FACC is the Physician Practice Director and Attending Cardiologist at Caediovascular Health, Riverside Medical Group in Williamsburg, Virginia. His Practice includes invasive cardiology, Cardiac device therapy, nuclear Cardiology, echocardiography, Cardiac CT and vascular medicine. His passion is preventive cardiology and patient safety. Dr. Ananthram is also an expert contribuior to health tap which is a leading physician patient interface.
ALL YOU WANTED TO KNOW ABOUT BLOOD PRESSURE
What is blood pressure?
Blood pressure, as most of us know, is designated by two numbers. Example as-120/80 The top number (120) or the systolic blood pressure (SBP) is the pressure in the blood vessels while the main pumping chamber of the heart is squeezing. This is dependent upon the volume of blood being ejected, the diameter of the blood vessels, the elasticity (or stiffness) of these blood vessels. The bottom number(80) or the diastolic blood pressure (DBP) is the pressure in these blood vessels while the pumping chamber of the heart is relaxing and is mainly dependent on the elasticity (or resilience) of the blood vessels. This seemingly simple explanation is however dependent on a complex interplay of a variety of chemicals in the body known in medical jargon as neurohumoral mechanism.
Why should there be blood pressure?
While pressure in the blood vessels is vital to bring blood to the various organs of the body, high blood pressure (hypertension) can cause over the course of time, damage to both the blood vessels and the various organs. This leads to premature aging of the blood vessels and organs leading to heart attack, stroke, kidney failure and poor circulation. Unfortunately most cases of hypertension are without symptoms and hence may be unrecognized and untreated thus lurking as a silent killer.
How is Hypertension classified?
Present guidelines classify blood pressure as noted below. The higher the blood pressure is over the normal limits, the greater is the risk of disease resulting from it. Normal blood pressure: SBP < 120 and DBP< 80 Prehypertension: SBP 120 to 139 and/ or DBP 80 to 89 Hypertension: SBP > 140 and/ or DBP > 90
What are the implications of hypertension?
Hypertension is a very preventable and treatable disease. Treatment of hypertension has enormous implications in decreasing the incidence of heart attack, congestive heart failure, atrial fibrillation (irregular heart rhythm), disabling stroke and kidney failure requiring dialysis. Hence the urgent need to increase public awareness.
Why does one get hypertension?
To answer this, one has to consider two types of hypertension.
Commoner type This is essentially due to a combination of genetic, environmental (unhealthy eating, lack of adequate exercise, high stress, obesity, excess alcohol intake, smoking) and age related factors which cause a lot of changes in the body. These changes include increase in the blood volume, hardening of the blood vessels, increase in the resistance of the blood vessels due to an excess of certain chemicals and a lack of others, and damage to the kidneys; all of which contribute to the development of hypertension. While there is not one correctable cause, a healthy life style has a favorable effect on these changes and helps improve blood pressure.
It is less common and noted more in adolescents and young adults. There is usually one identifiable cause which when dealt with can result in curing the problem. Examples include primary hyperaldosteronism and pheochromocytoma (resulting from tumors and hyperactivity of adrenal glands); hyperthyroidism and hypothyroidism (over and under activity of the thyroid gland), hyperparathyroidism (over activity of the parathyroid glands), Cushing’s syndrome (overproduction of steroids in the body), coarctation of the aorta (narrowing of the main blood vessel leaving the heart) and renal artery stenosis (narrowing of one of the blood vessels of the kidneys). Infrequently these factors may also contribute to difficulty in controlling hypertension in the elderly.
How is hypertension diagnosed?
Blood pressure is a dynamic entity varying by as much as 25 points or greater between different measurements. Hanging the hat on one or two readings will either lead to over or under diagnosing the problem! Diagnosing hypertension in the doctor’s office usually requires several readings at different times. For instance, if a blood pressure of 140-159/ 90 to 99 is noted for the first time, the doctor will generally advice life style modifications and check the blood pressure several times over six months before starting medications. The situation however becomes more urgent if there are other significant risks for heart disease or if there is evidence of organ damage in which case the decision will be made much sooner. Blood pressures of 160-179/ 100 to 109 will be followed up sooner and decision about medical treatment will be made by the third visit (or immediately if other risk factors or organ damage is present) Blood pressure over 180/ 110 usually warrant starting treatment right away upon conformation of the reading over 30 minutes Similarly normal or pre-hypertension should be confirmed by periodic readings. Prehypertension requires effective life style modification and reassessment in 6 months to a year.
