3. TREATMENT OF HYPERTENSION

MEDICAL TREATMENT OF HYPERTENSION

Hypertension is present in 20% of all Americans and is even higher in those over 50. Control of hypertension has been proven to be effective in preventing heart attacks, heart failure, and strokes. Virtually all prescription drugs have side effects, and some of the common ones are mentioned, but obviously someone taking medication for hypertension should not make changes or stop a medication without discussing it with his or her physician.

Diuretics are first-line therapy for many, and include hydrochlorthiazide (HCT), and Hygroton. Stronger “loop” diuretics are Lasix and Edecrin. Side effects include lowering the potassium levels, muscle cramps of the leg, and frequent urination leading to interrupted sleep. Potassium-sparing diuretics include Dyazide, Amiloride, and Aldactone. Many people end up needing to taking prescription potassium, 800 mg.(20 mEq)a day, but this can frequently be avoided by getting the potassium in the diet. It is well known that a banana contains potassium (10 mEq), but it is less well known that a baked potato contains 15 mEq of potassium. Diuretics are frequently used in combination with other types of hypertension drugs.

ACE inhibitors (angiotensin converting enzyme) are also often used as first-line. It has been shown to be particularly protective of the kidneys and heart when impairment is present. They are even recommended for diabetics who don’t have hypertension but have protein in the urine (a very early sign of kidney disease). Examples are Lisinopril, Lotensin, and Capoten. An occasional side effect is hives.

ARB’s (angiotensin receptor blockers) are equally protective for the heart and kidneys. Examples are Cozaar,Benicar,and Diovan.

Beta blockers counteract adrenaline, and are excellent for people who have other indications for them, such as migraine, angina, heart attack, heart failure, and even stage fright. It is less often used initially. Examples are Inderal, Atenolol, and Lopressor. They slow the heart rate, which often is a desirable effect.

Calcium-channel blockers (Cardizem, Verapamil, Calan, Norvasc) and direct vasodilators (Hydralazine and Minoxidil) work by dilating arteries. Some of these can cause annoying swelling (edema) of the legs.

Central alpha-adrenergic agonists (Catapres) decrease the activity of the nerves that interact with adrenalin. They are very effective used with other drugs for severe hypertension, but frequently cause fatigue that may limit their use.
An important principle in dealing with your hypertension is “don’t give up.” The majority of people with hypertension need more than one drug for good control. If a diuretic is used initially, an ACE inhibitor or ARB can be added for better control, and vice versa.

I have seen over the years instances of people who don’t take their blood pressure medicines because of the expense. Most diuretics,some ACE inhibitors and beta blockers are inexpensive. ARB’s tend to be expensive. Many times doctors may not know the cost of some of the medications they are prescribing. The pharmacies of Walmart, Target,and Shop Rite have lists of generic drugs for less than $4 a month, which is often less than insurance copays. Generics are regulated by the FDA and there hasn’t been a problem with generic anti-hypertensive drugs in decades. There are drugs from each class of anti-hypertensives with the exception of ARB’s on these lists. Don’t hesitate to discuss with your physician the use of these lists. $12 a month will enable most patients to take even 3 medications for hypertension, if that’s what’s necessary. Many drug stores enable you to get a blood pressure reading free of charge, so it’s easy to keep track of your blood pressure between office visits.
The message to remember is that good control of hypertension does work and does prevent serious,even catastrophic,illnesses.

THE NON-DRUG TREATMENT OF HYPERTENSION

In my second year of medical school, a cardiologist stated on our initial lecture on hypertension that once a patient has a high blood pressure reading, he or she always has to be on an anti-hypertensive drug for life. It is now known that the statement was totally false. Although the inaccuracy of this blanket statement is known by a growing number of Americans, the effectiveness of the non-drug treatment of hypertension is under publicized to the public, and as a result, underused.

