Hypertension 9 – Treatment and Compliance

Standard

291978-3541-12291978-3541-12

Hi everyone! I’m on time today. This is Dr. Louella checking in from the office. This ought to be our final post on hypertension but I feel the need to give a summary afterwards to draw all the essential points together. Let us finish up on treatment.

So, let’s say diet and exercise (as we discussed previously), fail. You ask what I mean by fail… well you just don’t do them or you make a half-hearted attempt to do so. Then they will fail. Or, better yet, say you do try, and get some results but not sufficient for your blood pressure to be called normal, what do we do?

It is obvious we turn to medication at this point. Antihypertensive medication is used to control but not to cure hypertension or high blood pressure. Some people’s blood pressures are so high that we have to put them on medication from the start, but this should be done in conjunction with diet and exercise.

Now I don’t need to go too much into the actual medications. There are many classes of antihypertensive drugs and several drugs in each class. One may work a bit better in an individual than another but none is clearly superior.

I do have a lot to say on “The Patient and the Taking of Antihypertensives” though. Oh my goodness! I have only dealt with patients from Trinidad but I am sure there are patients all over who behave similarly.

Many patients aren’t convinced of the diagnosis of hypertension. They say “so they say” but don’t own it for themselves. They are in denial. Others treat it like a minor irritation or joke. But I am usually quickly able to convince them of the diagnosis by giving them the normal range and showing where a number of their blood pressures, as recorded in the patient notes, are beyond that. Remember, if they were diagnosed based on one reading, they have a right to be skeptical.

I show them that antihypertensives work on everyone. If they do not have hypertension their blood pressures would run low if they took medication. Are their blood pressures running low? Or are they being maintained just normal, high normal or even too high? If your blood pressure is normal whilst on an antihypertensive, you need to continue on that treatment, or else it will go high.

blood-pressure-3399x1699

It is difficult to get hypertensive patients to take their medication because they don’t feel sick. This often leads them to rush to take a pill when they do feel something like a headache or neck pain. Recall that hypertension has no symptoms. I tell them if you are waiting to feel something, that’s when complications have already set in, and it will be too late.

A lot of our patient population think a water pill is to help them pass water and improve functioning of their kidneys, so they don’t take it because they pass water just fine. They are oblivious to the fact that it is a pill for treating hypertension, so I make this clear to them.

Many of them have their own regimen for taking medicines: once a day instead of twice, every other day, twice or three times a week, whenever they remember or whenever the blood pressure is high. No wonder the pills don’t work!!! I always ask why? What is your reasoning for this?

I will admit, years ago when I first discovered this deviant behavior I was shocked. I found out that we doctors increased the dosages of patient medication when needed but the patients themselves didn’t. So the notes may be saying as many as four tablets a day when the patient still routinely took one. My most gruesome discovery was bags and bags half-filled with medication at the homes of the elderly we visited in Cedros. I was upset and thought I was fighting a losing battle.

But I’m older and wiser now. I understand many of the reasons they don’t take their medicines as prescribed. I ask them point blank about it and spend some time on the topic. But even after explaining there is no guarantee they will follow comply. Most of our patients are unaware of the names of their medication and this makes it more difficult.

I explain to those that take their meds only when blood pressure is high is that they are doing more damage by allowing their pressures to go high and then taking a pill, as opposed to having it controlled at all times. If your blood pressure is good today it may be the pill you took yesterday. If you miss the pill today it will be high tomorrow or the next day. To decrease risk of complications blood pressure needs to be controlled at all times

Many patients are afraid of side effects. I try to explain that these side effects are only potential and nothing happens to most people. There is no automatic damage by the medication. And furthermore, the damage they will get from hypertension is more sure and worse than what the tabs will do.

For those who have decreased the dosages due to convenience, I explain to them that the drug only is effective in their system for a certain length of time and they need to take it as prescribed for it to work properly. It comes as though you’re wasting your time because the drug can’t work like that.