Every year 10 percent of patients with prehypertension will convert to hypertension!
White coat hypertension is a well recognized entity where in the blood pressure is abnormally high only in the doctor’s office and not elsewhere! This usually carries a good prognosis. In making this diagnosis your doctor will confirm the absence of any organ damage from high blood pressure such as kinking of arteries in your retina, absence of abnormal thickening of your heart muscle which is evident by an ECG and absence of any protein in the urine in addition to reviewing several out of office blood pressure readings. Masked Hypertension- Quite the opposite of white coat hypertension! It is encountered by solely relying on an office blood pressure reading. This simply means that the blood pressure reading in the doctor’s office was normal but other daytime readings are consistently higher. Thus the diagnosis of hypertension can actually be missed.
What is home self blood pressure monitoring?
To circumvent problems of blood pressure measurements in the doctor’s office, self blood pressure monitoring at home has comes very handy. In fact, it is well established that self- blood pressure measurements have a much better correlation with outcomes than office measurements. [Note: In doing self blood pressure monitoring, one should procure an instrument that is validated by AAMI (American Association for the Advancement of Medical Instrumentation). An apparatus which has memory makes it easier to track readings over time and obtain an average. One should be seated relaxed with adequate back support, feet planted on the ground and supporting arms at the level of the heart.
The cuff should be properly applied following the manufacturer’s instructions. During the initial evaluation blood pressures should be checked twice a day for seven days. Day 1 which is usually higher should be discarded and the other blood pressure readings should be averaged. If the average reading by such measurements is greater than 135/ 85, aggressive life style modification and/ or medical treatment is generally warranted. If it is less than 135/ 85, a healthy life style and periodic assessment is generally sufficient in the absence of other compelling conditions. Similarly such average blood pressure readings by self monitoring can also help to check the efficacy of treatment. Please do not drink caffeine or smoke for half hour prior to the blood pressure measurement (better still do not smoke ever!)]
What are the life style changes to be adopted?
- Positive life style changes are very much important in not only controlling blood pressure but also a host of other risk factors such as high cholesterol, diabetes and obesity.
- A diet emphasizing plenty of fruits and vegetables, whole grain, low fat dairy, low sodium (decreasing salt intake in half) was studied under the acronym DASH (Dietary Approaches to Stop Hypertension) and had positive effects in controlling blood pressure. Minerals such as calcium, potassium and magnesium are important in achieving good blood pressure control. However the results are forthcoming only when these nutrients were obtained thorough a wholesome diet rich in nutrients rather than concentrating on individual components. The sum of the whole is greater than its parts!
- Weight loss has been shown to substantially reduce blood pressure in overweight patients. Attaining an ideal body weight may be far fetched and disheartening for some obese patients. However studies have shown that maximal benefits can be obtained by shedding as little as 10 to 12 percent of one’s body weight. For instance a 300 pound individual can obtain maximal benefit by loosing 30 to 36 pounds which is very attainable by sustained effort. The benefits are far greater and longer lasting when this is achieved by healthy diet and exercise.
- Aerobic exercise for as little as 60 to 90 minutes a week at a comfortable level has been shown to lower blood pressure by an average of 12/ 8 points. This is easily done even by those hard pressed for time
- While alcohol in moderation (such as one drink a day for women and one to two drinks a day for men) may have beneficial effects, excessive alcohol intake is counterproductive and results in difficult to control hypertension, high triglycerides and obesity. Hence excessive alcohol intake should be avoided. Needless to say, smoking should be entirely discarded (decreasing rather than giving up smoking entirely has not shown to reduce the risk of heart disease or stroke).
