THE BLOG
11/12/2012 09:59 am ET | Updated Jan 12, 2013

High Blood Pressure: A Highly Controllable Risk Factor That We Fail to Control

While a 140/90 blood pressure reading now would put you into a regimen of medical care, if your 75-year-old great-grandfather's numbers were 180/110, no doctor would have blinked an eye throughout the 1950s. A mere 50 years ago, physicians described hypertension, or high blood pressure, with words like "essential" or "benign." That's because the thinking back then was that rising blood pressure was a normal -- even necessary -- part of aging. That was before the Framingham Heart Study published groundbreaking research in 1959 showing that people with elevated blood pressure had more heart attacks and coronary disease than those with normal blood pressure. Far from protecting elderly folks by forcing more blood through aging, stiff arteries to vital organs, as the old theory went, high blood pressure silently ravaged internal organs.

Finally, science showed that something had to be done to control the first proven risk factor associated with the nation's epidemic of heart disease, and researchers set about looking for solutions. In the past half century, pharmaceutical discoveries have come up with dozens of medications to help people keep their blood pressure under control. The arsenal of treatments includes diuretics, beta-blockers, ACE inhibitors, angiotensin antagonists, calcium channel blockers, alpha-blockers, alpha-beta blockers, nervous system inhibitors and vasodilators. If one doesn't work alone, often two or more in combination will do the trick. Protecting your heart, brain, kidneys and other organs from the destruction of high blood pressure is an area of medicine with dozens of individualized treatment options.

We've also learned that losing weight, eating a diet rich in fruits, vegetables and grains and low in salt, sugar and saturated fats, exercising daily and not smoking goes a long way in helping to control blood pressure. But we all know how difficult those lifestyle changes are to make and to stick with, and medications can help you stay safer even as you work on lifestyle changes. Working closely with your doctor will help you find what's right for you to get your blood pressure down and keep it down.

Unheeded Warnings

Modern medicine has made the control of blood pressure highly achievable. And yet far too many people have uncontrolled high blood pressure. According to a recent Centers for Disease Control and Prevention report, almost a third of Americans, or 67 million people, have high blood pressure, and more than half of them -- 36 million people -- don't have it under control. Some 14 million people are walking around with high blood pressure without even knowing it; another 5.7 million people know it but aren't taking drugs to control it; and 16 million are taking drugs, but the medications they're taking aren't doing the job of controlling their blood pressure.

The first step in controlling hypertension is knowing what your blood pressure reading is. We're all familiar with the cuff squeezing our upper arm as part of just about every medical encounter. Don't let the health care worker jot down your number without knowing it yourself and understanding what it means. Systolic, or the upper number, measures blood pressure within the arteries when the heart muscle is contracting. Diastolic, the lower number, is the minimum pressure in your arteries between beats, when the heart is relaxed. An optimal reading is less than 120/80; with a reading of 140/90 or higher, you need to consider treatment to lower your blood pressure.

Why It's Important

I've heard people protest that they don't want to take pharmaceuticals because they're unnatural and they carry side effects. Well, the "natural" side effects of uncontrolled high blood pressure are deadly. When your blood pressure is high, you are three times more likely to die from heart disease and four times more likely to die of a stroke. High blood pressure is responsible in part for 1,000 deaths in the United States each day, and this one highly controllable risk factor costs the American health care system $131 billion a year.

The damage done to your body by high blood pressure is silent for years and even decades. You won't notice a thing as the increased pressure of blood flowing through your vessels damages cells lining your arteries. Arteries once flexible become hardened and stiff. The damaged cells become collection points for fatty deposits, blocking free blood flow and endangering your brain, your heart, your kidneys -- even your eyes, arms and legs.

There are enough medications and lifestyle changes available to help lower blood pressure that, working with your health care provider, you can find a workable solution with few side effects -- or certainly side effects more acceptable than those resulting "naturally" from lack of treatment.

