High Blood Pressure Questions Answered by Cardiologists

Enlarged Heart and Cardiovascular Health

Question: I am 23 years old and in pretty good health. I have three children, and towards the end of each pregnancy, I have developed high blood pressure. Last week I went to a family doctor for a physical, and my blood pressure was 118/100. The doctor performed an electrocardiogram (EKG), and the results were abnormal — she said that the left side of my heart is enlarged. She referred me to a cardiologist, and I have an appointment next week. I am very concerned. Does this mean that I will die young? Can I live a long life with an enlarged heart? I would appreciate your advice.

Answer: I agree with your doctor that aggressive management of your blood pressure is warranted. Your history of high blood pressure associated with pregnancy is not uncommon, and can be a harbinger of sustained hypertension — such as what you seem to have developed. Although your top number, or systolic pressure, is not alarming, the bottom number, or diastolic pressure, is distinctly abnormal at 100 mm Hg. The criteria for assessing the enlargement of the left-sided heart in people your age are not definitive, and can depend on ethnicity and degree of physical training. Often, a trained observer can detect enlargement of the left ventricle, the main pumping chamber of the heart, on physical examination.

In your case, I definitely agree with your doctor's referral to a cardiologist for follow-up and management of your high blood pressure. You should have a full physical examination by a specialist, including a look in your eyes to assess the blood vessels there — an important part of the exam in your situation, which is too often neglected. In someone your age with your history, a few simple blood tests would be in order. The exam and tests can help the doctor sort out if you are one of the relatively few individuals who have a specific, treatable underlying cause of hypertension. You will likely need an echocardiogram, a simple noninvasive test that can give definitive information regarding enlargement of the left ventricle.

Regarding the anxiety that you describe, I would assure you that enlargement of the left ventricle can reverse with appropriate treatment. Moreover, there is a wealth of very strong scientific evidence that the control of blood pressure can lower the risk of stroke, heart attack, kidney disorders, and other complications of hypertension. You should look at the identification of high blood pressure by an alert doctor as an opportunity for you to manage this important cardiovascular risk factor aggressively, and to take charge of your cardiovascular risk. It is virtually certain that a combination of lifestyle measures and medications can control your blood pressure, and lower your cardiovascular risk. You can play a pivotal role in managing your blood pressure by monitoring it with a home device, keeping a blood pressure diary, and working with your doctor as an active participant in your management regimen.

Controlling Blood Pressure

Question: On some days, my blood pressure (BP) is 135/95 (heart rate, 74) upon waking, and on other days, it is 155/80 (heart rate, 90). I take a calcium-channel blocker (10 mg). What could cause this shift from isolated high diastolic BP to isolated high systolic BP?

Question: I currently take nifedipine and lisinopril to control my high blood pressure. Are there any other drugs that might help to control high blood pressure much better?

Answers: This is a response to both recent questions about high blood pressure. Congratulations to both of you for being diligent about treating your hypertension. This condition can be a “silent killer,” causing damage to the heart, blood vessels, and kidneys, as well as increasing the risk of stroke — even though you may feel just fine. Many of the current data from large clinical trials suggest that a low-dose diuretic of the generic thiazide class —such as chlorthalidone or hydrochlorothiazide — should be part of the drug treatment strategy to control hypertension in many patients.

I would suggest that both of you discuss with your doctor if you are eligible for a low-dose diuretic, as the recommendation requires many individual considerations. The thiazide medications are inexpensive, generally well tolerated at low doses, and yield improved clinical outcomes (e.g. reduced strokes) at least as well as more expensive drugs. In practice, many people with high blood pressure require more than one medication to achieve their goal levels (oftentimes more than 3 types of drugs.) The thiazides tend to “play well with others”, and work well in combination with newer classes of blood pressure medicines.

Excess Salt Intake

Question: If one does not have high blood pressure, is it advisable for him or her to consume unlimited amounts of salt and consider this non-risk behavior? I am concerned with a person who was told to go ahead and keep dumping the salt on, even with an autoimmune disorder and a family history of heart disease. Your thoughts are greatly appreciated.

Answer: For a population, reducing salt intake should lower cardiovascular disease. Certainly, our contemporary diet rich in processed foods and fast foods contains much more salt then we require. These considerations have led to recent efforts in New York City to limit salt content of restaurant food.

For an individual, the situation is more nuanced. Some people tolerate high amounts of salt in their diets without developing high blood pressure. Others have raised blood pressure in response to dietary salt. In general, people with high blood pressure should strive to limit salt intake. For the general public, we lack rigorous intervention trials to show a benefit of salt restriction, but the information we have available shows that limiting intake of processed and fast foods probably confers multiple health benefits.

