Hypertension
TreatmentSince the introduction of diuretic medication after the Second
World War and the further introduction of the beta-blockers in the 1960's there
has been a significant prolongation of life expectancy in hypertensive patients
throughout the world. By adjusting medication according to home monitoring devices,
a patient can expect to add about 10 to 20 years of life over a lifetime. However,
it is important to point out that despite that progress about 30% of patients
do not know that they are hypertensive and as Ref. 2 stated only 25% get adequate
anti hypertensive treatment. The following recommendations will
be useful for most of the patients with hypertension, but you should seek the
advice of your physician to ensure that you will get optimal antihypertensive
therapy with a minimum of side effects. The objective is bringing the blood pressure
under control with the help of medication. Blood pressure therapy is an ongoing
maintenance program, not a magic cure. Do not stop taking the medication without
the advice of a doctor, or you run the risk of a sudden stroke or heart attack.
Steps for
controlling blood pressure | Only
very few people will be able to control their blood pressure by dietary changes,
drastically reducing alcohol intake (less than 1 oz. per day) and restricting
the sodium intake to less than 2 grams per day. It is safer to treat the high
blood pressure with medication while changing life styles and habits and then
reducing or phasing out the medication at a future date. I vividly remember a
patient of mine who was in her 80's, was sharp in her mind, but also was resistant
to the advice of taking medicine. Within only 2 months she got a massive stroke,
from which she died within three days. Life is too precious to risk a stroke or
a heart attack! Here is the standard approach to high blood pressure: -
You should buy a blood pressure cuff to do
your own home monitoring. It does not matter whether it is an electronic
machine or the old fashioned manual model. Learn how to use it properly. Bring
it to the office and have the doctor check your technique. Alternatively
have a nurse show you how to do it. There are also free blood pressure clinics
with knowledgeable staff who can show you how to do it. Some prefer to follow
the instruction booklet of the equipment and this will work also. Write down the
value each time you measure the blood pressure. There is no point in measuring
more often than once or twice a day in the beginning. When you are on maintenance
medication it is sufficient to measure three times per week. Don't forget to bring
your booklet with the recorded values to the doctor. It is important for your
care that the doctor sees how well the blood pressure is controlled at home.
-
The treatment in the beginning is usually a low dose of a diuretic such as hydrochlorothiazide
(brand names: Esidrix ,Oretic, HydroDiuril) or chlorthalidone (brand name: Hygroton).
Diuretics work by removing some of the excess sodium in the body and the extra
fluid that had been accumulated. Other diuretics are the potassium sparing diuretics
such as spironolactone (brand name: Aldactone), amiloride (brand name: Midamor)
or triamterene (Dyrenium). There are a number of combination diuretics under the
brand names Dyazide, Moduretic and Aldactazide, which combine hydrochlorothiazide
with one of the potassium sparing diuretics to minimize the side-effects.
-
If this does not control the blood pressure (values below the 140/90 limit), a
beta-blocker is added. Beta-blockers block the beta receptors of the
arterial wall, which blocks the blood vessel constrictive effect of epinephrine
and norepinephrine. The original one, propranolol (brand name: Inderal), is too
sedating as a side-effect. Many newer beta-blockers have been developed with less
side-effects. A few common ones are: atenolol (brand name: Tenormin), timolol
(Brand name: Blocadren), pindolol (brand name: Visken), metoprolol (brand names:
Lopresor, Toprol XL), nadolol (brand name: Corgard), labetalol (brand names: Normodyne,
Trandate), acebutolol (brand name: Sectral). There are more beta-blockers as this
is a lucrative market and various drug companies like to get a share of this business.
About 85% to 90% of all hypertensive patients should be able to be controlled
on the above regimen of either a diuretic alone or in combination with a beta-blocker,
or a beta-blocker alone.
- If the blood pressure is still not controlled,
the physician might want to think about more tests to rule out secondary hypertension
as mentioned above. While this is being tested, the physician can either optimize
therapy by adjusting the dose or change to another class of antihypertensive.
The two more common other classes of medications available are: calcium blockers
and ACE inhibitors. People with asthma, for instance, are not allowed to take
beta-blockers as this can precipitate an asthma attack. Somebody with asthma should
likely be started on a calcium blocker or ACE inhibitor.
