High blood pressure is an extremely common problem that will shorten the lives of most Americans.  A blood pressure of 110/75 is ideal.  Those between 120/80 and 140/90 are considered borderline hypertension and are associated with an increase in health risks.  Blood pressure above 140/90 should definitely be treated, at least with non-medical interventions and usually with medication as well.

To prevent high blood pressure (HBP): 1) eliminate salt from the diet, 2) lose weight, 3) exercise, and 4) get on a good diet with plenty of potassium, take magnesium and folic acid supplements, and, if female, take calcium.  Non-medical treatments can be helpful.

To treat HBP medically, if necessary, add a diuretic (hydrochlorothiazide $3/mo) or an ACE Inhibitor (enalapril and lisinopril are very good $3-4/mo with enalapril my current favorite).  If the first type of medication by itself is not successful, then add the other.  Most patients with high blood pressure will need a diuretic plus an ACE inhibitor.  Some people will need a higher dosage of both.  The large majority of patients can get their pressures under good control with these combined with good habits, a good diet, and the above mentioned non-medical treatments.

Some will need yet a third medication.  Clonidine has a higher rate of side-effects, but it probably a good third or fourth choice for those not getting the side-effects.  It's also very inexpensive.  Beta-blockers like propranolol ($4/mo) and metoprolol are good options for non-responders.  Atenolol is probably not a desirable beta-blocker.  More popular than beta-blockers, but also much more expensive are the Angiotensin II Receptor Blockers (ARBs) ($50/mo, e.g. Cozaar, Avapro, Benicar, etc.).  Also, ARBs don't help people live longer.  Calcium-channel blockers may have a higher rate of death and are also more expensive ($30-$50/month).  These prices are wholesale prices.  Many other choices are available, although most are older and not covered here.

If you have high blood pressure, get your own blood pressure measuring device and use it.  This has been shown to help keep blood pressure down by keeping you better informed as to when you should take additional action.  It also motivates you to change your bad habits, the ones that have a good chance of killing you.

Frequency of High Blood Pressure

HBP Very Common: 70% Will Get It: According to National Center Health Statistics, HBP occurs in 25% over age 18, 60% between ages 65-74, and 64% men and 77% women over 75. One-third don’t even know they have HBP. Only 55% are being treated and only 21% are getting effective treatment. 43,000 Americans are killed by untreated HBP each year, an increase of 36% in 10 yr, and it is a contributing factor for another 210,000 per year. HBP increases the chance of stroke 7-fold and congestive heart failure 6-fold.

HBP Even More Common: 90% in Framingham Study, Under 120/80 best: Framingham study 20-25 year follow-up found 85% with HBP and estimate 90% overall after accounting for those on lowering meds. 35-44% have severe HBP of 160/100 at some point. Ramachandran Vasan of Boston University, JAMA 2/27/02. Framingham risk of cardiovascular disease associated with high blood pressure increases gradually - even before hypertension occurs. 23 million adults high-normal blood pressure levels (systolic pressure of 130-139 mmHg and/or a diastolic pressure of 85-89 mmHg) are 1.5 to 2.5 times more likely to have a cardiovascular event or to die within 10 years, compared to those with optimal blood pressure (systolic pressure of less than 120 mmHg and diastolic pressure of less than 80 mmHg). Normal 120-129 mmHg systolic, 80-84 mmHg diastolic. Lowering the average systolic blood pressure among Americans by 5 mmHg would result in a drop of 14% in deaths from stroke, 9% in heart disease deaths, and 7% in overall mortality.

High Blood Pressure Very Common in Aging: From the CDC’s 1999-2000 National Health and Nutrition Examination Survey, data on 4,805 adult found 58% with either hypertension or prehypertension. Prehypertension is a reading between 120/80 and 139/89. The highest prevalence of either prehypertension or hypertension was: among non-Hispanic blacks 63%, especially men 69%; among all those surveyed age 60 and over 88%; among those with less than a high school education 65%; and among those with body-mass indexes over 30, which indicates obesity. Youfa Wang, Qiong Joanna Wang, Univ. Illinois, Arch Int Med 10/25/04.

High Blood Pressure Up 10% in 1990s: One in four Americans surveyed in 1999 said that they had been told at least once by a doctor that they had high blood pressure, compared with 22.9 percent in 1991, the CDC said. Increases were reported in almost all age, racial and gender groups. 5/30/02.

Blood Pressure Up Again: A recent study of 4,531 adults in the U.S. reports that hypertension has increased by 30% from 1988 to 2000. Now, almost one-third of American adults have hypertension or are on medication to lower blood pressure due to hypertension. JAMA 8/24/04.

61% Taiwan Elderly HBP: A random selection study of individuals 65 or older found 31% being treated for HBP and 30% more with HBP but not previously diagnosed. Higher with higher BMI, but smoking, drinking, being a vegetarian, or exercising made no difference. J Gerontol A Biol Sci Med Sci 2000 Aug;55(8):M463-8. Ed: Chinese use a lot of salt, especially in soy sauce.  Soy sauce is responsible for killing hundreds of thousands of Chinese each year!

