By Dr. Jerome Robinson, MD., Cardiologist
Lifestyle modification by reducing salt intake, lowering the intake of alcoholic beverages to one drink a day for females, two drinks a day for males, increase in the use of fresh fruits and vegetables, and a reduction in the intake of red meat, along with a Mediterranean-type diet or the DASH eating program encompasses those ideals for lifestyle modification concerning diet and can be found online by Googling it on your cell phone or your computer.
The DASH diet can reduce systolic blood pressure by 8 to 12 mm of mercury and diastolic as much as 8 mm of mercury. This reduction in blood pressure is as good as 1 antihypertensive medication.
Let’s reduce the incidence of stroke, heart attack, and late stage renal disease, or ending up on dialysis and congestive heart failure. We can do this as long as you understand your increased risk of these consequences and know your numbers.
Our problem, of those diagnosed with hypertension (high blood pressure less than 60%), can be controlled.
There may be confusion on the part of Physicians as well as patients because, at last count, there were at least eight different guidelines proposed nationally and internationally for the management of elevated blood pressure. There are also concerns and confusion because there is no optimal blood pressure goal for patients with a prior stroke or those with diabetes, even though groups representing diabetics, as well as groups representing the hypertension community, have goals.
Our aim is for a systolic blood pressure goal of below or equal to 130 over 80 for all patients with cardiovascular disease, according to the American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines.
We advocate for this goal for patients who do not have cardiovascular disease but who have an increased risk of its development by greater than 10% in the next 10 years. This includes those with diabetes, chronic kidney disease, congestive heart failure or stroke; as long as it can be done without any adverse consequences secondary to therapy.
For those older patients greater than 75 to 80 years of age, we say start low and go slow with medication adjustments. We are also careful in selecting initial therapy as well as adding on drug therapy. We want to make sure to use drugs from different classes, depending upon the patient.
Remember, one size shoe does not fit all. There are also ethnic and social considerations to be made.
Identifying patients with resistant hypertension, defined as blood pressure not under control on three different medications of different classes, one of which should be a diuretic, we consider the following. Obstructive sleep apnea or any sleep deprivation is associated with a greater cardiovascular risk and can be treated appropriately. We also advocate four good sleep hygiene, with at least seven to eight hours of sleep for optimal health. Less than 6 to 7 hours of sleep per day may be a risk factor for cognitive decline, i.e., Alzheimer’s Disease. Obesity and low physical activity are other risk factors that are prominent in African American females and predispose them to the development of cardiovascular disease in the future.
Lastly, I must mention pregnancy-related hypertension as defined as hypertension occurring during pregnancy. Eclampsia or preeclampsia (disorders of hypertension during pregnancy) are significant risk factors for the subsequent development of hypertension and clinical cardiovascular disease, diabetes and hypercholesterolemia. These women need careful follow-up and screening for the subsequent development of cardiovascular disease. The treatment of hypertension during pregnancy has changed as well as the blood pressure threshold at which to initiate therapy. Initial drug therapy for this condition has also changed a great deal over time.
Hypertension is one of the most important causes of maternal and fetal death in pregnancy, particularly in the USA and among African American females. The United States ranks just below 50th among developed countries for maternal and fetal complications, including death and hypertension is one of the biggest risk factors.
I believe in intensive blood pressure control without its attendant complications in high-risk individuals in order to reduce the risk of development of cardiovascular disease in the future. This must be done as long as it is balanced against the risk of developing adverse consequences of therapy. I understand the cardiovascular risk benefit ratio may be less clear in diabetic patients, as well as older patients who have chronic kidney disease. This requires clear patient-physician communication, shared decision making and establishing clear goals of therapy.
Finally, confusion among patients and Physicians would be considerably reduced if various medical societies would collaborate on the development of hypertensive guidelines. We need a document that is generalizable to the approach to the treatment of hypertension.
Stay tuned next week. I will try to tackle congestive heart failure and try to make it a little bit more understandable.
