(December 16, 2008 - Insidermedicine) On a recent trip to Boston, we caught up with Dr. Randall Zusman, MD, who is an Associate Professor of Medicine at Harvard Medical School, and the Director of the Division of Hypertension at the Massachusetts General Hospital Heart Center.
What is systolic hypertension?
Systolic hypertension is an elevation in the top number in your blood pressure. There are two numbers: the systolic pressure (the top number) reflects the peak pressure in your arteries when the heart contracts, and the diastolic pressure (the lower number) reflects the resting tone of your blood vessels when you heart relaxes. It turns out that when we’re younger diastolic values are more predictive of cardiac problems (strokes, heart attacks), but at age 50-55 systolic and diastolic are equally important, and then as we age and go beyond 55 or 60, systolic takes on an increasing importance. Systolic blood pressure increases with age; so all things being equal, if you don’t change your diet, if you remain physically active, if your weight remains constant, your (systolic) blood pressure will go up over time as long as you remain alive, and your diastolic blood pressure will go down.
How might the initial diagnosis be made?
The diagnosis of high blood pressure is not made on the basis of one abnormal value, it requires repetitive values usually at least three abnormal numbers separated by 3-5 days each to make the diagnosis of hypertension, unless you have values of 160, 170, 180, in which case it’s very likely that you do indeed have an elevated blood pressure value. Especially if you have a family history, if you have an excessive ingestion of salt, if you are overweight and sedentary, there is a family history of vascular disease, stroke or heart attack, take every opportunity to have your blood pressure monitored.
What might be done in terms of assessment?
The most important component of the evaluation or workup is the historical aspect (dietary history, physical activity, family history, tobacco abuse, alcohol injection) to get a grasp on where you can go with non-drug therapy. In terms of the physical examination:
- we want to look in the eyes to see if there is evidence in the blood vessels or long standing blood pressure abnormalities,
- we want to listen to the chest to see whether you have any cardiac abnormalities (heart murmurs, or palpate the chest walls, or enlargement of the heart),
- we want to check the pulses in your neck, in your arms, in your legs, in your feet to see whether there is evidence of atherosclerotic cholesterol deposition, leading to diminished blood flow as an indication of vascular disease,
- we want to do an electrocardiogram: has the patient had a silent heart attack in the past, is there evidence of enlargement of the chambers of the heart
- a chest XRay is often important,
- urinalysis is often important in terms of evidence of kidney damage,
- blood testing: we want to look at the amount of sodium and potassium in the blood, we want to look at kidney function, we want to look at the blood sugar because diabetes and hypertension often go together, we want to look at the lipid profile, are you hyperlipidemic, is your cholesterol elevated, your triglycerides elevated, your good cholesterol low and your bad cholesterol high?
- Weight: calculate a Body Mass Index, we want your BMI to be 25 or less, and that can help us give guidelines in terms of how much weight do you need to lose in order to reach an optimum weight and improve your blood pressure control.
If I had systolic hypertension and were over 55…
If I had systolic hypertension, and if I were over 55 or 60 years of age, how would I proceed in terms of my own treatment and evaluation? Systolic hypertension is clearly associated with an increase in cardiovascular risk (heart attack and stroke or sudden death), so as you see your blood pressure going up, and this is something that happens in all of us, you need to think first about the non-drug therapies that you can employ to lower your blood pressure without becoming drug-dependant, and those therapies are salt –restriction (almost every patient I see ingests too much salt), so what do you do to reduce your salt intake: no pickles, pretzels, potato chips, olives, sardines or anchovies, no canned soups or vegetables, nothing in a bottle other than juice (eg soy sauce, steak sauce, etc are really salt water with flavoring), no luncheon meats (prepared luncheon meats at the deli have a lot of preservatives, and those preservatives are salt), no fast foods, no pizza, and also no cold cereals that are high in salt content (i.e. no cheerios, frosted flakes, corn flakes, wheaties raisin bran, etc.). There are 5 cereals you can have: 3 cold cereals: puffed rice, puffed wheat, and shredded wheat; 2 hot cereals: cream of wheat and oatmeal; these have no salt at all. Get the salt out of your diet. If you are not physically active, become physically active, and when we say physically active, we mean activities in which you are in motion: swimming, biking, jogging, running, walking, elliptical machine, treadmill, stationary bicycle, not weight lifting (this helps to maintain muscle tone, but you only really need to use minimal weights – 5-10 lbs – to maintain muscle tone). If you smoke, stop. That maybe is the hardest thing to do, but it is clearly essential to good cardiovascular health and blood pressure control. Also, if you ingest excessive amounts of alcohol, cut back to more appropriate levels: one drink in a woman, perhaps two drinks in a man, hard liquor and wine is much superior to beer, which has much more salt and has many more calories.
So those are the non-pharmacologic therapies that you can employ. You can lower your blood pressure by 5-10mm Hg with each of those strategies. So if you need to drop 15mm, you could do that without drugs if you have one or more of those strategies that apply to you. And then if you need to start on drug therapy, be consistent in your use of the drug (take it daily, at the same time each day) so that you can have the type of response that you’re looking for. Be open with your physician about any side effects that you experience, because there are many choices now, you don’t have to be fatigued, you don’t have to be depressed, you don’t have to sacrifice sexual function to have your blood pressure adequately controlled. Another thing is to avoid drugs that raise blood pressure. Many of the anti-inflammatory drugs sold over the counter will raise blood pressure, decongestants used excessively in sensitive patients may raise blood pressure, so again, share with your physician all of the drugs you take, over the counter or otherwise, prescribed or otherwise, in order to avoid some of these side effects.