Step up to better blood pressure JUL 2012

StephenW

To stay in the healthy zone, lock in the basics and talk to your doctor about escalating your medications.
Are you being treated for high blood pressure but your numbers are still higher than you want them to be? Your situation is fairly common, and there is much you can do. First, lock in on the basic moves, like regular exercise, that will help bring blood pressure into line. Then you and your doctor can take additional steps, such as home blood pressure monitoring or reducing salt intake further.
When self-help measures fail, doctors are sometimes forced to add more medication, says Dr. William Kormos, editor in chief of Harvard Men's Health Watch and a primary care physician at Massachusetts General Hospital. "There are many men who are always resistant to you adding on another pill, but if people aren't doing the other things, then our only choice is to use the medications."

Hypertension danger zones Hypertension has far-reaching effects all over the body. High blood pressure not only harms your arteries, making them stiffer and narrower, but can also damage your heart, brain, eyes, and kidneys. These are known as the "target organs" of hypertension.

Out of control Whatever your blood pressure, the risk for harm persists continuously until your pressure dips below 120 systolic (the upper number) and 80 diastolic (the lower number). Above this threshold, the risks increase. For anyone diagnosed with high blood pressure (hypertension), the first goal is to bring blood pressure under control. To your doctor, that means getting the numbers below 140/90 millimeters of mercury (mm Hg).
In a report in Circulation, researchers took a look at information about people with hypertension obtained from the National Health and Nutrition Examination Survey (NHANES). The people surveyed included more than 13,000 adults with high blood pressure. Based on 2007–2008 NHANES survey data, some 68 million Americans have hypertension, and only about half of them have their blood pressure under control.
Among the 33 million out of control is a special class of people with hypertension known to doctors as "treated but uncontrolled." These are people who have sought medical treatment to get blood pressure below 140/90—or perhaps even lower if they have diabetes or kidney disease—but for whom treatment is not working well enough.
Lock in the basics Fortunately, we know what to do about hypertension. True lifetime control requires a healthy lifestyle and optimizing medications. All of the components of a healthy lifestyle act to control blood pressure. Indeed, not following these basics is what leads to hypertension.

• Maintain a healthy weight.
  
• Eat a healthy diet rich in fruits, vegetables, and whole grains Get regular physical exercise.
  
• Drink alcohol in moderation (one to two drinks per day for men).
  
• Don't smoke.
  
  

What more can you do? Have you done your best with the basics and want to escalate your hypertension care? Here are some things you and your doctor can work on together.
Adopt the DASH diet: The medically proven Dietary Approaches to Stop Hypertension (DASH) plan, especially the low-sodium version, can lower your blood pressure by 10 points or more. (You can get more details about the DASH diet at health.harvard.edu/122.) The DASH diet emphasizes fruits and vegetables and reduces saturated fat, sugar, and salt.
Reduce salt: The basic DASH diet calls for limiting sodium to 2,300 milligrams (mg) daily. Studies show that for middle-aged or older people, African Americans, and those with hypertension, limiting sodium to 1,500 mg works even better for lowering blood pressure.
Monitor your own blood pressure: There are a couple of important things home monitoring of blood pressure can do. For one, it can provide a more accurate, long-term portrait of your pressure. Also, some people experience "white coat hypertension," in which blood pressure spikes higher than normal when measured at the doctor's office. Home monitoring can prevent the white coat effect.
Make your meds work for you In established hypertension, medication plays a vital role in achieving your blood pressure goals. Taking medications as recommended is fundamental to maintaining good control. An inadequate level of medication therapy—either because you are not being prescribed enough medication, or are not taking those you are prescribed as directed—is often at the root of uncontrolled hypertension.
The NHANES survey provides some insight. In the 2005–2008 survey data, about one-third of all people with uncontrolled hypertension were already taking medication. However, seven out of 10 people in this group (treated but uncontrolled) were taking only one or two medications. These folks were older and were at significantly higher risk of cardiovascular problems than people whose hypertension was adequately controlled with the same number of medications.
Naturally, many men would prefer not to take additional medications with the added expense and potential for side effects that comes with them. But over time, inadequate blood pressure control can have devastating consequences (see box below). By combining medications that work to lower blood pressure via different physiological "control circuits" in the body, your doctor can help you reach your target pressure. "You have to add medications for some people just to get their blood pressure better controlled," Dr. Kormos says. "You try to pick medications in different classes that complement each other and won't just be redundant."
On the other hand, nutrition, exercise, and other lifestyle measures can reduce the need for such medications and potentially enable you to stop taking some of them eventually. Is it time to schedule a reality check with your doctor about your blood pressure?
How hypertension harms the body
Hypertension is called the silent killer because you don't feel its effects directly. But over the years, the quiet effects of persistent high blood pressure grow louder and more noticeable. Eventually, hypertension damages not just the blood vessels themselves, but also the heart, brain, kidneys, and eyes. These are the "target organs" of hypertension, meaning the organs most likely to be affected by the disease.

• Stroke: Arteries weakened by hypertension may rupture in the brain (hemorrhagic stroke). Or, clotting can block blood flow (ischemic stroke).
  
• Blocked arteries: Increased blood pressure damages the artery walls, causing inflammation that encourages plaque buildup and narrowing. The higher pressure also contributes to stiffening or "hardening" of the arteries.
  
• Heart attack: High blood pressure causes changes in the physical makeup of your arteries. The middle layer of the arteries thickens. The lining is less healthy and tends to form more clots. If a clot forms in the coronary arteries, it triggers a heart attack.
  
• Heart failure: Because of narrowing of the arteries, the heart has to work harder. The left ventricle, the heart's main pumping chamber, becomes thicker and more muscular in order to contract with greater force. This thickened wall is stiffer and leads to impaired filling of the heart. Over time, these abnormal walls weaken, causing the heart to enlarge and lose strength.
  
• Kidney damage: High blood pressure causes blood vessels supplying the kidneys to get narrow, weak, and less elastic, which compromises the blood supply to the kidney tissue. Also, high blood pressure damages the tiny filtering units of the kidney.
  
• Vision loss: The arteries in the eye can become narrower and bleed, damaging the light-sensing retina (hypertensive retinopathy). High blood pressure can also cause swelling in the optic nerve.
  
• Vascular dementia: Compromised blood supply to the brain can cause brain damage that accumulates over time, eventually impairing mental functioning.
  
• Erectile dysfunction: By damaging arteries that direct blood to the penis, hypertension can contribute to erectile dysfunction (ED), or the inability to achieve or sustain an erection sufficient for sexual intercourse.
  
• General organ damage: Narrowing of the arteries and increased clotting deprives the organs of adequate blood supply and its oxygen and nutrients. Tissues accumulate damage over time.