- Sleep apnea characterized by disturbed sleep, excessive snoring, day time sleepiness and fatigue can result in resistant hypertension. It is important that this is recognized and treated not only to improve blood pressure control but also to avoid a host of other complications. It is important to inform the doctor about any of these symptoms.
- Ultimately, in order to achieve good blood pressure control it is important to take the prescribed medications properly and persistently. Discussion with the doctor about any problems causing nonadherence to treatment either due to cost, complexity or side effects is important. There is quite an array of medications available to allow tailoring appropriate regimen for most patients.
IS MY CHEST PAIN SERIOUS?
Q: How do you tell the difference of chest pain between a heart attack and other causes?
Chest pain due to heart problem is called Cardiac pain and that not due to the heart is non-cardiac pain. There is no fool proof way to distinguish between these two conditions by symptoms (Patient’s complaints) alone. It merits evaluation by a health care provider and even further diagnostic testing in order to rule out the life threatening causes of chest pain. Angina: Chest pain of cardiac origin is most frequently a result of an interruption of blood flow to the heart due to a partial or complete blockage of the coronary arteries (blood vessels that supply blood and hence nutrients and oxygen) This type of chest pain is called Angina. If the interruption of blood supply is gradual and partial, it results in a less threatening condition called stable angina. If on the other hand the interruption is sudden and near complete or complete, it results in a life threatening condition called unstable angina or a heart attack.
Anginal pain is usually described as chest heaviness, pressure, tightness, constriction, burning or an ache. It is usually diffuse and hard to pin point one area as the site of pain and is typically provoked by physical exertion, emotional stress, or cold exposure. It may commonly radiate to the neck, jaw, back, shoulder and arms. In stable angina, paint is commonly relieved within 2 to 5 minutes of resting. However if the pain is gradual in onset but worsens progressively to a point of being relentless may be associated with symptoms such as profuse sweating, cold clammy sensation, shortness of breath, nausea, vomiting and a sense of doom. This may be life threatening unstable angina or heart attack.
What are other life threatening causes of chest pain?
1. Aortic dissection:
Aorta is a major, large blood vessel that arises from the heart.Aortic dissection means a progressive tear in the aorta. Aortic dissection is usually associated with an intensely severe chest and/ or back pain of sudden onset often described as a tearing or ripping sensation.
2. Pulmonary embolism
In Pulmonary Embolism, a blood clot lodges in the lungs causing sudden shortness of breath and chest pain on either side of the chest which may worsen on breathing. The life threatening causes of chest pain require immediate medical attention. Hence any acute and previously undiagnosed chest pain lasting greater than 5 minutes calls for emergency medical attention to rule out these conditions. Non-Life threatening, non-cardiac chest pain Acid reflux Known in medical jargon Gastro-Oesophageal Reflux Disease (GORD) is the most common non cardiac cause for chest pain. It is important to exclude cardiac and other life threatening causes while making this diagnosis. Symptoms can be hard to differentiate from cardiac chest pain since the heart and the esophagus share common nerve supply and hence can produce similar symptoms. Pain can last from a few minutes to a few hours, usually intense at onset and easing gradually, may occur after eating or when lying down. It might even waken someone from sleep! It may or may not be related to exertion, may be provoked by bending or stooping. It causes regurgitation of stomach contents and a burning sensation in the middle of the chest. It may be associated with difficulty swallowing and may be relieved with antacids.
Once cardiac condition is excluded it may be treated with a high dose of acid suppression medications for 6 to 8 weeks. Relief of symptoms commonly confirms the diagnosis. If still unrelieved other tests may be required such as ambulatory esophageal pH monitoring to evaluate the acidity of the esophagus, manometry to look for abnormal esophageal contraction and endoscopy to rule out conditions such as ulcers, infections or tumors. There are still umpteen other less common causes for chest pain. But the most immediate concern is to rule out the life threatening conditions which require prompt medical evaluation. In conclusion, though all cheat pain may not be cardiac pain, no chest pain is trivial enough to be ignored!!.