- Calcium
blockers(or calcium channel blockers) block the calcium channels in the arteries
and thereby lower blood pressure. This has nothing to do with osteoporosis, there
is no loss of calcium from the body. It does not damage the arteries either. I
mention this just to dispel any misconceptions. The short-acting calcium channel
blocker nifedipine ( brand name: Adalat)has earned a bad reputation through some
studies showing that they can cause heart attacks in certain patients. However,
it turned out later that this was due to the fact that there is an initial fast
drop of blood pressure with the first dosage and in combination with a side effect
of giving the heart muscle less contractility this can be enough in some patients
with poor blood supply to the heart to cause a heart attack. In the meantime the
short acting form of this medication is not used for treating high blood pressure,
but is still an excellent medication for treating angina. The same medication
in a slow release form (brand names: Adalat XL and Adalat PA) is still very useful
as an antihypertensive. Other newer calcium blockers are: diltiazem, extended
release (brand names: Tiazac, Cardizem CD, Dilacor XR); verapamil, sustained release
(brand names: Isoptin SR, Covera-HS, Verelan, Calan SR). These medications cannot
be used in patients with heart failure and also not in patients with heart blocks.
Another group of newer channel blockers are the dihydropyridine derivatives. Some
of these medications are: felodipine (brand name: Plendil), amlodipine (brand
name: Norvasc), Nicardipine (brand name: Cardene), nisoldipine (brand name: Sular).
Among some of the side effects of this group of calcium blockers is a reflex tachycardia
(fast heart beat), which makes this medication not suitable for everybody. Your
physician can determine the best medication for you.
- ACE inhibitors
are relaxing the tension in the arteries by blocking the renin/angiotensin system
and inhibiting the degradation of bradykinin. The end result is a lowering of
the resistance of all of the blood vessels without a reflex tachycardia (fast
heart beat). This medication has a low side-effect profile except for an annoying
dry cough in 5 to 7% of patients. This type of medication seems to be the only
one, which in males does not produce sexual dysfunction, like diuretics, beta-blockers
and calcium blockers, which can be a source of frustration. ACE inhibitors improve
kidney function in case of a diabetic nephropathy, but it would be contraindicated
with renal artery stenosis. Some of these ACE inhibitors are: captopril (brand
name: Capoten), enalapril (brand name: Vasotec), lisinopril (brand name: Zestril,
Prinivil), fosinopril (brand name: Monopril), ramipril (brand name: Altace), benazepril
(brand name: Lotensin).
- Other antihypertensive medications: There
are a number of less common, but equally effective medications that can be used
to lower blood pressure (see Ref.5).There are medications, which will block angiotensin
II receptors. They are similar in action to the ACE inhibitors. Another group
of medications are the adrenergic inhibitors, which work through a central action
reducing the sympathetic outflow, but they have a side-effect of causing drowsiness,
depression and lethargy. There are the postsynaptic adrenergic blockers, which
work by blocking receptors right on the arteries and veins. This medication is
also useful for benign prostatic gland enlargement in males. It also reduces LDL
cholesterol (the bad cholesterol) at the same time. One of the brand names of
this group is Hytrin.
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Individualized
therapy: Ref.4 points out that physicians need to switch from
"indiscriminate therapy" to "individualized therapy". In other
words every patient with high blood pressure has a right to the best therapy for
his/her particular situation. We need to know about the side-effects, which are
all listed in the physician's desk reference book. The physician needs to balance
the pros and cons and come up with the right combination, if necessary, to control
the patient's blood pressure and bring it down to below 140/90. The patient
on the other hand does his/her part by watching the life style factors and doing
the home blood pressure readings on a regular basis. There may be some weight
loss necessary. Exercise may have to be
introduced to improve the blood cholesterol levels. The physician will give you
additional advice such as a low fat, low refined carbohydrate diet
and what to do and what to avoid. His advice is crucial, not only the medication
(Ref. 9, p. 505). What counts is that you are comfortable taking care of your
own blood pressure problem. You need all the help you can get, from the physician,
from the medication, from your life style changes. It is for your life! In
this context it is interesting to note (mentioned in Ref. 10) that a group of
Belgium cardiologists noticed that exercise alone could reduce blood pressure
in people with hypertension by 7 points systolic and 5 points diastolic (7/5 reduction).
Researchers at Duke University Medical Center added the DASH diet to exercise
and there was a reduction of 16/10 (16 systolic and 10 diastolic). As Dr. Bryan
points out, both exercise and the DASH diet are increasing nitric oxide in the
blood, which dilates veins and arteries, just as the blood pressure medication
does. The only difference is that eating beets, kale and green leave vegetables
and doing regular moderate exercise will not have any undesirable side-effects,
so try this first and add as little medication as you need on top of this.
It is time that not
only 12.5 million, but all of the 50 million (100%) hypertensive Americans in
the U.S. get treated adequately. The same is true for the rest of the world! |
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