By Vivek Sinha
One of the most prevalent conditions primary care providers face in this country is high blood pressure, also known as hypertension. It is one of the most common reasons for doctors’ office visits and is one of the biggest reasons for chronic prescription medication use. After much research, the guidelines for defining hypertension were updated in 2017. The American College of Cardiology/ American Heart Association adjusted the lower threshold for diagnosing hypertension. Utilizing this more recent and up-to-date criteria, a study performed by the American College of Cardiology showed that in 2018, 45% of adults older than 18 in the United States had hypertension.
Hypertension is diagnosed when blood pressure is measured to be greater than 130/80. Blood pressure is the measure of the pressure of the blood against the walls of the arteries. It is measured in millimeters of mercury (mmHg) and can be determined by using a manual blood pressure cuff or an electronic cuff. It is one of “vital signs” that are often measured any time medical care is initiated.
The top number, or systolic number, is the pressure recording when the heart is squeezing and actively “pushing” blood throughout the body. The bottom number, or diastolic number, is the recorded pressure when the heart is relaxing. Per most recent guidelines, blood pressure can be divided into stages. A normal blood pressure is defined as the top number below 120 mmHg and the bottom number below 80 mmHg. A reading with the top number between 120 and 129 mmHg and the bottom number below 80 mmHg is defined as elevated blood pressure. A top number between 130 and 139 mmHg or the bottom number between 80 and 89 mmHg is defined as Stage 1 Hypertension. Stage 2 Hypertension is defined as a top number being at least 140 mmHg or the bottom number at least 90 mmHg.
Accurately measuring blood pressure is extremely important. Proper technique is critical in order to avoid mistakes in diagnoses. The person getting their blood pressure checked should ideally be sitting in a chair with back support and their feet on the floor for at least five minutes. Caffeine use, exercise and smoking should not have occurred for at least 30 minutes before blood pressure is measured. A properly sized blood pressure cuff should be placed over the person’s upper arm. Best practices dictate that if it is the first time a blood pressure reading is taking place, two separate readings should be obtained utilizing both arms. The readings should be separated by one to two minutes.
Numerous studies have differentiated the use of blood pressures taken in a doctor’s office and those taken by a person in their own home. Blood pressures taken in the doctor’s office should be performed by appropriately trained staff and recorded. However, a higher stress environment like a doctor’s office can sometimes lead to higher numbers; therefore, it is critically important for people to record their home blood pressures as well. In order to accomplish this, an automatic blood pressure device is preferred. The upper arm – not the wrist – should be utilized to take the measurement after the person has been sitting in an upright position with their back and arms supported and legs uncrossed. At least two readings should be taken one minute apart and recorded. Ideally, blood pressures should be taken daily for two weeks anytime there is a change in medication regimen, and for one week prior to each doctor’s visit. These numbers should be recorded and brought into the visit.
Once hypertension is identified and diagnosed, a formal evaluation should take place. A detailed history, including current prescription and non-prescription medication use, physical activity frequency, smoking history, alcohol use and family history are some important factors that should be discussed. A thorough history and lab work should also be performed. The labs should include tests to determine if any damage has occurred and to possibly identify any causes of high blood pressure. Checking blood sugar, liver function tests, kidney tests, a urine sample, cholesterol and a thyroid test are some of the lab tests that should be reviewed and repeated periodically.
The treatment of hypertension is varied and depends on several factors. Severity of hypertension, how long it’s been present, the presence of any organ damage and other comorbid conditions are all factors that will dictate the type of treatment prescribed. There are certain conditions that, if present, can make the diagnosis of hypertension even more dangerous. For example, people with high cholesterol or diabetes have to be especially careful about controlling their blood pressure since there is a “synergistic effect” with these conditions that can increase a person’s risk for heart disease and stroke. Everyone with hypertension should be educated about lifestyle modifications like salt reduction, weight loss, exercise, limiting alcohol and smoking and they should be discussed in detail at every visit with a doctor.
For those who also require medication management for their hypertension, there are many options. There are several classes of anti-hypertensive medications, with multiple options within each class. Some medications are required to be taken once a day, while some are required to be taken multiple times a day. The most important thing to consider is that blood pressure medications should be taken exactly as prescribed, at the same time each day. Numerous studies have shown that patients will often get better results if combination therapy is utilized, or two different types of medications are used together. There are many options that include two different medications combined in one pill, thus allowing the person to take one pill but get the benefit of two medications. For people who are on medications for their hypertension, it is important to have regular follow up with their doctor. Lab work should also be checked regularly to ensure kidney levels, cholesterol and sugar levels are stable.
There is a reason why hypertension is often called “the silent killer.” There are often no symptoms until damage has occurred. If you or someone you love has concerns about their blood pressure, make sure to speak to your doctor. Check your blood pressure and follow up with your visits. Luckily, there is a lot that we know about high blood pressure and there are many excellent treatment options. Get checked, get informed and know your numbers!
The writer is the chief medical officer of Belleview Medical Partners, an office and house call practice based in Old Town.