The right way to treat high blood pressure

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How to avoid the mistakes that doctors make

The news snuck in quietly, like a kid slipping in the backdoor with a bad report card. Maybe that's because the news was a don't-tell-Mom kind of grade. Members of the American College of Cardiology, the American College of Preventive Medicine and six other health-care groups had taken a look at the treatment of high blood pressure in this country and found it wanting. They gave it a C-minus. Go to the back of the class.

That wasn't the only dunce cap issued. The National Heart, Lung and Blood Institute also released a statement saying 50% of the hypertension in the United States is either undetected or inadequately treated.

But "the statistics are even a little worse," says Harry Gavras, MD, vice-chairman of the American Heart Association's Council for High Blood Pressure Research and chief of the hypertension and atherosclerosis section of Boston University Medical Center. Thirty-five percent of people with high blood pressure don't even know they have the problem, and 27% are inadequately treated. Only 25% are adequately or well treated.

That's a shame, because high blood pressure is a risk factor for heart attack, stroke and, according to new research, congestive heart failure (Journal of the American Medical Association, May 22/29, 1996). And 50 million of us have it. Hypertension makes us 5 times more prone to strokes, 3 times more likely to have a heart attack and 2 to 3 times more likely to suffer congestive heart failure. And--guess what?--it's reversible.

But it's also sneaky and sly, the "silent killer." So it's understandable that one-third of the folks who have it don't know. A stubbed toe produces more pain. With hypertension, blood rushes through your vessels like a soundless speedboat. You don't feel it, but over time the force of that ride damages the blood vessels' surface. Fatty debris sticks easily to rough walls then. The vessels narrow. Clots can form and break loose, causing a heart attack or stroke. Even if that doesn't happen, the heart labors and strains, weakening and enlarging.

For all the drama, it's mute theater. That's why you should get your pressure checked once a year. You need a stethoscope to hear it. Once heard, though, what explains the high incidence of below-par medical treatment? Prevention asked five top blood-pressure specialists and found out the five biggest mistakes doctors make in hypertension treatment--and what you can do to prevent them.

#1 DOCTORS RELY ON TOO FEW BLOOD-PRESSURE READINGS
Here's what happens. "Patients get one high reading. Their doctors put them on medication. They come back; they're fine; the doctors say the medication has done the trick. But in many cases, if those people had come back even without medication, their pressures would have been fine," says Thomas G. Pickering, MD, professor of medicine at the hypertension center at New York Hospital-Cornell Medical Center in Manhattan.

That's because a blood-pressure reading is just one brief snapshot in time. One reading may not at all represent what's going on most days. Government guidelines for treatment suggest multiple readings during each doctor's visit.

"Even then, our research has shown that for some people, doctors' readings are often the least representative of their overall levels of blood pressure," says Dr. Pickering, author of Good News About High Blood Pressure (Simon & Schuster, 1996). The reason: About 20% of people with high blood pressure suffer from "white-coat hypertension." Doctors' offices make them nervous. Their blood pressure spikes. But they don't usually need to be medicated.

One way to get around that is to ask the doctor's nurse or technician to take your blood pressure. Another is to take your own blood pressure. "There's a big movement for home monitoring," says Dr. Pickering. You can buy manual or electronic home units that provide fairly reliable readings. (See "How to Choose a Monitor" on p. 79.)

With a home monitor, you can average out various readings taken during the course of a day. Your measurements may very well be different in the morning and evening, at work and after exercise. But you'll be able to get the total picture, especially if you track pressure for a few weeks and average out all the different readings. (See "What's Your Blood Pressure?" December 1995, for more on monitoring your own blood pressure.)

#2 DOCTORS DON'T PAY ENOUGH ATTENTION TO HYPERTENSION
Too often, high blood pressure gets short shrift in doctors' offices. And there are two big reasons for this. "Part of the problem is that even though hypertension is extremely common, it's not generally recognized as a medical specialty. There are no board examinations to qualify as a specialist. And, for most physicians, it's not their prime interest. So hypertension frequently doesn't get the professional scrutiny it needs. It's treated mostly by family practitioners, internists, nephrologists and cardiologists," says Dr. Pickering.

The other part of the problem is the sheer amount of time hypertension demands. "You have to give patients tender loving care. But it's hard to do on a 15-minute schedule. If you don't, though, you're doomed to failure," says Ray W. Gifford Jr., MD, professor of internal medicine at Ohio State University College of Medicine and consulting physician in the department of nephrology and hypertension at the Cleveland Clinic Foundation. "One of the most common mistakes is that doctors don't spend enough time up front convincing patients that the way to reduce their risk of stroke and heart attack is to lower their blood pressure. Then the doctors need to talk to their patients and make lifestyle changes tempting because people tend to resist them. They have to make sure patients know that those changes are almost sure to bring blood pressure down so they may not need medication.

