Hypertension and Controlling Blood Pressure

by Cecilia Mullen, R.N.C., N.P.

September 29, 2000

What is blood pressure?

Blood pressure is the force created by the heart as it pushes blood into the arteries through the circulatory system. Each time the heart beats, blood is pumped out and creates a surge of pressure. This is called the "upper" or systolic pressure. When the heart relaxes between beats the blood pressure goes down. This is called the "lower" or diastolic pressure.

Blood pressure is measured with a sphygmomanometer and is recorded in two numbers: systolic over diastolic; such as 120/80.

Blood pressure varies from moment to moment throughout the day. If you're excited or frightened or are exercising, your heart beats faster and harder than usual, which increases your blood pressure. That is normal.

Some people have high blood pressure. That means their blood pressure goes up and stays there. This is called hypertension. 

How are blood pressure education programs helpful?

Since the inception of hypertension education programs, the stroke mortality rate in the U.S. has declined by 40 percent. Progress has been made in improving the public's awareness and knowledge about hypertension and its adverse effects. However many people with hypertension do not stay on therapy and have not controlled their blood pressure. Only 35 percent of hypertensives are under control. Hypertension remains an important health problem. One half of the patients with hypertension discontinue therapy within one year. Of those who continue therapy, less than one-half adhere to therapy for more than a few years. Therapy involves complex behavior changes. Hypertension control begins with detection and requires continuous surveillance.

What causes hypertension?

Arterioles narrow and blood has difficulty passing through them. The heart pumps harder and increases blood pressure. Several factors contribute - heredity, obesity, lack of exercise, salt.

Evaluation at office

Prevention of Organ Disease

A. Cardiac

B. Cerebrovascular - brain

Factors you can control

Factors you cannot control

Cigarette smoking 

Age  

High cholesterol; total and LDL

  > 45 years men   >55 years women 

Low HDL cholesterol   

Family history of early heart disease,
father or brother < 55 year, 
mother or sister < 65 years 

Elevated blood pressure

 

 

 

 

Diabetes 

Obesity/overweight 

Physical inactivity 

What can be done about high blood pressure?

  1. Maintain normal weight

  2. Decrease salt

  3. Don't smoke

  4. Exercise

  5. Take medications as directed

  6. Moderate use of alcohol

Even if these lifestyle modifications are not adequate in themselves to control hypertension, they may reduce the number of doses of antihypertensive medication needed to manage the condition. Reducing the number and doses of medications helps to reduce unwanted side effects from the medications. 

1. Weight reduction

Excess body weight is correlated closely with high blood pressure. Particularly, excess fat in the upper body has been correlated with hypertension, dyslipidemia, diabetes, and coronary artery disease.  

Weight reduction in overweight patients enhances blood pressure medications and a reduction as little as 10 pounds can result in decreased blood pressure. Those overweight patients with stage I or mild hypertension, should attempt blood pressure management with weight loss and other lifestyle modifications for 3-6 months. 

All overweight hypertension patients should pursue individualized, monitored weight reduction and increased caloric expenditure by regular physical activity.

Don't be discouraged by setbacks. 1-2 pounds per week is ideal. Caloric intake should not be less than 1200 calories per day.

2. Decrease dietary sodium or salt

The difference between salt and sodium is that table salt is 40% sodium and 60% chloride.

The average American dietary sodium intake for adults is estimated to be 3400 milligrams/day. This figure does not include discretionary sodium, which is added during cooking or at the table. The largest single source of sodium in our diet is from processed foods. Preservatives and flavorings contain sodium. Careful reading of food labels is important.

The recommended daily intake should not exceed 2400 milligrams/day. This decrease in sodium intake can translate to a 10 point decrease in SBP.

African Americans and the elderly are particularly sensitive to salt intake and generally experience the greatest reduction in blood pressure when dietary sodium is reduced.

1 tsp of salt = 2000 milligrams of sodium, almost that of total daily allowance

3. Stop smoking

Cigarette smoking is a major risk factor for heart disease and stroke. Those who smoke will not receive the maximum benefit from antihypertensive therapy. Nicotine patches or chewing gum and/or medication in conjunction with counseling may assist. There are several programs available. Susan Holden Dodge of Manet Health Center offers individual smoking cessation programs. Quincy Medical Center and other hospitals all offer smoking cessation programs.

4. Exercise

There is an association between sedentary lifestyle and increased risk of chronic disease including heart disease, hypertension, type II diabetes, osteoporosis, obesity, colon cancer, and psychological disorders such as anxiety and depression.

