30% of hypertensive people are unaware of their condition, which puts them at risk of acute complications such as heart attack and stroke, and chronic slow progressive organ damage, such as kidney failure, often requires dialysis. So, how can we diagnose early, control or reverse to prevent complications?
Normal blood pressure is less than 120/80. This is not an arbitrary figure: research has proven that disease risk increases beyond this level, and at a higher BP level, mortality also increases .
Why do we have high blood pressure?
The heart and circulation are the body’s transport system. Flexible and clear arteries help transport oxygen and nutrients to every cell in the body. Unfortunately, the development of cholesterol plaques along the arterial wall causes them to stiffen. This forces the heart to pump harder to push blood through, resulting in high blood pressure.
Hypertensive patients can rarely present with fatigue, headache, or giddiness. High blood pressure (BP) can rupture tiny blood vessels in the nose, often causing severe nosebleeds.
However one-third of people with hypertension are unaware of it. You can have high blood pressure for years without any symptoms – that is why it is known as “the silent killer”.
Hypertension can affect us in many ways
Underdiagnosis of hypertension puts patients at risk of heart attacks and strokes. Many patients admitted to the hospital with these complications are not aware of having high blood pressure.
Even without symptoms, hypertension can quietly damage your body for years. Hypertension can cause bleeding or infarction (damage due to loss of blood supply) of the retina, resulting in vision loss.
In the brain, hypertension can also cause mild cognitive impairment or full dementia due to damage to tiny blood vessels (vascular dementia).
In the kidney, hypertension damages the filtering units, which often progresses to renal failure (ESRF), requiring dialysis.
Heart (pump) failure
The heart continues to pump harder against stiff arteries until the heart muscle becomes weak, initially causing left heart (ventricular) failure, which presents with difficulty breathing, especially with effort. The high pressure generated in the heart impedes the return of blood from the lungs, resulting in lung congestion when the person lies flat in bed at night, necessitating more pillows to sleep in a semi-sitting position.
This progresses to right heart failure, resulting in a build-up of blood in veins, leading to fluid retention. This initially shows up as ankle oedema that progresses over time to swell the abdomen and the genitals.
50% of people with high blood pressure also have sleep apnoea. Blood pressure is expected to fall at night but may not if you have sleep apnoea. You experience a cortisol surge every time your oxygen drops, which raises your blood pressure.
Hypertension is underdiagnosed in lean people, who can, therefore, have worse outcomes. A study proved that lean hypertension patients had the highest all-cause mortality compared to overweight and obese people.
This means we should adopt a strategy to detect cases early. Using simple technology available for everyone to implement.
Home BP readings
We can start home blood pressure monitoring. It’s a cheap and effective way to monitor your blood pressure at home. Not under any stress, these readings are reliable; doing them over time can establish a pattern that helps your GP’s evaluation.
With the recent increase in the quality of home BP apparatus, people can monitor their blood pressure. If possible, follow the American Hypertension Society guidelines:
- Take the reading at the same time of the day.
- Take the reading at least 30 minutes away from caffeine, nicotine, or exercise.
- Empty your bladder and rest for 5 minutes.
- Sit upright with your elbow resting on a table and the BP cuff at heart level.
- Take the measurement on bare skin, not over clothes.
- Take 2 to 3 readings one minute apart.
- Do not talk during the readings.
The old system of taking a single measurement in a hospital is unreliable and can cause a lot of confusion due to what is known as white-coat hypertension. This is usually explained as doctor-triggered anxiety, but it could be an early sign of more serious blood pressure complications.
A study revealed that white-coat hypertension could increase the risk of stroke, heart attack, heart failure and other vascular complications.
The dilemma resolved in most Western countries adopting the 24-hour ambulatory blood pressure monitoring as a reliable diagnostic tool. This should be an integral part of hypertension care.
Screening programmes
Hypertension is a common condition. You can only screen part of the population. It is sensible for GPs to focus on the high-risk group, which includes the sedentary, obese, and overweight people, but also normal-weight people with belly fat. People with other metabolic conditions, such as high cholesterol, diabetes, and gout.
We should also target menopausal women. Men are more likely than women to have high blood pressure, although this is reversed after the age of 65 due to the loss of protective oestrogen in women. Women’s metabolism slows down at the life turn, they gain weight and become vulnerable to metabolic conditions, including high blood pressure.
We also need to focus on people living in deprived areas where many risk factors of hypertension exist. These include smoking, excess alcohol and caffeine. They eat processed food, high in salt, but fewer fruits and vegetables.
Beware of the risk of falls and fractures
Prescribing hypertension medications to older adults without a proper diagnosis and a assessment puts them at risk of falls and fractures.
An American study revealed that antihypertensive medications were associated with an increased risk of serious fall injuries. The potential benefit/ harm balance should be assessed with great care in older adults with multiple chronic conditions.