"You can't tell patients to start a low-salt diet and an exercise program and come back in six months. They need to come in three times during those six months to reinforce lifestyle modifications. They need a physician who spends the time to keep evaluating them once they're on a program."

But how do you find a dedicated doctor if you can't look him up in the Yellow Pages under "Hypertension Specialist, Long Hours"?

Dr. Pickering has formed the Hypertension Network, which makes use of the Internet to provide people with up-to-date information about hypertension, including question-and-answer forums. It can also provide a list of physicians who have a special interest in treating hypertension. The Web site address is http://www.bloodpressure.com. (At press time, the site was expected to be ready in mid-July.) Or write to the Hypertension Network at P.O. Box 302, Wingdale, NY 12594.

If you don't want to look for a new physician because you already have a long-time family doctor you like, make an appointment for a heart-to-heart talk with her. Come prepared: Write down your questions and refer to them. If you've read up on the subject and made notes for discussion, bring them in, too. Tell your doctor your concerns about your blood pressure and its treatment. Let her know you're willing to take an active role in managing your condition by recording your blood pressure and by making appropriate lifestyle changes.

#3 DOCTORS DON'T INTERVENE EARLY ENOUGH
"This is a common problem--physicians often don't initiate therapy in patients with mild hypertension. They wait until the hypertension is worse. But this waiting game is considered a major public health concern by all the experts in this area," says William B. White, MD, chief, section of hypertension at University of Connecticut Health Center, Farmington. The fact is, even mild hypertension increases your risk of stroke and heart attack. Stage 1 (mild) hypertension means that your systolic reading (the top figure, which measures how hard your heart has to pump) is between 140 and 159. And your diastolic pressure (which measures the amount of pressure produced by your heart between beats) is between 90 and 99.

Dr. White thinks what happens is that doctors just fail to see mild hypertension as a significant problem in the vigorous person sitting across from them. "They think, O.K., this person is 40 and pretty healthy otherwise with a blood pressure of 140/90," says Dr. White. "And they think that this isn't very serious. The patient thinks he's healthy because he doesn't have something bad enough to get medicine for. But mildly elevated blood pressure is likely to become even higher over time. So the patient resurfaces five years later when his blood pressure is 160/110. During that interval, some damage has occurred, such as cardiac changes associated with blood-pressure elevation, or some kidney problems."

Dr. Gifford believes in very early intervention--when blood pressure is high-normal, 130-139/85-89. "But doctors don't tend to make much fuss if blood pressure is 135 over 85. The message doesn't come across that it might be risky. And that's the time to get to it. There's really good evidence you can prevent high blood pressure then, before it gets worse," he says.

Unless blood pressure is high--over 160/105, says Dr. Gifford--or it's complicated by a condition like diabetes, prompt treatment of choice means initiating lifestyle changes. "Lifestyle changes are very important," says Dr. Gavras. "Your doctor should educate you to eat less sodium and lose weight and exercise with activities like walking. Just by decreasing sodium intake and losing weight, one-third of those with hypertension can control their blood pressure.

But doctors seem more at ease with drugs than with eating or exercise regimens, says Dr. White. "We have a lot harder time educating patients about lifestyle changes. It's hard to implement because physicians don't have the time or the background information on how to educate patients during the short encounter they have with them," he says.

So when doctors finally nab blood pressure at Stage 1, they often do so with medication. "When a doctor doesn't have time, it's easy to just say to the patient, 'you have high blood pressure--I'll give you a prescription,'" says Sheldon G. Sheps, MD, chief of the hypertension division at the Mayo Clinic, Rochester, MN. If you find yourself in that position and your blood pressure is mild and uncomplicated, Dr. Sheps says: "Then it's all right for you to say, 'I've been reading that I might be able to help my blood pressure by losing 10 pounds, and I'd like to try that first. Is it O.K.? If it doesn't work in three months, I'll consider medication.'"

But if your blood pressure is high-normal and you'd like to take it down a notch even though your doctor seems unconcerned, ask him about lifestyle changes. "It's always a good idea to ask about ways to change your diet and exercise. I also think it's a good idea to ask if you should have a medical evaluation before you start an exercise program, especially in the case of middle-age men who have been sedentary for years," says Dr. White.

Here are the top lifestyle changes our experts recommend:

If you're overweight, lose some pounds. "You get the biggest bang for your buck right here," says Dr. Gifford. Even 10 pounds may be enough to give you the control you need. Why is it so important? Extra fatty tissue makes your heart pump harder.
Control your salt intake. Give up table salt and cooking salt, advises Dr. Gifford. And rely more on fresh foods than salty processed ones, he says. Half the folks who have high blood pressure are sensitive to sodium. Excess salt makes them retain water, which waterlogs blood vessels, narrows them, and makes the heart work too hard. (Talk to your doctor before making major dietary changes.)
Exercise. Aerobic exercise has been shown to reduce the level of blood pressure in people, if it's done for 40 minutes three times a week or more. The effect is greatest on the top systolic number. Aerobic activities include walking, biking and swimming. Whether or not poundage is a problem, working out tones the heart as well as the muscles, studies show. Weight training (when done properly--not holding your breath, avoiding prolonged gripping and using weights that you can easily handle) can also reduce blood pressure.
Cut down on alcohol--two drinks a day is the absolute maximum.
Stop smoking. It's the major risk factor for heart disease.
#4 DOCTORS PRESCRIBE TOO MANY DRUGS
"There's a tendency among physicians to just add blood-pressure medications when one isn't working adequately, rather than to try substituting them," says Dr. Pickering. "Some medications really just don't work on particular patients. In those people it would make more sense to substitute something that does work, not pile one drug on top of another."

