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Originally published in the Health and Stress
newsletter (July) of The American Institute of Stress
By Dr. Paul J. Rosch,
M.D., President, The American Institute of Stress, Clinical
Professor of Medicine and Psychiatry at the New York Medical
College
Up until a few weeks ago, if you asked anyone, including
doctors what they considered a normal or desirable adult blood
pressure to be, 120/80 would have been the most frequent
response.
Not any more.
According to the new JNC-7 government guidelines, 120/80
puts you in a new disease category called "pre-hypertension" and
at increased risk for heart attack, stroke, or kidney disease.
The recommendations for rectifying this potentially deadly
disorder are the usual advice to lose weight, avoid salt and
sodium rich foods, exercise regularly, stop smoking and reduce
stress. But even if you do achieve these goals, the results are
not that rewarding, even for patients with blood pressures of
160/100 and higher.
People with pre-hypertension are even less likely to find that
lifestyle modification will normalize their blood pressure,
which means that medication will be required.
Chalk another one up
for the drug companies.
The first advice generally given to all patients with high blood
pressure is to significantly restrict sodium intake. However,
the vast majority fail to respond to this unless they have
certain genetic traits. In some, calcium deficiency can be the
culprit and they improve with calcium supplementation. These
individuals may actually worsen on a low sodium regimen since
this would sharply reduce the intake of dairy products that are
the major source of dietary calcium. Others benefit from
potassium and/or magnesium supplements. Jogging and running may
help lower blood pressure for some people but more often has
little effect and can even cause a rise. Hypertension is
not a diagnosis like diabetes, but rather a description. It is
simply an elevated blood pressure reading on some measuring
device that can have many different causes. That helps to
explain why we have some
100 drugs to
treat high blood pressure. Unfortunately, there is no algorithm
to guarantee which one will work best or be the safest for any
specific patient.
Risk Factors
And Other Fallacies
In order to successfully treat a disease it is necessary
to remove or reduce its cause rather than its manifestations or
markers. Treating a persistently elevated blood pressure is very
different than treating an elevated blood sugar. While the goal
in diabetes is to lower the blood sugar to normal, responses to
medication and/or diet are much more predictable and sustained
since the cause can almost always be identified. Giving
non-specific drugs just to bring an elevated blood pressure down
to normal could do more harm than good in certain situations –
especially for many older individuals with arteriosclerotic
vessels, where a higher blood pressure is needed to maintain
adequate blood flow to the kidneys and other vital organs.
Whatever happened to the good old days when a normal systolic
pressure was 100 plus your age? Not everyone agrees with this
and the upper limit is now usually considered to be 140/90, even
for people over 70. Indeed, some senior citizens consistently
complain of weakness and dizziness if their blood pressures are
lower than the 120/80 value that is now recommended. This is
particularly true for women, who normally tend to have higher
blood pressures than men in this age group. Much of this
"one-size-fits-all" approach comes from confusion over what a
"risk factor" really represents.
Most risk factors for heart disease are merely "risk markers"
that simply have some statistical association with an increased
incidence of coronary events. There are over 300 risk factors
for heart attacks, including a deep earlobe crease, (shall we
all have our ear lobes surgically removed?) premature vertex
baldness, high selenium toenail levels, having a pot belly, not
having a nap or one or two glasses of wine a day. Attempting to
treat or remove such markers will accomplish nothing since they
do not cause coronary disease. The same can be true for lowering
an elevated systolic or diastolic blood pressure unless the
treatment is directed at what is causing the problem, which is
usually not clear.
No
randomized clinical trials have ever proven that lowering an
elevated systolic blood pressure to 140 reduces the risk for
death due to coronary disease.
A good example of this was the multicenter Multiple Risk Factor
Trial (MRFIT) designed to demonstrate that reducing
hypertension, high cholesterol and smoking would lower coronary
mortality. After screening some 350,000 middle-aged men, close
to 13,000 believed to be at greater jeopardy because of a
preponderance of these putative risk factors were selected. They
were divided into a treatment group to lower these markers and a
control group that received usual care. After 10 years and $115 million,
although the treatment group substantially achieved their
objectives, they fared no different than controls who received
usual care. In point of fact, a subset of hypertensives treated
with diuretics had the highest mortality rates, probably from
ventricular fibrillation due to potassium depletion.
The MRFIT objective
was to get blood pressures below 140/90. One can only wonder
what the mortality rate would have been if under 120/80 had been
the goal.
Stress and
Pseudo-hypertension
My personal experience has been that a significant
percentage of patients being treated for "essential
hypertension" can
stop their medication without any adverse
effects. When such individuals are admitted
to the hospital for surgery or some unrelated condition and
these drugs are discontinued deliberately or inadvertently, it
is not unusual for blood pressures to fall to normal levels and
remain there, only to rise again after discharge. Stress related
or "white coat" hypertension is quite common. In one study
published in the Journal of the American Medical Association,
more than one in four patients with elevated blood pressures in
the doctor's office were found to have normal values on
ambulatory monitoring. All were taken off drugs with no adverse
effects.
Decades ago, when healthy young men being examined for
insurance policies or entry into the armed services had high
readings but no retinopathy, albuminuria or other indication of
sustained hypertension, we used to reassure them and have them
lie down and relax in a quiet room. After 15 or 20 minutes,
repeated measurements were invariably much lower and usually
normal. Busy doctors don't have time for that today. It's much
easier and safer for them to prescribe a pill, since everyone
knows that hypertension is the "silent killer". In addition,
treating hypertension is easy, doesn't take much time or energy
and is apt to be quite remunerative since periodic
electrocardiograms and chest X-rays to monitor cardiac size and
laboratory tests are readily justified. Only a few questions
need to be asked, the patient often does not need to disrobe in
an examining room and the entire encounter often takes less than
ten minutes.
A not uncommon scenario is that when the patient returns
after the initial diagnosis of hypertension has been made and a
medication has been prescribed, he or she is even more nervous,
blood pressure is still high or higher and the dose is
increased. This may be repeated on subsequent visits and/or
additional drugs are ordered. The result may be dizziness or
other side effects that the patient now attributes to a
worsening of hypertension, causing even more stress. It is also
not generally appreciated that heart rate and blood pressure
shoot up whenever we speak or try to communicate in some other
way. The seminal investigations of this phenomenon showed that
such elevation is greater if we are talking to someone of
perceived higher social stature, more rapidly than usual, and if
the content of the conversation deals with some important
personal issue. Blood pressure rises in deaf mutes when they use
sign language but not when they move their hands meaninglessly
but with the same amount of energy.
We have also found that these rises are not blunted by any
anti-hypertensive drugs and are actually exaggerated by beta
blockers. It is not uncommon for anxious patients to talk
immediately prior to or even while the doctor is inflating the
cuff, which can increase blood pressure up to 50 percent in some
people. Time of day, room temperature, a full bladder, eating,
drinking or smoking within the past hour, and even the size of
the cuff used by the blood pressure device can all influence
measurements.
HEALTHSAVERS
COMMENTS
Let's recognize
this 'pre-hypertension' initiative for the scam that it is.
Considering the unscientific
methodology leading to the diagnosis (and the many
health-promoting non-pharmaceutical options available)
condemning so-called 'pre-hypertensives' to a lifetime of
health-destroying drug therapy can only be an obvious attempt by
the drug industry to expand their market.
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