The Minster Practice, Lichfield
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This is the text of version 33 of the booklet handed out by Dr Causer to his patients with high blood pressure. Please remember the site warning and obtain the latest version from your doctor. Introduction This booklet has been prepared to help you to understand what is meant by high blood pressure and how it may affect you. What is blood pressure? Everyone has blood pressure. The heart is a powerful pump, pumping about 8 pints of blood around the body every minute. This creates a force against the inside walls of your arteries producing blood pressure. This pressure is necessary to maintain the blood flow to your major organs. Blood pressure is measured in millimetres (mm) of mercury meaning how high the pressure in your arteries can raise a column of mercury. As mercury is phased out from medical practice we will still quote blood pressure in the same way. There are 2 figures: the top one is the systolic blood pressure which represents the pressure reached as the heart contracts; the bottom figure is the pressure as the heart relaxes and is called diastolic blood pressure. A blood pressure of 120/80 is spoken as 120 over 80. Blood pressure changes from minute to minute. It tends to rise with circumstances such as exercise and emotions and drops at rest and when asleep. Blood pressure also tends to rise as you get older. Prior to the menopause, less women have high blood pressure but after the menopause the incidence climbs. In fact, women ultimately have the same risk of heart disease as men but develop it 10 years later. What is high blood pressure? This is where blood pressure is persistently high. This situation called hypertension can damage the walls of the arteries leading to fatty deposits building up along the walls. This process is called hardening of the arteries or atherosclerosis. It is therefore important for me to identify people with hypertension. On the other hand I do not want to use medication unnecessarily. Hypertension usually causes no symptoms so regular blood pressure checks are necessary and several readings will be taken over a period of time before hypertension is confirmed. The first reading of the series is often high; the second check some time later may well be normal. The fact that you have this booklet means that your second reading was higher than ideal but hypertension may not have been confirmed yet. Each person’s situation has to be assessed on an individual basis. This is why a booklet like this cannot usefully quote “normal” values. Blood pressure of 130/85 is definitely normal but pressures higher than this may not be considered abnormal. Blood pressure above 160/100 is usually considered to be abnormal. If I have any doubt about the readings in my consulting room not being representative, I will offer you the opportunity of wearing a device (arm band & recorder) that will take readings over a 24 hour period. If hypertension is left untreated, the hardening of arteries can lead to blockage of a major artery causing a heart attack or a stroke, so this is why I need to be certain that I am not missing hypertension. Hypertension is a common problem affecting up to 15% of the middle aged adult population. The next step After 2 consecutive high readings I need to calculate your risk of heart or stroke disease over the next 10 years. To do this I need the results of some tests. The risk score is calculated using gender, age, systolic and diastolic blood pressures, smoking history, total cholesterol, the amount of the total which is good cholesterol (HDL), whether you are a diabetic and finally whether the wall of the main chamber of your heart (the left ventricle) is thickened. The score is further raised by a family history of heart attack or stroke at a young age. Young age is currently set at 55 for father, brother or son and 65 for mother, sister or daughter. Additional tests not used in the calculation of risk include checking kidney function. Hypertension can damage kidneys; also kidney damage can cause hypertension. No underlying cause of hypertension is found in 95% of patients so special investigations are only carried out in those aged over 40 if the blood pressure is difficult to control. What can you do? If you smoke, stop now. Smoking doubles your risk of heat disease and trebles your chance of dying before retirement age. One cigarette may raise blood pressure for up to 2 hours. The various forms of nicotine replacement therapy can double the success rate of giving up. However, they should not be used for longer than necessary to help giving up; nicotine itself may increase the risk of heart disease and cancer, even without the hundreds of other chemicals in tobacco smoke. Never give up giving up; you will succeed in the end. Keep your alcohol intake below the recommended limits of 3 units per day for men and 2 units per day for women. Today’s higher strength alcoholic drinks mean that a half pint of beer or a glass of wine is often more than 1 unit. Check the label. Higher levels of intake can increase blood pressure and also damage the heart and liver. Avoid being overweight. If you are overweight, blood pressure can drop by about 2 mm for every kilogram lost. In some cases, reducing weight can return blood pressure to normal so that medication is not necessary. Reducing weight also improves the effectiveness of treatment. Being overweight is also bad for your joints and breathing. To reduce weight, it helps to avoid foods high in saturated fats and calories such as dairy products, fried foods, cakes, biscuits and fatty meats. Even if you are not overweight, a diet low in saturated fats and high in fibre is good for your heart and blood vessels. A healthy diet includes more fish, white meat, plenty of fresh fruit and vegetables as well as using sunflower oils, sunflower margarine and skimmed milk. Benecol does lower bad cholesterol (LDL) but only if the recommended amount is taken each day and this is high in calories. The evidence for Flora Pro-Activ is not as strong. Don’t add salt at the table and avoid eating salty foods. Processed food and ready meals often contain a lot of salt. A high sodium intake raises blood pressure . Some people are very sensitive to salt and these people benefit greatly from reducing their intake.; limiting sodium intake to 2.4g per day can reduce blood pressure by 5-10 mm. Food will taste different for a while but the flavour will soon return. Don’t change to salt substitutes, such as Lo-Salt without checking with me. Although they have been shown to reduce blood pressure, some blood pressure treatments can raise potassium levels too high when used with potassium salts. Take regular exercise as it reduces blood pressure directly and also helps to keep weight down. Exercise does not need to be strenuous and you should build up your exercise steadily. 