A few of them cannot read so I emphasise to them that I am changing the dose and ask them to refer to a relative or neighbor to read it for them. Sometimes for the elderly or mentally challenged I ask for them to bring a relative. I explain to that person and charge them with the responsibility.

That’s it folks!!! We just completed the series on hypertension. Only the summary is left. Thereafter I’ll be starting a new topic. Now if I left out anything or you don’t understand something, feel free to comment before we move on. I enjoyed this because it was like a refresher for me and as you can tell, I love to share my patient experiences. Enjoy the rest of the weekend and the incoming week!

 

Hypertension 6 – Associations

Standard

It’s the Easter long weekend here in Trinidad and Tobago!!! That means church, beach, camp or partying for many. Dr. Louella here, and I’ve got to wrap this blog up quickly because I’ve got to go dance practice for our Glorifest concert of high praise this Saturday. I need to remember all my moves and get them really tight.

But first to continue our discussion about hypertension because it is very important. Before we talk about the treatment of hypertension though, you may have noticed that I omitted a well-known topic in hypertension. That’s salt intake. Everyone knows that hypertension is associated with a high salt intake.

Earlier, in our talk on causes of hypertension, I did not mention salt as a cause. In fact, what I did say is that the real cause of hypertension is not known. And that is true.

But there are a number of important dietary associations of the disease which should be mentioned. For example we know that high blood pressure is associated with a high salt (sodium) intake. It occurs more frequently in those who consume a lot of salt. But it does not occur in all of them.

Researchers have found that those with a high potassium intake have a lower blood pressure. That’s because potassium counters sodium in the body. Whereas the sodium from salt draws more water into the circulation encouraging a higher blood pressure, potassium does the opposite.

Eating oats seems to be a fad these days but it is a healthy one. Eating whole grain such as oats and bran flakes every morning is associated with a lower risk of developing hypertension. Oats also reduces blood cholesterol as well.

An important part of some person’s diet, alcohol, is also proven to elevate blood pressure. I saw this in one of my local alcoholic patients in Cedros. Once he stopped his drinking binge, his blood pressure would go to almost normal.

Also in my practice, I have come to expect, without even realizing it, most obese patients to have an elevated blood pressure, so commonly is obesity associated with hypertension, especially in our almost half African-descended population in Trinidad.

What I mentioned above are the PROVEN associations of hypertension. Note I did not mention highly seasoned food, sweets, fat intake, cholesterol and smoking, a few of the things I have heard people mention, as associations. These may cause other problems, by not hypertension, as far as is currently known.

Remember too, that we already discussed physical and emotional states that elevate blood pressure. Next we will determine what is the best approach to a diet that helps to lower blood pressure. But it won’t be from scratch. This wheel has been invented before.

So, we have a four day weekend here in Trinidad. Whatever you’ve got wherever you live, I hope you enjoy it! Till next week. Dr Lou is out!

Hypertension 4 – Complications

Standard

untitled (2)

Hi guys. It’s Dr Louella again. We need to wind up on hypertension but first I must report that I did not make it to Cedros (Trinidad) for the holiday, as I had no company for the two hour drive. But there’s gonna be a next time!

Well so far we’ve been through the symptoms, causes and diagnosis of hypertension and it’s time to get to the bottom line of how to treat it. But not quite. Because the problem with many people is that they don’t fully understand WHY we treat hypertension.

And why is that so? … If you recall, hypertension has no real symptoms. It does not make you feel sick. So in many people’s minds they do not really see the need to take medication when they are not sick. Many of them only take meds when they think their blood pressure is high. But there is no way to know without testing and you cannot test 24/7.

Once your blood pressure is higher than the ideal level of 120/80 your blood vessels are traumatized by the pressure of the blood flow and gradually, over months and years, the inner lining of the blood vessels is damaged. This can lead to thickening of the blood vessel walls by increase in the muscle content in smaller blood vessels and by cholesterol-filled atherosclerotic plaques in larger vessels.

Atherosclerosis is hardening of the blood vessel walls by the growth of plaques which are filled with cholesterol. The picture below shows the progression.

