Paul J. Rosch, M.D.
President, The American Institute of Stress
Clinical Professor of Medicine and Psychiatry
New York Medical College
Originally published in the Health and Stress newsletter
(July) of The
American Institute of Stress
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 guidelines, 120/80 puts you in
a new disease category called "prehypertension" 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. However,
we all know how difficult it is to achieve these goals, much less
maintain them. And even if you do, the results are not that rewarding,
even for patients with blood pressures of 160/100 and higher.
People with prehypertension 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, like fever, 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. Similarly, a fever of 103° in a patient
with lupus may require giving cortisone but if that identical 103°
temperature reading were due to tuberculosis, cortisone could bring
the fever down but might prove lethal. Conversely, appropriate antibiotics
would be an effective treatment for tuberculosis but would provide
little benefit in lupus.
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 or temperature 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.
An elevated temperature can be a purposeful physiologic response
to stimulate immune system defenses. Hyperthermia due to artificially
induced fever has been used to treat erysipelas, tuberculosis, neurosyphilis
and certain malignancies. Giving non-specific drugs just to bring
an elevated temperature down to normal could do more harm than good
in certain situations.
The same may apply to 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.
Nevertheless, some senior citizens will 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, 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 Pseudohypertension
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 have been done by Jim Lynch who showed that such
elevation are 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. The only time this does not occur is in schizophrenic
patients off of medication, possibly because they no longer communicate.
I have been involved in this research with Jim for over 25 years.
Although these transient spikes in both systolic and diastolic pressure
can be alarmingly high, patients are completely unaware of this
and have no symptoms. By using an automated blood pressure device
that displays systolic, diastolic and mean arterial pressure on
a monitor, it is possible to teach patients how to lower their pressures.
We have also found that these rises are not blunted by any antihypertensive
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. There is no good evidence that
such hyperreactivity is associated with any increased incidence
of sustained hypertension. The same is true for elite
weight lifters, who can have pressures of 400/250 or higher when
they perform the supreme Valsalva maneuver.
Another source of pseudohypertension is
that the same size cuff is used for all adults, which can cause
significantly false high readings in fat arms. The width
of the cuff should be 40 percent of the circumference of the arm.
This is important because of the large number of obese people and
others who are engaged in body building activities. Time of day,
room temperature, a full bladder, eating, drinking or smoking within
the past hour, standing, sitting or supine can all influence measurements.
Read the second
portion of this article in the next newsletter.
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