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ByPaul J. Rosch, M.D.
President, The American Institute of Stress
Clinical Professor of Medicine and Psychiatry
New York Medical College
Originally published in the Health and Stress newsletter(July) of TheAmerican Institute of Stress
Up until a few weeks ago, if you asked anyone, including doctorswhat they considered a normal or desirable adult blood pressureto be, 120/80 would have been the most frequent response. Not anymore. According to the new JNC-7 guidelines, 120/80 puts you ina new disease category called "prehypertension" and atincreased risk for heart attack, stroke, or kidney disease. Therecommendations for rectifying this potentially deadly disorderare the usual advice to lose weight, avoid salt and sodium richfoods, exercise regularly, stop smoking and reduce stress. However,we all know how difficult it is to achieve these goals, much lessmaintain them. And even if you do, the results are not that rewarding,even for patients with blood pressures of 160/100 and higher.
People with prehypertension are even lesslikely to find that lifestyle modification will normalize theirblood pressure, which means that medication will be required. Chalkanother one up for the drug companies.
The first advice generally given to all patients with high bloodpressure is to significantly restrict sodium intake. However, thevast majority fail to respond to this unless they have certain genetictraits. In some, calcium deficiency can be the culprit and theyimprove with calcium supplementation. These individuals may actuallyworsen on a low sodium regimen since this would sharply reduce theintake of dairy products that are the major source of dietary calcium.Others benefit from potassium and/or magnesium supplements. Joggingand running may help lower blood pressure for some people but moreoften has little effect and can even cause a rise.
Hypertension, like fever, is not a diagnosislike diabetes, but rather a description. It is simply an elevatedblood pressure reading on some measuring device that can have manydifferent causes. That helps to explain why we have some 100 drugsto treat high blood pressure. Unfortunately, there isno algorithm to guarantee which one will work best or be the safestfor any specific patient. Similarly, a fever of 103° in a patientwith lupus may require giving cortisone but if that identical 103°temperature reading were due to tuberculosis, cortisone could bringthe fever down but might prove lethal. Conversely, appropriate antibioticswould be an effective treatment for tuberculosis but would providelittle benefit in lupus.
Risk Factors And Other Fallacies
In order to successfully treat a disease it is necessary to removeor reduce its cause rather than its manifestations or markers. Treatinga persistently elevated blood pressure or temperature is very differentthan treating an elevated blood sugar. While the goal in diabetesis to lower the blood sugar to normal, responses to medication and/ordiet are much more predictable and sustained since the cause canalmost always be identified.
An elevated temperature can be a purposeful physiologic responseto stimulate immune system defenses. Hyperthermia due to artificiallyinduced fever has been used to treat erysipelas, tuberculosis, neurosyphilisand certain malignancies. Giving non-specific drugs just to bringan elevated temperature down to normal could do more harm than goodin certain situations.
The same may apply to many older individualswith arteriosclerotic vessels, where a higher blood pressure isneeded to maintain adequate blood flow to the kidneys and othervital organs. Whatever happened to the good old dayswhen a normal systolic pressure was 100 plus your age? Not everyoneagrees with this and the upper limit is now usually considered tobe 140/90, even for people over 70.
Nevertheless, some senior citizens will consistently complain ofweakness and dizziness if their blood pressures are lower than the120/80 value that is now recommended. This is particularly truefor women, who normally tend to have higher blood pressures thanmen in this age group.
Much of this "one-size-fits-all" approach comes fromconfusion over what a "risk factor" really represents.Most risk factors for heart disease are merely "risk markers"that simply have some statistical association with an increasedincidence of coronary events. There are over 300 risk factors forheart attacks, including a deep earlobe crease, premature vertexbaldness, high selenium toenail levels, having a pot belly, nothaving a nap or one or two glasses of wine a day.
Attempting to treat or remove such markers will accomplish nothingsince they do not cause coronary disease. The same can be true forlowering an elevated systolic or diastolic blood pressure unlessthe treatment is directed at what is causing the problem, whichis usually not clear. No randomized clinical trials have ever proventhat lowering an elevated systolic blood pressure to 140 reducesthe risk for death due to coronary disease.
