Article VIII - Put a Leash on the Silent Killer

“Doctors are lowering the goal post every few years, what was desirable a few years ago has become unacceptable now,” commented Ansaar, a patient of high blood pressure for the last ten years, as I drew his attention to the new targets of blood pressure. “Initially I was told that blood pressure of 160/90 is the goal and now I am being told that it is too high,” he continued. I tried to explain, “New research has established that the risk of heart disease has a continuous relationship with blood pressure and there is no safe lower limit. We have recognized that lower blood pressure accrues more benefits for the patient with reduction in death rate and lesser complications pertaining to heart, brain, eyes and kidneys.”

The aims of blood pressure treatment are to reduce cardiovascular diseases like heart attack, angina and stroke and reduce and prevent kidney related complications and deaths. This is achievable by aiming to treat blood pressure to less than 140/90 mmHg in general population and less than 130/80 mmHg in patients with diabetes or chronic kidney disease. It is important to achieve systolic blood pressure goal, especially in persons more than 50 years of age.

It is important to take steps to keep blood pressure under control. How to control elevated blood without resorting to drugs? In this section we will learn about blood pressure-lowering lifestyle habits and blood pressure medications.

1. Lifestyle:
Adopting healthy lifestyle habits is an effective first step in both preventing and controlling high blood pressure. Physical activity is perhaps the best way to counteract high blood pressure. It helps to reduce weight, lowers cholesterol and hence the risk of heart disease. If lifestyle changes alone are not effective in keeping the pressure controlled, it may be necessary to add blood pressure medications.

2. Reduction of salt:
A key to healthy eating is choosing foods low in salt and sodium. Most people consume more salt than they need. The current recommendation is to consume less than 2.4 grams (2,400 milligrams) of sodium a day. That equals 6 grams (about 1 teaspoon) of table salt a day. This includes all salt and sodium consumed, including that used in cooking and added at the table. For someone with high blood pressure, the advice is to eat less salt and sodium. Recent research has shown that people consuming diets of 1,500 mg of sodium have lower blood pressure. The lower-sodium diets prevent blood pressure from rising and help blood pressure medicines work well.

3. DASH Diet.
A diet known as Dietary Approaches to Stop Hypertension (DASH) is now recommended as an important step in managing blood pressure. This diet is not only rich in important nutrients and fiber but also includes foods that contain more electrolytes, potassium, calcium, and magnesium, than are found in the average diet.

Avoid saturated fat although include calcium-rich dairy products that have no or low-fat. When choosing fats, select monounsaturated oils, such as olive or canola oils. One study reported a reduced need for anti-blood pressure drugs in people with a high intake of virgin olive oil, but not sunflower oil a polyunsaturated fat.

Choose whole grains over white flour or pasta products. Choose fresh fruits and vegetables every day. Many foods are rich in fiber, which may help lower blood pressure. Important foods include most fruits (especially potassium-rich fruits including bananas, and oranges) and vegetables (especially carrots, spinach, mushrooms, beans, potatoes), includes nuts, seeds, or legumes (dried beans or peas).

Choose modest amounts of protein (preferably fish, poultry, or soy products). Soy in combination with fiber-rich foods or supplements may have specific benefits. Oily fish may also be particularly beneficial. They contain omega-3 fatty acids, which have been associated with heart and never protection.

In one study, after eight weeks on the diet, subjects from a broad range of backgrounds, experienced a significant reduction in blood pressure. Evidence now also suggests that it may be a good diet for lowering LDL cholesterol levels – although the beneficial HDL levels also decline.

4. Weight Loss
Weight gain seems to be a primary determinant in blood pressure increase, and weight loss may be even more important than salt restriction in controlling blood pressure. Losing weight, particularly in the abdominal area, immediately reduced blood pressure. Weight loss, particularly accompanied by salt restriction, may allow patients with mild hypertension, even older people, to safely reduce or go off medications. The benefits of weight loss on blood pressure appear to be durable.

5. Stress Reduction and Psychological Therapy
Improving mood or relieving stress may be helpful. The following are some studies suggesting possible benefits:

Two small studies reported that active religious faith was associated with healthy blood pressure levels, possible indicating the combined benefits of a strong social network and reduced stress from spiritual activities.
Studies suggest that stress reduction programs, such as those that use cognitive-behavioral therapy, can reduce blood pressure. In some cases people can even go off medication.
Even pets can provide healthful support. In a small 2001 study, medication had no effect on blunting blood pressure that increase in response to stress, but owning a pet did.
In another study, a simple relaxation technique called transcendental meditation (TM), which involves silent repetition of a single sound, was shown to be effective in reducing blood pressure. This is equivalent to our Tasbeehat which we ought to offer regularly.

6. Drugs:
If above measures are unable to normalize blood pressure, then one has to resort to drugs. Here is brief description of main types of drugs and how they work, their benefits and main side effects. Often, two or more drugs work better than one.

1. Diuretics
Diuretics are called “water pills” because they work in the kidneys and flush excess water and sodium from body. For decades, diuretics, have been the mainstay of antihypertensive therapy and are still considered the first choice by many experts.

Benefits of Diuretics. Diuretics significantly reduce the risk for stroke; they may in fact be the most important agent for preventing brain attack. They also appear to protect against stroke in people without high blood pressure. They are associated with a lower risk for heart attack (although this not as significant as their protection against stroke).
Diuretic Types. Diuretics are available in many types and are generally inexpensive. Most need to be taken once a day. Three primary types of diuretics are:

Thiazides. Thiazides are most frequently used and most effective agents for the treatment of high blood pressure. They may either be taken alone for mild to moderate hyper-tension or used in combination with other types of drugs.