HBP up 100% in 6 Years in Philipines: In 1992, 11% had HBP, now it's 22%. It's highest in Mindanao where salty preserved fish, shrimps, and sauces are popular. Fatty salty fast foods are also held to be a factor in the dramatic increase, although there is no research documenting this as the cause. In some still undeveloped countries, HBP is as low as 7% of the population vs. US 26%. Lancet 8/22/98 reports BP not increase by the non-chloride salts of sodium. It notes the famous INTERSALT study (Br Med J ’88 297:319-28) where very little HBP in four populations who had no salt intake. A randomized Dutch study of infants fed low salt for first 6 months found lower BP with a difference still found after 10 yr.

Blood Pressure 110/75 Best: In a nationwide Chinese study of 31,728 adults ages 35-64, compared with BP < 110/75 mm Hg, the risk of cardiovascular disease increased 109% (RR = 2.09), 223% (RR = 3.23), and 1081% (RR = 11.81) when BP was 120 - 129/80 - 84 mm Hg, 140 - 149/90 - 94 mm Hg, and >/= 180/110 mm Hg, respectively. A prospective study of relationship between blood pressure and 10-year cardiovascular risk in a Chinese cohort aged 35 - 64 years. Wang W, Zhao D, et al. Capital Medical University Affiliated Anzhen Hospital, Beijing. Zhonghua Nei Ke Za Zhi. 2004 Oct;43(10):730-4

For Lowering High Blood Pressure, the Systolic Lowering is What Counts: In an analysis for trials including 12,903 patients ages 30-49, 14,324 ages 60-79 years, and 1209 very old (over 79), antihypertensive treatment reduced SBP/DBP by 8.3/4.6 mm Hg in young, by 10.7/4.2 mm Hg in old, and by 9.4/3.2 mm Hg in very old, resulting in ratios of DBP to SBP lowering of 0.55, 0.39, and 0.32 (P=0.004 for trend with age). Treatment reduced the risk of all cardiovascular events, stroke and myocardial infarction in the 3 age strata to a similar extent. Absolute benefit increased with age and with lower ratio of DBP to SBP lowering. In patients with a larger-than-median reduction in SBP, active treatment consistently reduced the risk of all outcomes irrespective of the decrease in DBP or the achieved DBP, even if the achieved DBP averaged <70 mm Hg. Systolic and diastolic blood pressure lowering as determinants of cardiovascular outcome. Wang JG, Staessen JA, et al. University of Leuven, Belgium. Hypertension. 2005 May;45(5):907-13. 

General Items

Non-Dippers More Ill Effects: Individuals who do not have a 10% to 20% reduction in blood pressure (BP) during the night are known as 'nondippers'. There is a growing body of evidence linking a nondipping BP pattern with target organ damage. There is evidence to suggest that individuals with hypertension who exhibit a nondipping BP profile are at higher risk of cardiac and extracardiac morbidity and mortality. In particular, nondippers with essential hypertension have been found to have more advanced left ventricular hypertrophy, left ventricular mass and left ventricular mass index, carotid artery wall thickness, carotid artery atherosclerotic plaques, silent cerebral infarct, stroke, cognitive impairment and microalbuminuria. Night-time blood pressure patterns and target organ damage: A review. routledge FS, et al. Dalhousie University, Halifax, Canada. Canad J Cardiol 2007 Feb;23(2):132-8.

HBP Risk High for Young Men: 10,874 Chicago men 18-39 were followed for 25 years. 62% at baseline had high-normal BP (130-139/85-89) or stage 1 hypertension (140-159/90-99). Life expectancy was shortened 2.2 yr for high-normal BP and 4.1 years for stage 1 HBP with 34% and 50% higher CHD risk. Arch Int Med 6/25/01, Northwestern Med school.

Systolic More Important: In a 14 year prospective study of 4,714 French men aged 52 found no increase in coronary heart disease with elevated diastolic but a doubling if the systolic was > 160 vs. below 140. Arch Int Med 3/2002.

RN Office Checks May be Unreliable: The last time I saw the doctor, the BP check by the nurse was so quick that there was no way she could have accurately measured it.  Since I check my BP every day with my own monitor and roughly monthly at a pharmacy, I was surprised to see the lowest pulse pressure that I had seen in many years at that doctor's office. I now trust machines better than humans. T. Radecki, 3/17/05.

Treatment of Systolic Hypertension: In a MEDLINE search of English-language literature from 1966-2004, 1064 studies were analyzed. The authors conclude that there is strong evidence to support the treatment of older persons with systolic blood pressure (SBP) of at least 160 mm Hg. Large-scale trials to assess the value of antihypertensive therapy for older patients with SBP of 140 to 159 mm Hg have not been performed, and recommendations to treat these patients are based on observational studies that show a graded relationship of cardiovascular risk with increasing SBP. Systolic hypertension in older persons. Chaudhry SI, Krumholz HM, Foody JM. West Haven Veterans Affairs Medical Center, Connecticut. JAMA. 2004 Sep 1;292(9):1074-80

Correction for Obesity: Systolic and diastolic blood pressures were significantly higher in obese patients when the standard cuff was used. For every five cm increase in arm circumference (from 35 cm upwards), an incorrect increase of 2-5 mm Hg in systolic blood pressure and of 1-3 mm Hg in diastolic blood pressure was measured. Special cuffs are hard to find and for use with arms >33cm. Blood Pressure Monitoring 2003:8:101. Guadalajara.

