Dear Mainstreet Doctor,

I am 60 years of age, and have been taking medicine for high blood pressure for about 10 years. I consider myself to be in good health and try to walk a couple times a week. My doctor has tried all kinds of different blood pressure drugs but I can never seem to get my blood pressure to where it should be. What gives? Thanks, Dave G.

Dear Dave,

You have definitely touched on a very common problem. The solution to your problem may or may not be easy. Hypertension (high blood pressure) has many factors that cause it and can affect it. Let me review some of them and hopefully you can find something I say helpful for your particular situation.

First, you are right to want to control your blood pressure. Hypertension is a major risk factor for heart disease and stroke (some people lump these two diseases in the same basket called “cardiovascular disease”). The most recent report from the National Committee on Hypertension, which was reported in May 2003, and is called the “The JNC 7 Report” (JAMA, May 21, 2003—Vol 289, No. 19; p2560), concludes that the risk of cardiovascular disease, beginning at the blood pressure reading of 115/75, doubles with each increase of 20/10. By normalizing blood pressure, the hope is to reduce the chance of heart attack, heart failure, stroke, kidney disease, peripheral vascular disease (generalized hardening of the arteries), and retinopathy (a disease of the back of the eye).

Most people with hypertension have the problem because of a family history of hypertension. Therefore, usually doctors do not need to do any elaborate testing to make the diagnosis, other than taking a detailed history. Then, what I do before I start a patient on blood pressure medicine, is to obtain an inexpensive panel of routine chemistry blood tests. In your case Dave, since your blood pressure is not controlled, it may require further testing, based on other historical elements and the physical exam performed by your doctor. Please read on though, maybe something I say will apply to you.

At this point, it is important to talk about other cardiovascular risk factors because they often accompany high blood pressure, and will also need attention in order to lesson the total risk for cardiovascular disease. These risk factors include smoking, high cholesterol, diabetes, obesity, and physical inactivity.

Next, often times, when attempting to control blood pressure, doctors and patients forget about, or just gloss-over the things you can do yourself to improve your blood pressure. We call these lifestyle modifications. For example, with a 20 pound weight loss the blood pressure can be lowered 5-20 points—a very significant reduction. Restrict sodium in your diet and eat more potassium, which means eating less processed foods and more fruits and vegetables—heard that before, haven’t you. Decrease alcohol consumption. (I have seen blood pressure completely normalize in patients who quit alcohol. So I know that works.) As far as physical activity, it has been shown that brisk walking for 30 minutes a day, 5-6 days per week can lower blood pressure 4-9 points. I have also seen similar reductions in blood pressure by decreasing caffeine intake and quitting smoking.

If you happen to be doing everything right, then what other reasons could explain your uncontrolled blood pressure? First, make sure you have enough blood pressure readings, besides the doctor’s office, to help make a decision about whether or not you have “white coat hypertension” (elevated blood pressure only related to the anxiety of being in the doctor’s office). Taking your blood pressure yourself will also tell you what time of the day your blood pressure is highest. Maybe this will show you that your blood pressure elevation corresponds to the part of the day when you are most stressed. Sleep apnea can be another cause of uncontrollable blood pressure. In that case, your blood pressure might be highest in the morning. There are certain medications that can affect blood pressure, such as cold medicines (pseudoephedrine), diet pills with ephedra or ma haung, birth control pills (obviously does not apply to you Dave), cocaine, amphetamines, steroids, and even nonsteroidal anti-inflammatory drugs (arthritis medicines, for example, ibuprofen).

Lastly, I will talk about the prescription medications for hypertension. There are approximately one hundred medications that can be used for the control of blood pressure, and the list is growing all the time. This is actually good news, because with all the different classes of anti-hypertensive medications, both old and new, most patients’ blood pressure can be controlled. The other good news is that many of these medications are now generic, so that the cost in some cases is very reasonable. Also, there is enough variety of medications that they can be individualized for each person’s medical condition, and can be also be adjusted based on that patient’s unique response and tolerance to different drugs. I will not list all the different drugs. Just listing the various classes is impressive enough. They are diuretics, beta-blockers, alpha-blockers, calcium antagonists, Angiotensin converting enzyme inhibitors (ACE drugs), Angiotensin II receptor blockers (ARBs), central alpha agonists, and vasodilators. The latest JNC 7 guidelines suggest that diuretics should be the first line drug, because it works as well as, or better than everything else, plus they are the cheapest. These guidelines go on to say that, most patients will need two or more medications to achieve their blood pressure goals.

I have found that in tough cases, like yours, control of the blood pressure may require three or four different medications at maximum doses.

Dave, I hope this extensive answer is helpful. I am sure you and your doctor working together can control your blood pressure.

Best wishes,

Donald Ebersole MD

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