Part IV: Q & A about hypertension

Q: What’s the best device to measure blood pressure?

A: We used to use machines that measured BP with mercury inside a glass tube. You need some skills with a stethoscope for those mercury devices. That was the gold standard. Now we rely on automatic electronic machines. Omron makes the best. Most doctors have given up on the mercury sphygmomanometers.

Q: What’s the best technique to measure BP?

A. The diagnosis of hypertension cannot be made with just a few readings. The least accurate way is in doctors offices, for a variety of reasons. Ideally home readings obtained on multiple occasions is best. Some experts prefer 24 hour recordings (ambulatory readings,) but self measured readings done properly is best. Always take your readings sitting and after resting for 5 minutes. Then repeat 2 or 3 times before writing own the measurement for your doctor

Q: Which of the new guidelines should your doctor follow?

A: He should use the one that he has most confidence in, but he should be aware of the concerns of experts in multiple American guidelines as well as those from Europe. Mostly he should persevere until your BP is below his target, which is generally 130-140 systolic, depending on age and other variables such as atherosclerotic risk factors and other diagnoses such as kidney disease. Doctors need flexibility to provide the best care, and sometimes rigid rules by non-physicians stand in his way.

Q: Why do doctors need flexibility in caring for their patients?

A: Dr. Franz Messerli, in the European Heart Journal said, “Regardless of how guidelines define hypertension, we should remember a simple but inescapable truth in medicine: patients are genetically, physiologically, metabolically, pathologically, psychologically, and culturally different. Accordingly, there never will be only one way to diagnose and treat many medical disorders, including hypertension.”

Q: At what point should treatment begin for hypertension and at what point is treatment successful?

A. The guidelines spell out these thresholds, and the disagreements are not very far apart. Most American doctors would and should go by the American Heart Association/American College of Cardiology recommendations. This means that all patients (and there are exceptions) should achieve a BP of less than 130/80. But under 120 systolic is generally considered excessive.

Q: What are the caveats regarding successful treatment of hypertension ?:

A:

——1. Patients over 65 years old can be more sensitive to drugs and are at risk of consequences due to BP readings that are too low for them resulting in risky events such as dizziness and fainting. If you are having such symptoms, take your blood pressure standing to assess for “orthostatic hypotension.” Your medication may require adjustment.

—-2. What about young and apparently healthy individuals with hypertension? Doctors can begin with non-pharmacological forms of treatment such as dietary modifications, exercise, weight reduction, stress control, etc. But if a young person has worrisome risk factors such as family history of early coronary disease, then more aggressive early approaches should be considered.

—3. Drug treatment often should be done with 2 or 3 kinds of medications at the same time; even rolled into one pill.

—-4. Diastolic hypertension is less important than systolic, but all guidelines encourage doctors to pay attention to that variable.

—–5. Should mild hypertension be treated: yes

—–6. The new guidelines will diagnose people who consider themselves to be heathy. The diagnosis can cause all sorts of psychological adverse reactions. Doctors need to be conscious of these consequences.

—-7. “Masked hypertension” is when office blood pressures are normal, but home readings are high. This is unusual but must be treated.

—-8. “White coat hypertension” with high readings only in the office is a worrisome condition that requires treatment

—9. Most of the time a “primary physician” can handle a case of hypertension, but sometimes a referral to a specialist is needed. Patients should demand that guideline goals be met.

If you have hypertension, get a machine at the drugstore and take your readings frequently. Keep a written record with the time of day and special circumstances (such as forgetting your meds, or being stressed out, or losing sleep, etc)

Do not place the cuff over clothing, be seated, keep cuff arm level with heart, make sure cuff is not too small for your arm, and take your device to the doctor to compare readings on the assumption that the doctor has kept his equipment calibrated. (Fat chance, but at least your readings at home will be on the same page with his.)

Omron makes one that is for doctors offices, but it costs about $500.00 A perfectly good Omron for home use is about $60.00 depending on features.

I hope our 4 part series has alerted you to the complexity of hypertension and the importance of obtaining quality care under the guidance of a real doctor who treats you as an individual and believes in the doctor-patient relationship.