HBP Lowers Cognitive Tests: A 20-year Swedish study of almost 1,000 men starting at age 50 found those with HBP, especially uncontrolled HBP, scored lower on cognitive tests. Energy Times 2/99, reference?

Longevity Higher with Low BP: Italian study of individuals with high longevity found lower than expected diastolic BP and this trait also found in their offspring. Cugini, Clin Ter 11/98; Lower BP, less smoking, and higher forced vital capacity linked with living to age 75 as well as lower heart rate in men and parents living at age 75 for women in Framingham study. Goldberg, Arch Intern Med 3/96. Kyoto study of 40-69 year-olds found BP <140/90. Hazard of death ratio for borderline HBP 1.86 and HBP = 2.03. Nippon Koshu 12/93. Majority of Americans over 35 have BP over optimal 120/80 and HBP a major cause of cardiac and stroke death and great potential for improved health through control of BP problem. Stamler, Arch Intern Med 3/8/93, Natl HBP Educ Prog. In 11-15 year follow-up of middle aged Harvard grads, RR of death for those with normal BP was only 0.52. Lean body mass and exercise and not smoking were other positive factors. Paffenburger, NEJM 2/23/93. Men with BP less than 120/80, cholesterol less than 182, no diabetes, no tobacco, and no previous heart attacks lived 9 years longer in the 25 year People Gas, 30 year Western Electric and 15 year Chicago Heart studies. Dyer, Northwestern, Cardiol 93;191. Best predictors of coronary heart disease were HBP, smoking, and sex with parents’ ages at death also important in 40 year follow-up of Framingham patients. Brand, Boston U, J Clin Epid 92. In a 16 year follow-up of 17,000 Harvard alums, exercise added 1 ¼ years to those burning over 2,000 calories/week (top 35%). If everyone exercised there would have been 16% fewer CHD deaths, 9% fewer if no HBP, 25% fewer if no smoking, 6% fewer if no obesity, and 11% fewer if no parental CHD. Paffenbarger, Acta Med Scand Suppl ’86. HBP was the best clinical predictor of CHD although lack of exercise with the best community predictor. JAMA 7/27/84 Paffenbarger.

HBP Linked to Bone Loss: 3,676 white women over 65 were followed for 3 ½ years. Those with systolic BP >147 suffered twice the bone loss as those <124. Jos. Zmuda, U Pitt, Lancet 9/18/99. 97% of your calcium is in the bones. HBP drugs didn’t change bone-loss. Hormone replacement reduced bone loss by half.  Salt siphons calcium out of the body and high-salt diets lead to HBP and may be the cause of the association.

Lowering Hypertension in Elderly Helped Cognition a Little: In a small 24-week DB PC study of 81 elderly over age 69 with hypertension, low dose captopril 12.5 mg twice daily or bendrofluazide 2.5 mg daily did equally well at lowering BP and in cognition scores. The 19 patients in the quartile that lowered their diastolic blood pressure most ( > or = 19 mm Hg) had improved scores on Anomalous Sentences (P = .012) and Paired Associates (P = .044) compared to the 19 subjects in the least blood pressure responsive quartile (fall < or = 5 mm Hg)s. The effects of antihypertensive treatment on cognitive function: results from the HOPE study. Starr JM, Whalley LJ, Deary IJ., London, UK. J Am Geriatr Soc. 1996 Apr;44(4):411-5.

Systolic BP Most Important: In a prospective cohort study of 53,163 healthy men followed for 5.7 years in the Physicians' Health Study, there were 459 CVD deaths during follow-up, systolic BP was the most consistent and significant predictor of CVD death across all ages. Diastolic BP was not as strongly associated with risk. Effect of age on blood pressure parameters and risk of cardiovascular death in men. Bowman TS, et al. Massachusetts Veterans Affairs Epidemiology. . Am J Hypertension 2006 Jan;19(1):47-52.

Urinary Dipstick Albuminuria Specific but Not Sensitive for Kidney Damage: In a study of 182 newly diagnosed hypertensive, dipstick testing for protein (microalbuminuria) was positive in 31 urine samples (16.7% of the test samples). The albumin/creatinine ratio was elevated in 33 samples (17.7% of the test samples). The sensitivity of detecting microalbuminuria was 26%, specificity 89%, positive predictive value 45%, and the negative predictive was 88%. Repeated dipstick testing 48 hours after the initial testing in 40 randomly selected patients showed a good reproducibility (98%). Swiss Med Wkly. 2005 Jan 22;135(3-4):57-61.

Thomas E. Radecki, M.D., J.D.

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