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Hypertension

By: Bruce Leppink, M.D. - White Bear Clinic

One quarter of Americans have elevated blood pressure.  Hypertension is defined when blood pressure in the arteries is too high.  A patient without other medical problems is considered to have hypertension when the blood pressure is greater than 140/90.  The top number is called the systolic blood pressure and the bottom number is called the diastolic blood pressure.  Both of these numbers do not need to be elevated in order to have hypertension. Treatment for blood pressure is usually recommended when blood pressure is elevated greater than 140/90, though 130/80 is used for initiation of blood pressure management for such high risk groups as diabetics.

It is felt that one third of people with hypertension have their blood pressure well controlled, one third are not well controlled, and one third are unaware that they have high blood pressure.  There have been many attempts to get the one third who don't know identified through ad campaigns such as "Know your number."  This ad campaign ran several years ago and this did lead to increased awareness by patients of their blood pressure.  MinnHealth has required for years that blood pressure be checked at every visit to help better identify and treat hypertensive patients. 

Once identified, there has been a push by the medical community to get the one third that are at less than ideal blood pressure to goal. One of the main obstacles to ideal blood pressure control was found to be doctor and patient resistance to adding more medications until the ideal blood pressure was reached. It was found that in the group that had well controlled blood pressure that the majority required two to three blood pressure medications to achieve normal blood pressures.  A moderate dose of several medications proved to do better than a large dose of one medication. With this method of treatment, effectiveness was increased and side effects were usually reduced.

Patients who were made aware of the goals and the risks of not getting to goal were much more accepting of the multiple medication approach.  As a general rule, on initiation of a medication the higher your blood pressure or the lower the target goal, the more medications that will be needed to treat to goal.  Though the treatment usually is only initiated when the blood pressure is greater than 130- 140/80- 90, the risk for stroke or heart attack actually starts increasing when the blood pressure is greater than 120/75. This is why a patient and doctor should try to get the blood pressure as close to ideal as possible, even if it means multiple medications.

So with the goal of aggressive lowering of blood pressure set forth, it is very important to assess blood pressure accurately. The guidelines for accurate blood pressure management are as follows:

• The patient be seated with their feet resting comfortably on the floor in a chair that has a back.
• The patient should not have used any caffeine or nicotine products within the thirty minutes prior to taking the blood pressure.
• The patient should have been allowed to be in a resting state for approximately five minutes prior to the blood pressure being taken, and if elevated on the initial evaluation, it should be repeated again after five or ten minutes.
• The proper blood pressure cuff size should be used.  A general rule of thumb is to use the largest cuff that fits the patient appropriately.
• The patient should not have their legs crossed, either at the knee or at the ankle.

Therefore, this technique usually requires the patient NOT to be seated on an exam table, as this often leaves the patient's legs dangling and sitting without a well controlled back rest.  It is important that the patient assist with the blood pressure monitoring in that if they are seated on the exam table when the blood pressure is taken and it is elevated that they ask it to be rechecked while sitting in the chair.  Also that they ask if the examiner is using the largest size appropriate cuff. 

Just as it is important for diabetics to check their blood sugars at home, it is important for hypertensives to check their blood pressure at home.  Patients should write down their blood pressure readings and bring readings to their next doctor visit.  Sometimes significant differences can be found between the home readings and the office readings.  Therefore, a patient can further assist with their own blood pressure monitoring by purchasing a home blood pressure cuff to acquire more blood pressure readings.  Consumer Reports has reviewed these monitors in the past and has recommendations that can be found on the internet or through the local library.  Generally most quality home blood pressure cuffs can be acquired for under $100.00.  It is recommended that the arm cuff is preferred, as the wrist and finger monitors have a larger amount of variability and they are prone to give inaccurate readings.  It is also requested that the blood pressure cuff be brought to the doctor's office for comparison yearly to make sure that the home blood pressure cuff correlates reasonably well with the office blood pressure readings. 

Lastly, for those individuals who are unsure of their blood pressure numbers, it is important for them to get their blood pressure measured by a qualified individual and then discuss those results with their physician if we are going to continue to identify those individuals who are unaware of their high blood pressure.  So when you are in your doctor's office, make sure to ask your doctor if your blood pressure is concerning because you want to "know your number" and understand your risk. 
 

 

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