If you’re currently taking a blood pressure medication OR your doctor has remarked that she’ll be keeping an eye on your “borderline” high blood pressure OR high blood pressure runs in your family and you have concerns about it, please read this Health Tip closely. The issues surrounding blood pressure are far more complicated than you might guess.
Importantly, your doctor, who we can safely assume intends the best for your health, may be basing her recommendations and prescribing your medication on what she may not know is actually some very controversial information. She simply may not be aware that she’s starting you on what could be decades of inappropriate medication for a condition you don’t really have…and one that isn’t even dangerous to your health.
In fact, based on new government guidelines in which your doc is paid less by insurance companies for failing to reach certain clinical goals (like getting your blood pressure down to a designated low number), she may be encouraged to prescribe more meds for your potentially non-existent elevated blood pressure. Read that sentence a couple of times and let it sink in. It means if your blood pressure is not at a particular “normal” level AND your doctor has failed to give you medication to reach that level, she can be financially penalized, even if your actual blood pressure level is totally harmless to your health. Tell me that’s not just a little bit spooky.
Part One: what exactly is “normal” blood pressure?
This simple question is actually fraught with controversy, backbiting, scandal, and truly egregious self-serving behavior on the part of highly placed–and highly paid–physicians, drug companies, and apparently neutral organizations like the Food and Drug Administration (FDA) and the World Health Organization (WHO). For an idea of how the answer to this question has shifted, if you have some spare time take a look at this piece, which examines the scope of change in high blood pressure treatment over the course of a decade.
If you remember what I wrote about statins and high cholesterol–that lowering the number for ideal cholesterol meant an increase of multiple millions of statin users–precisely the same sequence of events has occurred with high blood pressure meds.
Over the years there have been numerous studies, all but one financially supported by the pharmaceutical industry, to determine a risk-free blood pressure number. When I was first in training, I learned that blood pressure levels normally rose with a person’s age. The magic formula we were taught? The systolic reading (the top number) was 100 plus your age. The bottom number should be 90 or lower.
Thus, a healthy blood pressure for a 50-year-old could be 150/90. Basically, you started treatment when someone’s blood pressure was 160/100 or higher. I remember one professor saying he preferred 160/95.
But then a series of studies began to appear in the US and Europe saying that the risks for heart disease and stroke increased if that formula (100 plus your age) was followed, and the ideal blood pressure was reported as 120/80, with treatment beginning at 140/90. And here’s where the controversy began.
Change the number, create a patient
Although data did show that patients with consistent blood pressure higher than 140/90 were at some risk for heart attack and stroke, there was not much evidence that using more meds to drive the blood pressure further down–to that magic 120/80–really prevented much of anything. And it certainly increased pill taking, side effects, and symptoms due to blood pressures actually dropping too low.
From Big Pharma’s perspective, “change the number, create a patient” is an important phrase, possibly a central tenet:
- Bringing total cholesterol down to an ideal number anywhere below 200 with an LDL (the bad cholesterol) below 70 hits the financial jackpot. These strict guidelines will increase the number of potential statin users from 12.8 to 48 million.
- Adjusting “ideal” blood pressure from 160/100 to 140/90 added 13.5 million new drug users. Trying to medicate people with 140/90 BP to even lower levels will add tens of millions more pill swallowers.
Added to the problem of changing the standards of what constitutes high blood pressure and what does not, doctors are well aware that most people get anxious in the doctor’s office and this itself drives up blood pressure. Called white-coat hypertension, this phenomenon has resulted in tens of thousands of utterly unnecessary blood pressure prescriptions.
I don’t mean now to deliberately trigger your TMJ, but it turns out that virtually every lead investigator of the studies that pushed blood pressure “normals” to lower levels had financial ties to the pharmaceutical industry, as did (and does) the FDA and WHO.
My take on normal blood pressure
So what’s normal? Most doctors agree it depends on the individual’s situation.