Part of the problem, he says, is that trying to find out whether a medication is working involves taking lots of blood-pressure measurements. But if you get only three readings at a doctor's visit, and you have only one visit every few weeks, it's difficult to get enough data to make a good decision on medication. If you're trying a series of drugs to see which is best, it's cumbersome and expensive to do it by going to the doctor every week.

One thing a patient can do, Dr. Pickering says, is "self-monitor your blood pressure. It's economical and easy to tell if medication seems to be working by using a home monitor. Then you can phone in or fax in your readings. The doctor can get a feel for whether the stuff is working. It's a valuable way to assess medication."

#5 DOCTORS DON'T TELL YOU ABOUT TIMING
Strokes and heart attacks tend to occur early in the morning. Blood pressure tends to be high then, too. So it would make sense to take your medicine in the morning when it would do the most good. But many doctors don't talk about the best time to take blood-pressure medication.

Even when they do, "medicines don't affect everybody the same," says Dr. Sheps. The rate at which your body absorbs medications may be different from your neighbor's. "And some medications need to be given on an empty stomach," he says.

But you can double-check the timing yourself, with a home monitor. "Take one reading in the morning after you get up and get ready for the day but before breakfast," says Dr. Sheps. "Sit down for five minutes--read the paper or watch the news--and take your blood pressure seated. Take it again at the end of the day. Use the same sequence of letting your body settle down for five minutes. This tells you when your peaks and valleys are--in the morning or evening. Then your physician can adjust the timing of your medication."

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by Peggy Morgan with Toby Hanlon

MISTAKES PATIENTS MAKE
Nobody's blameless. And patients make mistakes, too. The two big ones in blood-pressure treatment are both what doctors call "compliance" problems.

AVOIDING LIFESTYLE CHANGES. "The likelihood that a patient will comply long-term with nondrug therapy is pretty dismal," says Dr. William B. White, "Somebody will be really great for four to six months--they'll lose weight so their pressure goes down. You see them the next year and they've gained weight back and stopped exercising. The next thing you know, the pressure's back up. Then the physician is likely to resort to prescribing medications to control blood pressure." Before you and your doctor reach that point, though, there are a few other tac-tics you can try:

* Ask your HMO or local hospitals and health groups where to find hypertension support groups.

* Look in your local newspaper for heart-healthy cooking classes. They're cropping up all over.

* Use a home blood-pressure monitor regularly to get feedback on how well lifestyle changes are working for you.

* Tap into the patient-support group on the Hypertension Network's high blood-pressure Web site at http://www.bloodpressure.com.

* Join (or rejoin) a health club or a gym. Or find a buddy to work out with.

NOT TAKING THE MEDICATION. Sometimes people don't take the drug that can help them because they regard even an aspirin with distrust. Often it's because they're having side effects with one drug, which makes them dismiss all drugs in the blood-pressure arsenal.

"It's very difficult to convince people to take medication for the rest of their lives. Often, people feel well, so they tend not to take medication," says Dr. Harry Gavras.

If the idea of taking a pill every day of your life turns you off, you need to do a little research on why it's so necessary. Ask your doctor to point you in the direction of information. If it's side effects that have understandably put you off pill taking, be aware that there are six very different classes of drugs for blood pressure and many medications in each class. "You really need to get on different medication. It shouldn't produce side effects," says Dr. Thomas G. Pickering.

HOW TO CHOOSE A MONITOR
Sure, stethoscopes were fun to play with when you were a kid. But they're not the easiest tools to maneuver when you're taking your own blood pressure. There are some blood-pressure monitors that have addressed the ease of taking measurements, though, says Dr. Thomas G. Pickering.

One home blood-pressure unit that Dr. Pickering likes incorporates the stethoscope on the blood-pressure cuff. "It's reliable but still requires a certain degree of skill and hearing ability. So not everybody can use one."

Most people find electronic home units the easiest systems to manage. They read blood-pressure via sensors and print out the reading. Avoid the units that measure pressure from your finger or wrist--they're not reliable, says Dr. Pickering. Home monitors should be taken to a doctor's office to make sure they're accurate, he says. No matter which kind of monitor you purchase, test drive the new machine alongside your doctor's to make sure they're in sync. Then take it in once a year for an accuracy checkup. (The manual models aren't as touchy.)

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