Blood Pressure – Diagnosis, Symptoms, and Treatment

What is Hypertension?

Hypertension is the medical term for high blood pressure which can cause damage to almost every organ in the body if not treated.  Recent research by the American Heart Association has revealed that patients can benefit from blood pressure treatment if they have a blood pressure over 130/80 mmHg regardless of their age or gender. This is a significant decrease from the previous recommendation of 140/90 mmHg and is why many patients have begun blood pressure treatment in the past few years. 

What Causes Hypertension?

Hypertension is generally classified as primary or secondary.  Primary hypertension – otherwise known as benign essential hypertension – is the most common (> 90% of cases).  We don’t know exactly what causes it, but it is most likely related to genetic (family history) and environmental factors (e.g. high-salt diet).

Secondary hypertension is high blood pressure caused by specific medical  conditions.  These conditions can include:

• Chronic kidney disease
• Hyperthyroidism
• Primary hyperaldosteronism
• Coarctation of the aorta
• Chronic alcohol use or illicit drug use
• Sleep apnea
• Pheochromocytoma

A diet high in sodium can contribute to hypertension.  Paradoxically, your doctor can even cause this problem, a phenomenon known as “white coat hypertension.”  There are also certain medications that can increase blood pressure, the most common of these are:

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Adderall (amphetamine and dextroamphetamine) - for attention deficit hyperactivity disorder (ADHD)
• Sudafed (pseudoephedrine) - for nasal congestion
• Corticosteroids (e.g., prednisone) & oral contraceptives
• Effexor XR (venlafaxine) - for depression

How Common is Hypertension?

Hypertension is extremely common in the United States. Over 45% of the US adult population is thought to have hypertension to some degree, the majority of which would benefit from treatment. Middle-aged men and men and women over the age of 60 are the most commonly affected. 

A large part of this high prevalence is likely due to the Western diet and obesity pandemic.  In fact, one important aspect of hypertension management is dieting and exercise.

Signs and Symptoms

Hypertension is often referred to as “the silent killer.” It generally results in no symptoms until a complication such as a stroke, heart attack, or serious organ damage develops. In some cases, a sudden and extreme increase in blood pressure can result in symptoms. This is known as a hypertensive emergency and is usually associated with blood pressures over 180/120mmHg. 

• Headache
• Changes in vision
• Chest pain
• Leg swelling

And as we mentioned, untreated hypertension can also result in stroke and heart attack.

Diagnosis

Hypertension is diagnosed by measuring your blood pressure in both arms.  This is usually done in the physician’s office, but can also be performed by the patient with the use of home automated blood pressure machines.  The problem with blood pressure machines is that sometimes they are not as accurate as manual blood pressure readings with a sphygmomanometer.  This is especially true of wrist blood pressure monitors.

The key to diagnosing high blood pressure is getting multiple blood pressure values over the course of multiple weeks and averaging them.  It is best to have your blood pressure checked at the same time of the day, preferably in the morning.  You should be in a quiet room and sit and relax for 5 minutes before having your blood pressure checked.  When checking your blood pressure, your arm should be passively held at heart level with your feet flat on the floor.

Your doctor will probably order an ECG in addition to blood tests, including a complete blood cell count, comprehensive metabolic panel, thyroid function, cholesterol, and urine analysis. These tests and others are used to search for secondary causes of hypertension that may require treatment other than simply providing medications to reduce blood pressure.

Blood Pressure Medication and Treatment

Blood pressure treatment begins with setting a goal blood pressure. The new American heart association guidelines state that most individuals should have a goal blood pressure of 130/90mmHg or lower. The exceptions to this are people with extremely high blood pressure, elderly individuals that are prone to passing out, and those with recent heart attacks. 

The treatment usually begins with dietary and lifestyle changes.  Alcohol consumption is known to increase blood pressure. In men, alcohol consumption should not exceed 2 drinks per day, and in women no more than 1 drink per day.  Most nutritionists and doctors recommend that you incorporate 5 or more servings of fruits and vegetables in your daily diet and that you limit or reduce your sodium (salt) intake.  Regular exercise, at least 30 minutes of moderate-intensity activity, 3 times a week has been associated with a moderate reduction in blood pressure.

Sometimes diet and exercise alone are not enough to achieve a blood pressure goal and medications are prescribed to lower your blood pressure.  There are several classes of blood pressure medications, including:

• Diuretics
  • Hydrodiuril (hydrochlorothiazide)
  • Lasix (furosemide)
• Angiotensin-converting enzyme (ACE) inhibitors
  • Vasotec (enalapril)
  • Lotensin (benazepril)
• Angiotensin receptor blockers
  • Cozaar (losartan)
  • Diovan (valsartan)
• Calcium channel blockers
  • Norvasc (amlodipine)
  • Adalat (nifedipine)
• Beta-blockers
  • Lopressor (metoprolol)
  • Coreg (carvedilol)

Generally, a single medication will be started and increased in dosage as necessary to achieve a blood pressure goal. If you begin to experience side effects from the first medication started your physician will lower the dose slightly and start a second medication in another class to reduce blood pressure further while minimizing side effects. 

Almost all patients will be started on either an ACE inhibitor or the diuretic hydrochlorothiazide as the first treatment for hypertension. These medications are known for having the lowest rate of side effects, the lowest cost, and the best effect in a large number of patients. Your individual response to any one blood pressure medication is likely to be different than that of other patients. Your physician will customize your medication regimen to take into account any other medical conditions, daily medications, and allergies. 

Beta-blockers are not typically prescribed as first-line medications unless there is another condition that may benefit from its use – such as atrial fibrillation or systolic heart failure.  Beta-blockers have actually been shown to increase the risk for falls in the elderly and should generally be avoided in this population.

References:

1. Kovell LC, Ahmed HM, Misra S, et al. US Hypertension Management Guidelines: A Review of the Recent Past and Recommendations for the Future. J Am Heart Assoc. 2015 Dec 7;4(12).
2. Armstrong C. JNC8 guidelines for the management of hypertension in adults. Am Fam Physician. 2014 Oct 1;90(7):503-4.