blood pressure.

Several major studies have attempted to differentiate among the many categories of hypertension drugs, to determine which are best and under what circumstances. For example, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) examined blood pressure control and cardiovascular events in more than 42,000 men and women, ages 55 and older, who had mild to moderate hypertension. For five years, the participants took one of three drugs: chlorthalidone (a diuretic), amlodipine (a calcium-channel blocker), or lisinopril (an ACE inhibitor).

Journal of the American Medical Association The findings were reported in 2002 in the . To many people's surprise, the diuretic seemed to perform as well as or slightly better than the newer drugs in controlling blood pressure and preventing complications such as stroke and heart failure. These results and the low cost of diuretics prompted the JNC to recommend thiazide diuretics as the first line of treatment for most people with hypertension. And a 2005 subgroup analysis of the ALLHAT data found that diuretics were just as effective for people with diabetes as they were for the other study participants.

Even so, the consensus is growing that diuretics are not always the best first choice, especially for people with certain health problems, including diabetes, kidney disease, or heart failure. Two studies in particular indicate that there is no one-size-fits-all recommendation when it comes to picking the right blood pressurecontrol drug regimen.

Lancet, The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) involved more than 19,000 people with hypertension who were between the ages of 40 and 79. ASCOT was designed to see whether using a combination of two drugs a calcium-channel blocker (amlodipine) with an ACE inhibitor (perindopril) added, if necessary was better at preventing heart attack and stroke than the more traditional approach of using a beta blocker (in this case, atenolol; brand name Tenormin) with a thiazide diuretic added, if necessary. As reported in 2005 in the researchers found that the amlodipine-perindopril combination reduced the risk of major cardiac events (such as heart attacks) by 16%, the risk of stroke by 23%, and the risk of dying from cardiovascular disease by 24% more than the older drug combination.

However, experts have cautioned against interpreting this study as evidence that the newer drugs trump the old. Instead, the picture is more complex. One clear take-home message is that lowering blood pressure in whatever way you can provides real benefits: People who took the calcium-channel blockerACE inhibitor combination lowered their systolic blood pressure by an average of 2.7 mm Hg more than people taking the beta blockerdiuretic combination and some experts think that perhaps the blood pressure reduction helps explain the reduction in heart disease risk. Second, the calcium-channel blockerACE inhibitor combination significantly lowered the risk of developing diabetes, and may have had other heart-healthy benefits as well a reminder that tackling multiple risk factors at once is good for your heart.

Indeed, this two-pronged message about the value of lowering blood pressure while also reducing diabetes risk was also underscored by the 2004 Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial. The VALUE trial compared valsartan (an angiotensin II receptor blocker) to the calcium-channel blocker amlodipine in order to determine which was better at reducing the risk of cardiovascular events such as heart attack and stroke. The study involved more than 15,000 hypertensive patients ages 50 and older who were at high risk of cardiovascular problems because of underlying disease or a history of heart attack or stroke.

As with the ASCOT trial, the VALUE study results were complicated. On the one hand, the calcium-channel blocker lowered blood pressure more significantly than the angiotensin II receptor blocker, especially initially: In the first few months of the study, amlodipine lowered systolic blood pressure by 4 mm Hg more than valsartan, while beyond six months, it lowered systolic blood pressure by a less dramatic but still significant 2 mm Hg. Amlodipine also significantly reduced the risk of suffering a heart attack. But the people who took valsartan were less likely to develop diabetes. And in a surprise both drugs provided the same protection against actually dying from a heart attack.

Clearly the ASCOT and VALUE studies both underscore the importance of controlling blood pressure to reduce the risk of heart attack and stroke. But these two trials have led experts to question the JNC's advice to start with thiazide diuretics. It now appears that people should use whatever drug is most likely to work for them, given their other cardiac risk factors. In particular, both the ASCOT and VALUE trials provide additional evidence that reducing your risk of diabetes may also help protect you against cardiac events.

So what do all of these studies mean for you? To put it simply, there is clearly no cookie-cutter approach to protecting yourself from cardiovascular disease. Designing an effective medication program for hypertension is like fitting together the pieces of a jigsaw puzzle. Matching the benefits and side effects of the dozens of available drugs to a particular person's risk factors, health conditions, and lifestyle considerations is often a trial and error process. What may work well for your neighbor or cousin may not be right for you. It may take some time to find a medication that offers you the best blood pressure control with the fewest side effects.

So talk with your doctor about which medications are best for you. The best regimen is one that's tailored to your needs and is based on your medical history, any coexisting diseases, your preferences about how and when to take medications, and your concerns about side effects. The general recommendations for particular subgroups of people, found in the following pages, may also be helpful.

Tips to help you remember to take your blood pressure medicine

Take your medicine after you brush your teeth. Keep it with your toothpaste as a reminder.
Put "sticky" notes in visible places to remind yourself.
Use a weekly pillbox to store your medicines so you can see at a glance whether you've taken the current day's dose.
Keep your medicine on the nightstand next to your bed to remind yourself to take your evening medications.
Ask a friend or relative to call your telephone answering machine to remind you to take your medicine; then don't erase the message.
Establish a buddy system with a friend who also takes a medication each day.