This is because, hip fractures are associated with a higher mortality rate in older adults. One study revealed that those aged 65-69 who experienced a hip fracture were five times as likely to die in the first year following the adverse event.
Management of hypertension
The management of hypertension has moved from relying on medication 100% to 20%, with the other 80% being lifestyle changes.
Doctors agree that patients with very high blood pressure should receive immediate medical attention and medication to lower their blood pressure to a safe level before adopting any lifestyle changes.
However, a ground-breaking study showed that only 30% of patients on long-term hypertensive medication get their blood pressure under control.
By contrast, obese patients with high blood pressure will benefit from achieving their ideal body weight. By reverting to a normal BMI, most obese patients control their blood pressure without further effort.
Even reducing your body weight by 5% or, much better, by 10% has a positive impact, meaning most patients can come off some of their medications.
Diet Approach to Stop Hypertension
Abbreviated to the DASH diet, this is helpful to most patients. Like the Mediterranean diet, high in fruits and vegetables, which are rich in potassium, the nutrient that lowers blood pressure. DASH is low in salt, a well-known risk factor for high blood pressure. It is high in fibre in beans, nuts, and seeds, ensuring reasonable blood sugar control. It is rich in oily fish, high in anti-inflammatory Omega 3. DASH reduces alcohol (a high-risk factor) and caffeine in tea, coffee, sports drinks, and hot chocolate.
In addition to DASH, you can increase your potassium intake by eating green bananas, avocados, sweet potatoes, and leafy greens such as kale and spinach.
Leafy greens are also high in nitrite, which gives nitric oxide, the chemical that relaxes your arteries and lowers your blood pressure.
Reducing sodium, which is high in processed food, is particularly important for people with genetic salt sensitivity. This is true for all types of salt, including pink Himalayan and sea salt.
Take more magnesium, which is essential for relaxing the blood vessels. Foods rich in magnesium include seeds, nuts, and dark chocolate.
Vitamin D is known to stabilise both systolic and diastolic BP. Treat those people with low vitamin D with supplements and regular daily sunshine, free of charge!
Vitamin K2 is essential for moving calcium from the arteries, where it can harden the walls, into the bone, where it belongs. Foods rich in vitamin K2 include egg yolks, grass-fed butter, and cheese.
Hibiscus tea is wonderful for lowering BP. Take 2-3 cups every day.
Exercise
The hypertensive patient should gradually start adopting gentle physical activity. This should start with cardio, like walking around the block, and gradually increase the distance, aiming for 30 minutes of brisk walking at least five days a week. Over 6 to 8 weeks, this should build up an excellent cardiopulmonary (heart-lung) fitness base. You can then progress to the next level by adopting strength or high-intensity interval training.
The low-grade cardio activity helps your cells to increase the number of mitochondria (energy plants). With more energy plants in your cells, you then progress to optimise mitochondria function through strength and high-intensity training. The latter also helps you build your muscle mass. An enormous muscle mass accelerates your metabolism. This puts you in the right direction to burn fat, lose weight and control your blood pressure.
Owning a pet keeps your blood pressure at bay
Other positive steps include getting an adequate restful sleep in a dark room at night and enjoying the sunshine during the day to establish a good circadian rhythm, which improves sleep quality.
Lower your stress level by practising meditation, deep breathing, listening to your favourite music and humour, taking Epsom salt baths, walking in nature, and having pets!
A study found that pet owners had lower blood pressure than non-owners and a lower incidence of hypertension.
I have met patients who made these simple changes and who are now well enough to come off their pills, and some can give up their overnight CPAP as they recover from sleep apnoea.
Hypertension is underdiagnosed: one-third of cases are unaware, increasing the risk of acute complications such as heart attack and stroke and chronic, slow multi-organ damage. Early diagnosis using simple technology is critical to controlling and reversing hypertension. Using straightforward life changes that need not include medication.
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References
Prevalence and Associated Risk Factors of Hypertension: A Cross-Sectional Study in Urban Varanasi
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5733954/
Obesity, malnutrition, and the prevalence and outcome of hypertension: Evidence from the National Health and Nutrition Examination Survey
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10018144/
Antihypertensive Medications and Serious Fall Injuries in a Nationally Representative Sample of Older Adults
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4136657/
Hip Fracture and Increased Short-term but Not Long-term Mortality in Healthy Older Women
Twenty-Four-Hour Ambulatory Blood Pressure Monitoring
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356999/
Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension
https://www.nature.com/articles/s41569-021-00559-8
Pet Ownership and Cardiovascular Risk: A Scientific Statement From the American Heart Association
Why don’t you want high blood pressure?
https://thevitalityclinic.co.uk/why-dont-you-want-high-blood-pressure/