Let’s call 145/95 (taken at home, not in the doctor’s office, over a number of days) borderline high blood pressure.
If there are no other risk factors (smoking, overweight, diabetes, previous heart issues), I start treating at this point or anything higher with salt restriction and stress reduction, including yoga, tai chi or meditation. If there are risk factors such as those just listed, I’ll prescribe a medication and discuss the lifestyle changes outlined below.
Very high blood pressures, like 160/110 or higher, do require prompt pharmacological intervention.
Part Two: which medication?
Here’s where the infighting among physicians gets nasty. It turns out that every study that had drug money behind it recommended one or more drugs that were newly released at the time and therefore high-priced: beta blockers initially (like Inderal), then angiotensin-converting-enzyme inhibitors (ACE inhibitors such as Lisinopril), angiotensin II receptor blockers (ARBs such as Cozaar), and amlodipine (Norvasc).
But each of these had side effects and were often prescribed in various combinations, increasing the number of possible side effects. Also, driven by that artificially low magic number of 120/80 or lower, some people simply felt poorly having such low blood pressures. The meds didn’t magically place you right at 120/80. Sometimes they overshot the goal. For example, a blood pressure of 90/60 can make many an adult feel woozy and lightheaded.
(This from a patient: “My dad is on three blood pressure meds. He has to stand up real slowly or he gets lightheaded and once fainted.”
The only study with no drug money behind it, the ALLHAT study (short for Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), found that the oldest of the blood pressure meds, water pills called diuretics, were the very safest and had the very best outcomes for stroke and heart attack prevention.
Yes, there was fury.
Physicians receiving financial largesse from Big Pharma looked mightily for flaws in the ALLHAT study. The drug companies ran full-page ads in the Journal of the American Medical Association basically tweaking ALLHAT data in an attempt to prove their branded drugs were just as good as diuretics. But they weren’t. Diuretics were best.
With this background, what should you do?
- If you’re already taking blood pressure meds, work with your doctor when it comes to medication adjustment. Quitting or reducing blood pressure drugs is not a DIY project. If your physician doesn’t recommend going off your medication, ask him or her if you can be switched to a diuretic.
- If you don’t have your own blood pressure measuring device, buy one. It must be one that measures from your upper arm (not your wrist or finger), and if you’re obese be sure to get an extra-wide cuff. Take your blood pressure three to four times a week at the same time of day. Record all readings and bring them to your doctor. This will eliminate the white-coat hypertension issue.
- Seriously live by the DASH diet, which (don’t be shocked) emphasizes veggies, fruits, whole grains, fish, and poultry and limits salt, sugar, and red meats. Nibble celery, proven clinically to lower blood pressure.
- If you’re in the group of patients with severe high blood pressure–diastolic (bottom number) of 110 or higher–and your blood pressure is controlled on meds, stay on them. If you’re on several blood pressure medications and your at-home readings are good, your doc may at least be able to trim the number of meds you take.
- If you have mild high blood pressure and are on medication, or you’re borderline and your doctor is considering putting you on medication, be proactive. Lose weight, stop smoking, begin regular exercise, and reduce your salt intake. Learn stress reduction techniques such as yoga, meditation, and tai chi. Consider getting (and using!) a portable Resperate unit (which costs about $99 online), the only biofeedback device FDA-approved for high blood pressure.
- If, after your best efforts, you can’t budge your BP below 145/95, try taking two natural products in addition to your medication: Vasophil, containing the amino acid arginine, precursor of nitric oxide, which opens blood vessels (start with one capsule twice daily, increasing to two capsules twice daily if needed) and CoQ10 (UBQH 100 mg daily).
- If you do need a prescription med, start with a diuretic (Hydrochlorothiazide 25 mg daily or Dyazide one daily or Furosemide 20 mg daily).
Just don’t be a victim of the several superficially unbiased (but actually highly biased!) organizations that have their best interests, not yours, at heart.
David Edelberg, MD