Glossary

aldosterone: A hormone secreted by the adrenal glands that signals the kidneys to conserve sodium and water; the result is higher blood pressure.

angiotensin: A protein that increases blood pressure by constricting blood vessels and stimulating the release of aldosterone. The inactive form is angiotensin I, and the active form is angiotensin II.

antihypertensives: Medications used to treat high blood pressure.

arterial resistance: The pressure that the artery walls exert on blood flow; in general, the less elastic the arteries, the greater the arterial resistance and the higher the blood pressure.

atherosclerosis: Thickening of the inner layer of artery walls from the buildup of debris, such as fats and cholesterol, from the bloodstream; this narrows the passageway and diminishes blood flow.

autonomic nervous system: The part of the nervous system that controls involuntary processes, such as heartbeat and breathing. Its two arms are the sympathetic and parasympathetic nervous systems.

coronary artery disease: Narrowing or blockage of the arteries that supply blood to the heart muscle. The condition can cause angina and heart attack.

diabetes: A disorder in which blood glucose (sugar) levels are elevated.

diastolic pressure: The second (bottom) reading of a blood pressure measurement, which reflects the pressure in the arteries between heartbeats.

epinephrine: A chemical released by the sympathetic nervous system that constricts blood vessels and increases heart rate; also called adrenaline.

essential hypertension: High blood pressure for which there is no known underlying cause; also called primary hypertension.

heart failure: A condition in which the heart loses its ability to efficiently pump blood throughout the body.

isolated systolic hypertension: A form of hypertension characterized by elevated systolic blood pressure and normal diastolic pressure.

labile hypertension: Blood pressure that frequently fluctuates between normal and abnormal during the course of a day, often within only a few minutes.

left ventricular hypertrophy: Thickening of the left ventricle, the chamber of the heart that pumps blood to the body.

malignant hypertension: A dangerous type of hypertension marked by an unusually sudden rise in blood pressure to very high levels, often accompanied by headache, blurred vision, and seizures.

neurotransmitters: Chemicals released by nerve cells that transmit messages to other nearby cells.

norepinephrine: A neurotransmitter that constricts blood vessels.

pulse pressure: The difference between your systolic and diastolic blood pressures; this measurement may help predict heart disease risk.

renal artery stenosis: Narrowing of an artery that supplies blood to the kidney.

renin: An enzyme released by the kidney that stimulates production of angiotensin.

resistant hypertension: Blood pressure that remains persistently elevated despite drug therapy and lifestyle changes.

secondary hypertension: High blood pressure that has an identifiable, often correctable, cause.

systolic pressure: The first (top) number of a blood pressure measurement, which reflects pressure in the arteries when the heart contracts.

vasoconstrictors: Substances that constrict blood vessels.

vasodilators: Substances that widen blood vessels.

white-coat hypertension: Blood pressure elevations that occur in response to visits to a doctor's office.

Resources

Organizations

American Heart Association www.americanheart.org 7272 Greenville Ave. Dallas, TX 75231 800-242-8721 (toll free)

This nonprofit organization publishes pamphlets and booklets on preventing and treating hypertension, all at no charge or for a nominal fee. The organization also operates a consumer hotline to answer general questions on heart health.

American Society of Hypertension www.ash-us.org 148 Madison Ave., Fifth Floor New York, NY 10016 212-696-9099

This is the largest U.S. organization devoted solely to the awareness, prevention, and study of hypertension and related cardiovascular diseases. The organization maintains a list of hypertension experts around the country. Educational materials about high blood pressure and links to other hypertension organizations are available on the Web site.

International Society on Hypertension in Blacks, Inc. www.ishib.org 100 Auburn Ave. NE, Suite 401 Atlanta, GA 30303 404-880-0343

This organization, originally focused on hypertension in African Americans, provides information on preventing, recognizing, and treating most types of cardiovascular disease, especially in ethnic populations. Write for free brochures.

National Heart, Lung, and Blood Institute (NHLBI) Information Center www.nhlbi.nih.gov P.O. Box 30105 Bethesda, MD 20824 301-592-8573

This division of the National Institutes of Health (NIH) supports research, training, and education in the prevention, diagnosis, and treatment of cardiovascular disease. Its Web site provides a wealth of materials on hypertension, diet, and exercise, as well as JNC guidelines.

National Hypertension Association www.nathypertension.org 324 E. 30th St. New York, NY 10016 212-889-3557

This organization, dedicated to hypertension research, education, and detection, publishes brochures on hypertension, nutrition, and healthy lifestyles. Write or call to order publications.

Publications

The Harvard Medical School Guide to Lowering Your Blood Pressure Aggie Casey, R.N., M.S., and Herbert Benson, M.D., with Brian O'Neill (McGraw Hill, 2006, 187 pages)

This book emphasizes lifestyle approaches to controlling blood pressure. It provides advice on nutrition, stress reduction, and exercise, and how to create a personalized program that is right for you.

The Healthy Heart: Preventing, Detecting, and Treating Coronary Artery Disease Thomas H. Lee, M.D., and Harvey B. Simon, M.D., Medical Editors (Harvard Health Publications, 2005)

This report provides everything you need to know about the risk factors for coronary artery disease, including high blood pressure, and what you can do to reduce your risk. It discusses dietary changes, medications, surgeries, and screening tests.

Review Date: 2007-01-01

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