But sometimes people just don't do what physicians recommend. Researchers have studied the issue of noncompliance, most rigorously among elderly Medicare patients. Here are some astonishing and costly findings. As many as 55 percent of elderly patients don't take the drugs their doctors have prescribed. One large teaching hospital examined 23 patients, all of whom were admitted over a two month period because of consequences of failing to take their medications, and found that those patients racked up 590 days in the hospital, at an avoidable cost of $60,000.

Some reasons people don't take their medications are that the dosing regimen is confusing to them, especially if multiple drugs are needed as is sometimes the case with high blood pressure; they fear or don't like specific side effects; the costs are prohibitive, or they have failed to understand the importance of taking the drugs.

Expect Help From Your Provider

The CDC, understanding how important it is that patients stick with their blood pressure drugs, has begun recognizing health delivery systems that do a good job of helping their patients. Two such systems were Kaiser Permanente in Denver and the Ellsworth Medical Clinic in Ellsworth, Wis. The two systems are important for what they show us about what works and what to expect from your own provider. In four years, the Denver facility improved blood pressure control among patients from 61 percent to 82.6 percent. In the Wisconsin clinic, blood pressure control among patients with cardiac disease went from 67 percent to 97 percent; and among all patients, blood pressure control reached 90 percent in 2011.

Both systems have made blood pressure control a priority. They take readings at every visit. They email or phone patients with reminders about medications. They work with pharmacists to encourage and support them in providing advice and counseling to patients with high blood pressure. They consider providing 90-day prescriptions rather than 30-day prescriptions so patients have fewer opportunities to run out. And they take into account the cost of medications and co-payments when writing prescriptions so that patients with few resources can afford their drugs. Most patients with hypertension can be controlled with generic medications rather than costly trade name pharmaceuticals.

But you can't just passively wait for your doctor to get your blood pressure under control. This is your body. Know your blood pressure number. There are a number of affordable home blood pressure monitoring devices on the market, and your doctor can help you choose one. Then you can record your own blood pressure regularly at various times of the day and let your doctor know if it shows a pattern of climbing to unacceptable levels. (Blood pressure rises and falls throughout the day. It's a problem when it stays at elevated levels.)

You can stop smoking, become physically active and work to maintain a healthy weight. If you need a prescription for a blood pressure lowering drug, take it as prescribed every day.

Heart Healthy Diet

A diet that helps to control blood pressure is the same eating plan that helps control your weight and improve your overall health. Make it rich in fruits, vegetables and grains. Get much of your protein from fish or chicken or nuts and limit fatty meats.

Limiting salt intake has been a controversial element in controlling blood pressure. The evidence indicates that a reduction in dietary salt can lower blood pressure in many people. The effect is more pronounced in some individuals, including elderly patients, African-Americans and obese patients. But the evidence is less clear that eating less salt means fewer heart attacks and strokes among people with normal or high blood pressure. Some studies suggest that salt is unhealthy for hearts; others fail to support that conclusion; still others suggest that salt is bad for some people, but not everyone. That's likely because some individuals are, indeed, more sensitive to salt than others.

For now, we have no proven way to sort out salt sensitive people, and the federal government recommends lowering salt intake to 2,300 milligrams of sodium a day. Even lower levels, to 1,500 milligrams a day, reduces blood pressure even more. (The average man consumes 4,200 milligrams of sodium a day while the average woman consumes 3,300 milligrams a day.)

A Medical Dilemma With Proven Answers

The frustration over this nation's inability to control blood pressure in so many people is that this is a problem with very good solutions, tested and proven over half a century. We know for sure that high blood pressure leads to all sorts of bad health outcomes. And we not only have answers, we have highly individualized solutions. If lifestyle changes alone don't work, we have drugs. If one drug doesn't work, we have others to try, or combinations of drugs. Yet we're confronted with failures in the health care delivery system, and in the lives of individual patients, that get in the way of what we know should be done. Those failures contribute to costs of billions of dollars, a decreased quality of life for millions of people and hundreds of thousands of premature deaths every year. We can and must do better, and, if you're among those whose health could benefit markedly. I urge you to take the appropriate steps, pronto, to lower your blood pressure.