High Blood Pressure During Sleep

Question: What would cause blood pressure to spike extremely high while sleeping? Should one be able to see and feel it when it does this?

Answer: My number one concern from your query is whether we are dealing with obstructive sleep apnea. This common condition, associated with obesity, can cause many problems, including high blood pressure. Normal individuals have a “dip” in blood pressure during the night. Other individuals have a paradoxical nocturnal rise in blood pressure. Obstructive sleep apnea typically associates with snoring and episodes of disturbed breathing during the night. In addition to a personal history and physical examination, interviewing the patient’s sleep partner is a first step in diagnosing the condition. A formal sleep study can clinch the diagnosis. Treatment involves weight loss and a breathing device to be worn at night. Treatment of obstructive sleep apnea can help control high blood pressure and can increase alertness during the day, in addition to other health benefits.

Most often, increases in blood pressure do not cause symptoms. This is one of the reasons that this risk factor is so pernicious. An individual can feel perfectly well, yet have high blood pressure that predisposes to cardiovascular events.

Difference in Blood Pressure Between Arms

Question: At a recent check of my blood pressure, my left arm was 135/88 and my right arm was 149/94. This has been going on for about a year. Should I have it checked out, and with what type of doctor?

Answer: Persistent differences in blood pressure between the arms can indicate disease of the arteries in the chest. An examination by a vascular specialist can help define the cause, and determine if it is an indication of a disease process and whether it needs treatment. The causes of a difference in blood pressure between arms include hardening of the arteries or atherosclerosis, inflammatory diseases of the arteries, and certain structural abnormalities.

White Coat Hypertension

Question: I was diagnosed with high blood pressure a few years ago, and I am currently on medication to treat it. I take home measurements of my systolic blood pressure daily, and it stays within 123-135. But when I go to the doctor to have my blood pressure measured, I notice the systolic number jumps by 30 points. I have a phobia of doctor offices, and I am very nervous and uncomfortable while there. Could the systolic blood pressure reading vary that much between home and the doctor's office, or is there some other factor at play?

Answer: You describe very well what doctors call “white coat” or “office-only” hypertension, a situation that is by no means uncommon. You are not alone! Up to one-fifth of individuals with hypertension will show accentuation in the doctor’s office. The level of risk of complications (including heart attack, stroke, and kidney disease) due to such episodic blood pressure elevation appears to lie in between people with totally normal blood pressure and those with sustained elevations. White coat hypertension often coexists with milder levels of sustained blood pressure elevation, which seems to be the situation in your case.

In addition to lifestyle measures such as regular physical activity and weight control, a large body of very solid medical evidence suggests that medications to control blood pressure and lower the risk of complications, especially stroke. I cannot ascertain your particular target level of blood pressure without knowing more about your specific medical condition; however, if your systolic blood pressure exceeds 140, or 130 if you have kidney disease or diabetes, you should be on medication. Click here for a summary of the current U.S. guidelines for blood pressure treatment.

Because of the hour-to-hour variations in blood pressure, and situations such as you described where blood pressure fluctuates with the environment, many specialists advocate ambulatory blood pressure monitoring. One resource for information on the devices for home monitoring can be found at dableducational.org. Note that this Web site is sponsored by several manufacturers of devices, and that we do not endorse any particular product.

30-year-old Male with BP 164/106 and Overweight

Question: Do you have any recommendations for a program for an overweight 30-year-old male with blood pressure 164/106?

Answer: In addition to lifestyle measures such as regular physical activity and weight control, a large body of very solid medical evidence suggests that medications help to control blood pressure and lower the risk of complications, especially stroke. I cannot ascertain your particular target level of blood pressure without knowing more about your specific medical condition; however, if your systolic blood pressure (the upper number) exceeds 140, or 130 if you have kidney disease or diabetes, you should be on medication. Click here for a summary of the current U.S. guidelines for blood pressure treatment.

For a specific program, there are no quick fixes. In general, making physical activity a part of your daily routine, and changing your eating habits in sustainable and incremental ways that lead to gradual weight loss until you achieve your target weight, and then allow you to maintain that target weight, is more desirable than a “crash” diet program. Set yourself up for success by having realistic goals. Often a weight loss of only 5 or 10% of one's body weight can make enormous inroads against cardiovascular risk factors such as high blood pressure.

You should have a medical evaluation before embarking on a vigorous exercise program, but you don’t need a stress test before making walking part of your life. Every day presents opportunities for making healthy choices: Take the stairs rather than the elevator if you are only going up a few flights. Don’t fight for the parking space near the mall entrance; instead, walk from a more distant spot. Try a piece of fruit instead of ice cream or cake for dessert. And cut out sugary beverages — such drinks represent “empty calories” without nutritional value. You can easily learn to live without them, and eliminating them is an easy way to lose weight.

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