Loop diuretics. Loop diuretics block sodium transport in parts of the kidney; they act faster than Thiazides and have a great diuretic effect. It is important to use the medication cautiously and avoid dehydration and potassium loss.

Potassium sparing agents. These diuretics conserve potassium. Potassium-sparing diuretics include Amiloride, and Spironolactone.

· Side Effects and Problems:
The loop and Thiazide diuretics deplete the body’s store of potassium, which, if left untreated, increases the risk for arrhythmias. Arrhythmias are heart rhythm disturbances that can, in rare instances become serious. As such, we either prescribe low dose diuretic, recommend potassium supplements, or use potassium-sparing diuretics in combination. Potassium-sparing drugs have their own risks, which include dangerously high levels of potassium in people with existing elevated levels of potassium or in those with damaged kidneys. However, mild diuretics are well tolerated and in general diuretics are more beneficial than harmful.

Common side effects of diuretics are fatigue, depression, irritability, urinary incontinence, loss of sexual drive, breast welling in men, and allergic reactions. Diuretics can trigger attacks of gout. Diuretics may raise cholesterol level marginally.

2. Beta-Blockers
· Benefits: They affect the force and frequency of heart beats, slow certain metabolic processes and ease the workload of heart. They are very effective in reducing blood pressure and have been associated with the reducing the number of deaths from heart diseases. They have an added advantage in patients with high blood pressure, angina and hyper dynamic circulation.
· Side Effects and problems:
Because they can constrict bronchial airways, patients with asthma, emphysema, and chronic bronchitis should avoid them. Beta blockers should be used with caution in patients with poor heart function, and those who have heart failure. As they can reduce heart rate so patients with slow heart rates should not be prescribed beta blockers. Fatigue and lethargy are the most common psychological side effects. Some people experience vivid dreams and nightmares, depression, and memory loss. Dizziness and lightheadedness may occur upon standing. Exercise capacity may be reduced. Other side effects may include coldness of extremities that is, legs and toes, arms and hands. Angina, heart attack, and even sudden death have occurred in patients who discontinued treatment without gradual withdrawal.

3. Angiotensin Converting Enzyme Inhibitors
They are the first line drugs and are being prescribed most commonly for blood pressure. Angiotensin converting enzyme (ACE) inhibitors block the effects of the angiotensin-renin-aldosterone system, which is though to have many harmful effects on heart and blood vessels.

· Benefits: They may be very important agents for patients with diabetes. They may help protect kidneys and heart of these patients, independently of their effect on blood pressure. They may help prevent changes in heart muscle cells leading to heart failure, specifically in reducing enlargement of the left side of the heart, a major risk factor for heart failure. ACE inhibitors can improve a patient’s odds of surviving a heart attack.

· Side effects and problems:
Major side effect of ACE inhibitors is severe persistent irritating cough. This cough does not respond to any medication except for cessation of the drug. Although ACE inhibitors can protect against kidney disease, they also increase potassium retention in kidneys. This increases the risk for cardiac arrest if levels become too high. Because of this action, they are not generally given with potassium-sparing diuretics of potassium supplements.
Side effects include excessive drops in blood pressure, and allergic reactions.

4. Vasodilators
Vasodilators, which widen/dilate blood vessels, are often used in combination with a diuretic or a beta-blocker. They are rarely used by themselves. Some of these drugs should be used with caution or not at all in people with angina or who have had a heart attack.

5. Calcium Channel Blockers
Calcium channel blockers, or calcium antagonists, have an immediate effect on reducing blood pressure. Studies continue to report that they are equally effective or better than other anti-hypertensive agents in preventing heart events, stroke, or kidney complications. Recent research support their positive role in reducing death and complication rate as compared to other classes of drugs.

· Benefits: Calcium channel blockers are effective and safe. They are used in preference in patients with angina. Certain Calcium channel blockers have a useful role in controlling arrhythmias. They are very well tolerated and have no serious side effects.
· Side Effects and problems.
Side effects vary among different preparations. Most drugs can cause fluid accumulation in feet, along with constipation, fatigue, impotence, gingivitis, flushing, and allergic symptoms. Interactions with drugs also differ depending on the drug. For example, Verapamil and Diltiazem interact with Digoxin, but Dihydropyridines do not.

6. Angiotensin – Receptor Blockers
Drugs known as angiotensin-receptor blockers (ARBs), also known as angiotensin II receptor antagonists, are similar to ACE inhibitors in their ability to lower blood pressure.

· Benefits: ARBs may have fewer or less severe side effects, including cough. Recent studies have documented that ARBs protect the heart and kidneys as were benefits found with ACE inhibitors. Many comparison studies are underway. In a very promising study, the ARB Losartan reduced the risk of heart attack, death, and stroke more effectively than the beta blocker Atenolol. This is the first study finding any drug superior to a beta blockr for achieving these results. They may even improve quality of life when added to a drug regimen—a finding also found with no other anti-hypertensive drugs.
· Side effects and problems: The side effect profile is benign and most patients tolerate the drug very well. Though initially the drug was very expensive and out of reach of most people, it is now available at comparable cost.

7. Alpha Blockers
Alpha blockers widen arterioles and veins and thereby reduce blood pressure. They are recommended for reducing blood pressure along with other agents, as their side effects profile is benign.

8. Combinations:
To achieve desirable reduction in blood pressure different groups of drugs may be combined. Adding different drugs add the effects and decrease the side effects attached to higher dosage. New guidelines have issued clear directive to start therapy with two agents, if blood pressure is considerably higher than the target blood pressure.

High blood pressure is a common disease afflicting a large population. It has been termed as a silent killer as it can be asymptomatic in spite of effecting target organs. Life style modifications should be employed in the start but drugs can be added if desirable effects are not achieved.

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Ref: Heal Thy Heart written by Prof: Dr. Muhammad Hafizullah