A good example of this was the multicenter Multiple Risk FactorTrial (MRFIT) designed to demonstrate that reducing hypertension,high cholesterol and smoking would lower coronary mortality. Afterscreening some 350,000 middle-aged men, close to 13,000 believedto be at greater jeopardy because of a preponderance of these putativerisk factors were selected. They were divided into a treatment groupto lower these markers and a control group that received usual care.
After 10 years and $115 million, although the treatment group substantiallyachieved their objectives, they fared no different than controlswho received usual care. In point of fact, asubset of hypertensives treated with diuretics had the highest mortalityrates, probably from ventricular fibrillation due topotassium depletion. The MRFIT objective was to get blood pressuresbelow 140/90. One can only wonder what the mortality rate wouldhave been if under 120/80 had been the goal.
Stress and Pseudohypertension
My personal experience has been that a significant percentage ofpatients being treated for "essential hypertension" canstop their medication without any adverse effects. When such individualsare admitted to the hospital for surgery or some unrelated conditionand these drugs are discontinued deliberately or inadvertently,it is not unusual for blood pressures to fall to normal levels andremain there, only to rise again after discharge. Stress relatedor "white coat" hypertension is quite common. In one studypublished in the Journal of the American Medical Association, morethan one in four patients with elevated blood pressures in the doctor'soffice were found to have normal values on ambulatory monitoring.All were taken off drugs with no adverse effects.
Decades ago, when healthy young men being examined for insurancepolicies or entry into the armed services had high readings butno retinopathy, albuminuria or other indication of sustained hypertension,we used to reassure them and have them lie down and relax in a quietroom. After 15 or 20 minutes, repeated measurements were invariablymuch lower and usually normal.
Busy doctors don't have time for thattoday. It's much easier and safer for them to prescribe a pill,since everyone knows that hypertension is the "silent killer".In addition, treating hypertension is easy, doesn't take much timeor energy and is apt to be quite remunerative since periodic electrocardiogramsand chest X-rays to monitor cardiac size and laboratory tests arereadily justified. Only a few questions need to be asked, the patientoften does not need to disrobe in an examining room and the entireencounter often takes less than ten minutes.
A not uncommon scenario is that when the patient returns afterthe initial diagnosis of hypertension has been made and a medicationhas been prescribed, he or she is even more nervous, blood pressureis still high or higher and the dose is increased. This may be repeatedon subsequent visits and/or additional drugs are ordered. The resultmay be dizziness or other side effects that the patient now attributesto a worsening of hypertension, causing even more stress.
It is also not generally appreciated thatheart rate and blood pressure shoot up whenever we speak or tryto communicate in some other way. The seminal investigationsof this phenomenon have been done by Jim Lynch who showed that suchelevation are greater if we are talking to someone of perceivedhigher social stature, more rapidly than usual, and if the contentof the conversation deals with some important personal issue. Bloodpressure rises in deaf mutes when they use sign language but notwhen they move their hands meaninglessly but with the same amountof energy. The only time this does not occur is in schizophrenicpatients off of medication, possibly because they no longer communicate.
I have been involved in this research with Jim for over 25 years.Although these transient spikes in both systolic and diastolic pressurecan be alarmingly high, patients are completely unaware of thisand have no symptoms. By using an automated blood pressure devicethat displays systolic, diastolic and mean arterial pressure ona monitor, it is possible to teach patients how to lower their pressures.
We have also found that these rises are not blunted by any antihypertensivedrugs and are actually exaggerated by beta blockers. It is not uncommonfor anxious patients to talk immediately prior to or even whilethe doctor is inflating the cuff, which can increase blood pressureup to 50 percent in some people. There is no good evidence thatsuch hyperreactivity is associated with any increased incidenceof sustained hypertension. The same is true for eliteweight lifters, who can have pressures of 400/250 or higher whenthey perform the supreme Valsalva maneuver.
Another source of pseudohypertension isthat the same size cuff is used for all adults, which can causesignificantly false high readings in fat arms. The widthof the cuff should be 40 percent of the circumference of the arm.This is important because of the large number of obese people andothers who are engaged in body building activities. Time of day,room temperature, a full bladder, eating, drinking or smoking withinthe past hour, standing, sitting or supine can all influence measurements.
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