Weight reduction: Not everyone with hypertension is overweight, but it is a major risk factor in hypertension. In those that are, weight reduction can lower blood pressure. The percentage drop in weight necessary to see a difference varies frequently from 10 to 30%.

A “2 gram sodium restricted diet” has been standard suggestions to those with hypertension for years. In the 1950’s, when only a few anti-hypertensive drugs were available, the “Duke University” diet used a brown rice and fruit diet and frequently dramatically lowered the blood pressure. A common response to telling a patient that salt restriction may help their hypertension is “I don’t add any salt to my food.” Studies have shown that the usual American diet can still contain over 5 grams of sodium without using any table salt. Now that food products are labeled, reading labels for the first time for sodium content can be quite shocking. Soups frequently contain 700 mg. of sodium per serving, and many people eat two servings at a meal. Fast food outlets frequently have sodium information available on the internet, but how many people actually take the time to research this information? Most people know that fast food french fries are salty, but how many know that fast food hamburgers frequently contain as much sodium as a serving of French fries.

A study published in September, 2009 in the American Journal of Health Promotion estimated the effect that a reduction of sodium to 2300 mg./day in the United States. Hypertension cases was predicted to be reduced by 11 million cases, saving in health care costs would total $18 billion, and 312,000 quality of life years would be gained, worth $32 billion annually.

Vitamin D insufficiency has been shown to adversely effect enzymes related to the control of blood pressure, and some studies have shown that correcting the insufficiency can improve blood pressure. Remember, at least 70% of Americans have vitamin D insufficiency, and over 95% have levels that are less than ideal.

Calcium supplementation has been reported to have a minor effect on lowering blood pressure. The calcium data is questionable, as the same dairy industry that has been accused of sponsoring deliberately misleading studies is behind much of the calcium data. Societies with very low calcium intakes but don't have rich diets have less, not more, hypertension.

Magnesium supplementation has been shown to have a definite but small effect in lowering mild hypertension. In the October 2009 issue of American Journal of Hypertension a study gave 600 mg. of magneisum daily, and the systolic and diastolic blood pressure readings dropped a few points over 12 weeks compared to placebo.

Low animal protein diets, such as vegan or vegetarian diets, frequently lower blood pressure independent of the weight of the individual.

Exercise and relaxation have an independent effect on lowering blood pressure.

Lack of sleep, especially chronic, has been shown to have a deliterious effect on blood pressure.

Pain can acutely or chronically raise blood pressure. Severe dental pain and chronic back pain in particular has been shown to have an effect on blood pressure, but the effect can probably be found in pain of all kinds.

Alcohol has a very variable effect. Many alcoholics have normal blood pressure. But in a definite percentage of drinkers, alcohol can have a major effect on raising blood pressure, with rapid improvement with cessation of drinking.

Caffeine can raise blood pressure acutely and long term, although the coffee lobby has tried to suppress this information with misleading publicity.

Eating whole grains can lower blood pressure. In the September, 2009 American Journal of Clinical Nutrition a study showed that men who eat the top 20% of whole grains have 19% less hypertension than those that ate the bottom 20%. Other studies have shown a similar effect in women.

Avoiding high sugar foods can lower blood pressure in some people. Eating high sugar foods cause the heart rate to increase in some, but not all, people, with pulse rates increasing as much as 20 beats per minute for as much as a few hours. Along with this, the blood pressure can go up. Specifically a study was presented at the American Heart Association Hypertension Research Conference September, 2009. 74 men were given an extra 50 Calories a day of fructose for just 2 weeks. The systolic blood pressure increased by 6 mm., the diastolic blood pressure increased by 3 mm.

Patients especially who suffer from many side effects of anti-hypertensive drugs such as fatigue or erectile dysfunction can benefit from modifying the many factors in the non-drug treatment of hypertension. The information is not new; a classic article “Non-Drug Treatment of Hypertension” by Norman M. Kaplan, M.D., was published in the Annals of Internal Medicine in March, 1985.

Revised 10/18/09