From: cdc.gov

Once thickening of blood vessels occurs, the lumen or passageway of the blood vessel narrows so less blood can flow through it. This especially affects blood vessels in the heart and brain causing ischaemic heart disease, which may lead to heart attack, and stroke.

People with ischaemic heart disease usually suffer with recurrent chest pain due to poor blood supply to the heart.  During a heart attack the blood supply is cut off completely and part of the heart dies. This may result in sudden death of the individual or they may have to live with a severely weakened heart.

There are other ways hypertension can damage the heart. The high pressure of the blood can put a strain on the chambers of the heart as they contract leading to thickening of the muscle of the largest chamber, the left ventricle. This becomes stiff and less able to contract. It is further weakened by the poor blood supply in the narrowed arteries. Finally, the heart muscle starts to stretch and can no longer perform its function.

The description above is that of heart failure and is usually accompanied by an enlarged heart. The heart muscle in heart failure does not have its full strength and the heart cannot properly perform circulation of the blood without the help of medication. The individual often suffers with extreme fatigue, shortness of breath and/or swelling of the feet.

Ok! That’s a mouthful. As we can see, hypertension causes some major problems in the heart. Next week we’ll finish these complications. We have not yet spoken about a big one, stroke. I will share my own personal experience with this awful disease. See you then!

Hypertension 3 – Causes/Diagnosis

Standard

It’s another long weekend here in Trinidad and Tobago! But before enjoying the relaxation let me push a little further into our discussion on hypertension.

It slipped me to mention in my previous blog about other causes of hypertension. While the vast majority of cases of hypertension, about 95%, are called ‘essential hypertension’ where the cause is not really known and has something to do with the kidneys, 5% of cases of hypertension actually have an identifiable cause.

A red flag goes up especially in younger individuals who may develop a variety of conditions which may be hormonal, renal or otherwise, which may be associated with ‘secondary hypertension’. These include polycystic kidneys, nephrotic syndrome, phaechromocytoma and thyrotoxicosis among others. Doctors ought to actively search for a cause in younger persons.

… So you’ve heard a bit about hypertension. Suppose you would now like to discover if you have this silent killer or not, how is it done? Well checking blood pressure is so easy nowadays we are without excuse. You can check at the hospital, health centre, doctor’s office, pharmacy, at a friend’s, at home.

You can use older methods that require someone with a sphygmomanometer and stethoscope or you can do it all by yourself at home with a completely automated device. I advise all my hypertensive patients to get a blood pressure gauge at home because they are generally affordable and they can better alert their doctor as to what is happening with their blood pressure.

Diagnosing hypertension is a slightly different matter. It should not be done based on one reading unless the blood pressure is extremely high. A few readings ought to be taken and the average used. Remember we spoke about how your blood pressure could be temporarily elevated due to different states of the individual (increased physical or emotional activity). One would not want to mistake one of these readings for hypertension so a number of readings should be taken to get a true picture.

I advise my patients to take their blood pressure when relaxed so we can get the best readings. Current guidelines recommend being seated quiet for 5 minutes prior to checking it.

We’ve heard these figures over and over but we must try to remember that an elevated blood pressure is equal or greater to 140/90. Over 160/100 is severe hypertension. 120/80 and under is ideal. Next time I’ll tell you what these figures mean. It’s real simple.

I would like to remind everybody that one isolated elevated blood pressure does NOT kill. Some people panic and get stressed when they hear their blood pressure is high. What we need to do is repeat it. If the high reading is the trend then we need to treat it. But the great thing is, WE HAVE TIME! High blood pressure does not cause its deleterious effects after one day, after one month ore even after one year. It is a chronic illness and it takes YEARS for the effects to be seen so we have time to get it right and control that blood pressure.

Next time our main chat will be about treatment. … I’m thinking of going to Cedros, at the south-western tip of the island for the holiday. Usually calm sea waters for me to find peace and meditate. Also a place where I was the community doctor, so I’m known there. Let you know if it happens (keeping my fingers crossed)..