Why Treat Hypertension?
Most of the patients I see in the office with hypertension feel "healthy." So for them, it is disturbing to hear from a doctor that they are "sick" and need to take medication. When medications are necessary, I explain that hypertension is a condition that does not necessarily imply ill health and that the goals of treatment are to prevent the development of serious problems such as heart attack and stroke. In fact, since the 1970s it is estimated that treatment of hypertension has reduced the occurrence of heart disease and stroke by 50%. For those skeptical of medical science, an example from the business world is highly persuasive. Insurance companies, who directly depend on assessing life expectancy for profit, determined long ago that the presence of hypertension predicts an increased risk of death. In an age of numerous effective treatments for hypertension, no one has to be an insurance statistic.
Does Exercise Improve Blood Pressure Control?
Daily aerobic exercise can lower blood pressure in patients with hypertension, and exercise has the additional benefit of improving lipid levels and decreasing weight. I routinely recommend exercise to my patients as long as there is no serious heart condition that could make it dangerous. Remember to speak with your doctor before undertaking a new exercise program.
If I Have Hypertension, Should I Restrict Salt Intake?
Many patients experience a decrease in their blood pressure when they reduce the amount of sodium (salt) in their diet. The effect of salt restriction is not uniform, however, and some patients seem to be more "salt sensitive" and achieve greater benefit from sodium restriction than others do. In general, African-Americans, the elderly, and patients with more severe hypertension experience a greater reduction in blood pressure with salt restriction. In patients with established hypertension, I recommend a moderate sodium restriction of 5 to 6 grams per day. After one month this may allow a decrease in or elimination of the medications needed for their blood pressure control.
You should be aware that a small minority of physicians disagrees with this approach; they maintain that salt restriction is not useful and might even be harmful. Their opinion is based on some research studies that I feel are questionable and which have created great controversy and debate in the medical community. Unfortunately, the popular press has picked up on this "salt debate," leaving the general public confused as well as many of my patients.
A patient of mine with kidney and heart failure recently showed me a book which proclaimed that everything that your doctor ever told you about salt was wrong and went on to list many tasty recipes rich in salt content. "Why didn't you know what the authors of this book had discovered?" he asked. The next 20 minutes were spent convincing him that the information he had read was based on shaky evidence, which did not even apply to his particular condition. It is crucial to remember that high blood pressure often exists with other medical conditions that guide a physician's treatment plan. As an example, for patients with hypertension and certain kinds of organ damage salt restriction is mandatory, but in others with uncomplicated hypertension it might only be advisable. As in my patient's case above, for someone with kidney and heart failure, an increase in salt intake could have been extremely dangerous.
How is the Treatment Strategy Developed?
For many people, medication is not needed immediately, and the treatment of hypertension begins with lifestyle modifications:
- low salt diet
- weight loss if obese
- avoidance of excess alcohol
- regular aerobic exercise
- smoking cessation
For some, these changes may be the only therapy they need. For others who require medication, lifestyle modifications will mean fewer pills at lower doses and improvement or prevention of other medical conditions such as heart disease.
Like most medical conditions there is no "one size fits all" approach to controlling high blood pressure, particularly since hypertension frequently does not occur in isolation. When planning therapy, I consider each patient's risk factors for cardiovascular disease. Important cardiovascular risk factors include
- smoking
- high cholesterol
- diabetes
- family history of heart disease
- male sex
- postmenopausal state
- age over 60
Hypertension interacts with these risk factors and greatly increases the overall risk status of an individual patient. As an example, when I evaluate a patient with hypertension who also has diabetes and high cholesterol, I may decide to start medication at a lower blood pressure than for a similar patient with no other associated conditions. In addition, patients who have evidence of subtle damage to the heart, kidneys, eyes, or brain warrant starting drug therapy sooner at a lower blood pressure than a patient without organ damage.
Even more important than the level of blood pressure at which to initiate therapy is the goal to which the blood pressure should be lowered. For patients with cardiovascular risk factors and evidence of organ damage, the optimal blood pressure is significantly below the commonly used cutoff for diagnosing hypertension (140/90). Studies have not completely defined the optimal blood pressure, but a target of less than 120/80 has been recommended for patients with other cardiovascular risks. This point cannot be overemphasized in the face of alarming evidence that less than 25% of all patients with hypertension are adequately controlled.
Why Is Hypertension So Poorly Controlled?
Non-compliance with their medication (that is, not taking medicine as prescribed) is a major reason why only 25% of patients with hypertension achieve adequate control. I view the treatment of hypertension as a partnership between physician and patient, which requires ongoing evaluation and communication. It is the physician's responsibility to devise a regimen that is well tolerated and acceptable to the patient. But patients also have a responsibility to their physician to reveal their concerns (such as cost) and any side effects from the medications they are taking. Most side effects are not initially predictable by the physician because they do not occur in everyone. But no one needs to suffer with them. Fortunately, the number of different drugs available for treatment of high blood pressure is enormous and continues to grow. This allows for selection of alternative medications with minimal or no side effects in most people. In addition, once daily medicines are much more convenient to take and should be used whenever possible.
Many patients will ultimately need to take two or even three medicines at once for adequate blood pressure control. Yet, giving low doses of two different medicines is often associated with fewer side effects and works better than a high dose of a single medicine for many patients. However, a very small number of patients have truly "resistant hypertension" which may require a hypertension specialist for further treatment and evaluation.
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