In the U.S. about 250,000 deaths per year or about 12 percent of total deaths are attributable in part to a lack of regular physical activity. Sedentary persons have two times the risk of acute MI's and death from heart disease compared to physically active people. As a risk factor, physical inactivity is comparable to smoking, hypertension, and increased cholesterol.

Regular exercise helps you lose weight. Losing weight lowers blood pressure. Vigorous physical exercise for 20 minutes per day 3 times per week is good for the heart and directly lowers blood pressure. It does this by decreasing workload on the heart at a resting state and by changes in the chemicals in the blood. Exercise has also been shown to increase HDL (the good cholesterol) and decrease LDL (the bad cholesterol). Exercise has also been shown to decrease SBP by almost 10 points. All types of physical activity lower blood pressure, and daily activity is better than 3 times per week. Low to moderate intensity (40-60%) is just as effective as high intensity. Exercises such as walking, cycling, dancing, and gardening are beneficial.

Sedentary and unfit individuals have a 50% increased risk of developing hypertension. The majority of patients with uncomplicated hypertension can safely increase their level of physical activity slowly without an extensive medical or fitness evaluation. Patient with known cardiac disease or other serious health problems need a more thorough examination prior to initiation of an exercise program.

5. Take medications

The decision to start medication therapy in individual patients requires consideration of several factors:

Reducing blood pressure with drugs clearly decreases incidence of cardiovascular mortality and morbidity. Studies indicate a 42% reduction in stroke with a 5-6 point drop in DBP. There is approximately a 20 percent reduction in heart disease with the same decrease in DBP.

Stage I and Stage II Hypertension

If blood pressure remains at or above 140/90 during a 3-6 month period despite vigorous encouragement of lifestyle modifications, antihypertensive medications should be started especially in individuals with known risk factors for heart disease. In the absence of significant risk factors, your physician may elect to withhold antihypertensive drug therapy for those individuals with stage I hypertension. Careful follow-up is indicated at 3-6 month intervals because blood pressure may rise to higher levels and cardiac and vascular changes may occur. The goal is to initiate antihypertensive drug therapy before the development of target organ disease.

Initial drug therapy is usually 1 drug. There are many drugs to choose from. Your doctor will choose a medication that is most beneficial to your particular needs and start at the lowest possible dose. If after 1-3 months, the response is inadequate despite proper use of medication, your doctor may consider further options including increasing the first drug, changing your medications or adding a second medication. 

Stage III and Stage IV Hypertension

Similar approaches are taken but may be at an accelerated rate. Shorter intervals between visits and changes will be necessary. Higher doses of medications will be necessary. Maximal therapy is considered three hypertension medications at maximal doses.

Step Down Therapy

Your doctor may decide to attempt a decrease in the medication dosage while maintaining lifestyle modifications. After blood pressure has been effectively controlled for one year and at least four consecutive visits, it may be possible to reduce drug therapy in a slow progressive manner, although complete cessation may not be possible. This step down approach is particularly successful in those individuals who follow lifestyle treatment recommendations. The advantage to decreasing medication dosage is reducing side effects. Remember hypertension is not curable, it is a considered a lifelong condition.

Medication generally needs to be a lifelong commitment along with lifestyle modifications.

Tips about medications

At first it is difficult to remember to take the medication. Take at the same time every day and incorporate it into your routine.

Do not stop taking your medication for any reason unless instructed to do so by your physician or nurse. If you experience side effects, call your doctor. Most side effects can be easily managed with slight adjustments. Do not stop taking medications until speaking with your doctor first.

It is not possible to tell how high your blood pressure is by how you feel. Don't skip or add any doses. The medication must be taken as prescribed.

6. Moderate alcohol

"The French Paradox" is a term receiving widespread attention recently. This refers to the low incidence of heart disease among the French despite a rich, high cholesterol diet. It is thought that the wine consumed with the meals offsets the detrimental effect. Some studies indicate that 1-2 glasses of red wine each day may have cardioprotective effects but this needs further study. However, excessive alcohol has been shown to increase blood pressure and cause resistance to antihypertensive treatment. Chronic or excessive use of alcohol can cause damage to the liver, brain, or heart. Alcohol consumption should be limited to 2 oz of hard liquor or 8 oz of wine or 24 oz of beer for men and half that for women. Remember that alcoholic beverages are high in calories and low in nutrients.

7. Relaxation and biofeedback

Stress can raise blood pressure acutely and may contribute to the cause of hypertension, but present studies lack evidence that stress management reduces blood pressure. Although stress reduction is an appealing concept, its direct effect on blood pressure has not been proven.

Cecilia Mullen is a nurse practitioner at Granite Medical Group. The information in this column is not intended to diagnose individual conditions. Readers should see their own doctors about specific problems.

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