20-30 minutes of moderate exercise three times a week should be enough. Brisk walking, swimming and cycling are all suitable. Reduce stress. Avoiding stress is difficult and there is doubt as to whether stress leads to permanently raised blood pressure. The various forms of relaxation therapy do lower blood pressure but only for the duration of the procedure. However, do ensure that you make time for yourself to do things you enjoy doing. They may seem unproductive but they are definitely not unproductive in health terms. Doing all these things right may not avoid the need for medication but will certainly reduce the dose or number of tablets you have to take as well as reducing other risk factors for arterial disease. Diabetes and hypertension If you have diabetes, the latest research shows that I need to control your blood pressure even more carefully and set lower targets. In fact, control of blood pressure is probably more important than control of blood sugar. Treatment No two people are the same so medication has to be individually chosen and some have a range of doses to be used depending on progress. Nowadays, I tend not to use maximum doses of any one drug but add a drug acting in a different way if the blood pressure is not controlled. Common types of drug are diuretics (e.g. bendrofluazide), cardioselective betablockers (e.g. atenolol), ACE inhibitors (e.g. lisinopril, ramipril), angiotensin II antagonists (e.g. candesartan), calcium antagonists (e.g. Adalat LA, Coracten XL), alphablockers (e.g. doxazosin) and others (e.g. moxonidine). Side effects are listed on the patient leaflet issued with the medication. Please note that only a small proportion of patients experience these symptoms and even then they are usually mild and clear up quickly. It is quiet common to feel a little dizzy with the first few doses of a treatment but this usually settles as your body adjusts to the new lower level of blood pressure. If you experience dizziness which is severe enough to make you feel a little faint and is not solved by getting up more slowly, I will need to check your blood pressure both sitting and standing in case the treatment is upsetting the way your body copes with changes of body position. Even if this is the case, the problem can usually be solved by using a treatment that works in a different way. How blood pressure lowering drugs work Diuretics increase salt and water loss from the kidneys and also directly relax blood vessels. In the early days of treatment you may pass more urine than normal but this usually returns to normal. Betablockers reduce the work of the heart, slow the heart rate and probably affect hormones controlling the kidneys. I use the type that is more specific for the receptors controlling the heart—cardioselective. ACE inhibitors and Angiotensin II antagonists work by preventing the production of a hormone that causes salt retention and also narrows blood vessels. Calcium antagonists open up arteries and some reduce the work of the heart. Alphablockers work by relaxing the walls of the arteries. Do not stop your medication without seeking advice from a doctor or pharmacist This is because your blood pressure can shoot back up even higher than it was before starting medication. In some cases, this can be very dangerous to your health. Do take your medication with you if you have to go to hospital as an outpatient or inpatient The doctors you see will need to know what you are taking so that they do not give you something that will react badly with your medication. It is particularly important that an anaesthetist knows what you are taking before you receive an anaesthetic. It is probably a good idea to carry your repeat prescription request slip (see below) with you at all times as you never know when an emergency may occur Monitoring of blood pressure and medication Your blood pressure will need to be checked on a regular basis so that I can ensure that it remains controlled by your medication. Blood pressure rises with age but the reason why perfect control over years can stop suddenly is often a mystery. As hypertension usually causes no symptoms, regular blood pressure checks are necessary. Once a stable situation has been reached, you will usually attend every 6 to 12 months for a blood pressure check. Health Authority rules do not allow me to issue medication for those 6 months in one go. We operate a repeat prescription service approved by the Health Authority which allows you to pick up your medication each month without having to make an appointment to see me. We have a leaflet explaining this service (available in the corridor) or visit our website for further information: http://www.minster.org.uk/rep_scripts.htm A new NHS service called Repeat Dispensing may enable me to issue you with all your scripts: one per month in one package. Use of aspirin We now have a clear view regarding who benefits from regular low dose aspirin. If you only have high blood pressure, aspirin 75mg daily produces more benefit than harm only in those aged over 50 whose blood pressure is under control. In these cases, heart attacks are reduced by 36% without any significant increase in fatal brain haemorrhages. Duration of treatment There is no cure for hypertension so treatment is usually considered to be required for life. Some people, particularly those with well controlled blood pressure who have made significant lifestyle changes, may be eligible for a trial period off treatment. However, close monitoring is still required as it can take over a year for blood pressure to rise again after discontinuing medication.
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