targeting high blood pressure
by Jenny Bryan
When Geoff first discovered he had high blood pressure it had climbed to 190/110 and he was shocked when his doctor warned him that he risked a heart attack or stroke. Seven years later and Geoff has tried most types of drug designed to bring his blood pressure down. Some have made him feel tired, with others he can't sleep. For a while, just going to the doctor to have his pressure measured sent it sky-high.
© C4
Nearing 70, Geoff isn't the sort to sit in a chair and admire the view. If he's not keeping his hedges neatly trimmed or playing for the village cricket team, he's directing the local play, or driving around the country visiting old friends. Telling Geoff to slow down and act his age just isn't on the itinerary.
His GP, at a loss to know what to do, referred him to a specialist. More juggling of drugs and doses followed. Today, Geoff takes three different drugs to control his blood pressure. It's come down to 150/95 and, although it's still above the recommended level, everyone's agreed that Geoff's off the hook. As long as it doesn't go much higher and Geoff feels well, he's free to get on with his busy life.
what should my blood pressure be?
Blood pressure targets for people like Geoff are tougher than ever. Whether you are young or old, when your doctor takes your blood pressure, it should be less than 140/85. If you have diabetes, it should be lower still – less than 140/80 (see abc of body under 'blood pressure', 'hypertension', 'diastolic', 'systolic').
Professor Graham MacGregor, president of the British Hypertension Society, explains that recent research has shown that, when it comes to blood pressure – lower is better.
'There's increasing evidence that lowering blood pressure reduces your risk of heart attacks and strokes and that the lower, the better. Two recent studies showed it was beneficial to lower blood pressure even when it is in the normal range,' he explains.
In the past, we've been notoriously bad at keeping our blood pressure under control. Doctors coined the term, 'the rule of halves.' Only half of the people with high blood pressure even knew they had a problem, only half of these were receiving treatment, and only about half of these managed to achieve the old, easier blood pressure target of 160/95.
But things are improving. A recent analysis showed an awareness rate over 70%, with nearly 60% on treatment, and 65% of these achieving a target of 160/95. The bad news was that only 29% of those on treatment managed to get their blood pressure below 140/90 – nearer to today's target levels.
hitting the bullseye
Blood pressure specialists like Professor MacGregor believe that, in addition to healthy eating and exercising, cutting back on alcohol and salt and, if necessary, losing weight, many people with high blood pressure will only be able to achieve today's targets by taking two or three different drugs. At St George's Hospital, he sees patients, like Geoff, whose GPs have found hard to treat. But, even amongst this tricky group, he has found that 40% can hit the new targets when they take three drugs.
'We need to start telling people from the outset that they will probably need three drugs to control their blood pressure and they will be very lucky to get away with taking only one or two,' says Professor MacGregor.
Yorkshire GP, Dr Terry McCormack, says the same. Working far away from the academics who produce blood pressure guidelines, he is still an enthusiast for getting levels down.
'Doctors used to be taught that combinations of drugs were not good science, but when it comes to blood pressure we now know that many people need three or more drugs to achieve good control,' he says.
what about the side effects?
Hitting the blood pressure targets should not mean feeling ill from the side effects of treatment. Nearly all drugs have some side effects, and those that lower blood pressure are no exception. But people vary in their responses and, with literally dozens of blood pressure drugs to choose from, there really is something for everyone (see which drug is right for me?).
Most GPs start patients off on a diuretic or a beta blocker. Dr McCormack explains that although these are older drugs, they still work very well. If blood pressure doesn't fall enough with a diuretic or a beta blocker alone, a combination of the two drugs may do the trick. Alternatively, if a diuretic isn't enough, many doctors will add an angiotensin converting enzyme (ACE) inhibitor (see abc of body under 'ACE inhibitor').
Men with prostate problems as well as high blood pressure are often prescribed an alpha blocker, since these drugs help to shrink the prostate as well as lower blood pressure. And people with asthma should not be prescribed beta blockers since these can make their asthma worse.
Calcium channel blockers are another option for controlling blood pressure but some people find that they make their ankles swell. For African-Caribbean groups , diuretics and calcium channel blockers seem to be more effective than ACE inhibitors and beta blockers.
Side effects are important and shouldn't be ignored. If you don't feel well with any blood pressure drug, be sure to tell your doctor so that the drug or the dose can be changed.
Professor MacGregor spells it out:
'I start a patient off with one drug. If it lowers their blood pressure and they feel well but their pressure is still not controlled, I add another drug. If there's been no effect on their blood pressure or they feel unwell with it, I switch them to something else.'
He repeats the process until the blood pressure is controlled and his patient feels well. Ideally, he'd like to be able to prescribe two or three blood pressure lowering drugs in a single tablet, and pharmaceutical companies are certainly working hard to achieve this.
what if I can't reach the target?
Both Professor MacGregor and Dr McCormack accept that some people won't reach their blood pressure target, however hard they try.
People with the highest starting blood pressures are often the most rewarding to treat. Those with borderline problems may be harder to sort out because they will be less tolerant of side effects for small improvements.
Age also plays a part in deciding whether to go for broke. The over-80s are vulnerable to sudden drops in blood pressure when they stand up. A fall and a possible broken hip is too high a price to pay for meeting blood pressure targets. Dr McCormack doesn't prescribe more than two drugs to lower blood pressure in this age group, while he may try much harder to hit the target with his younger patients, for whom a premature heart attack or stroke would be catastrophic to their working and family lives.
'A target should be just that – a target,' concludes Dr McCormack. 'There will always be people who won't hit it. If someone had rip-roaring blood pressure and you get it down to 160/90 with three or four drugs and they feel well, then you should probably accept that you've achieved a great deal and it's common sense to stop there, not make the patient ill by giving them anything more.'
which drug's right for me?
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Drug | |
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A good idea if you have (or are) … |
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Probably not if you have (or are) … |
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Alpha blockers |
Prostate problems |
Incontinence |
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ACE inhibitors |
Heart failure Diabetes |
Pregnant |
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Angiotensin II receptor antagonists |
Side effects with ACE inhibitors |
Pregnant |
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Beta blockers |
Had a heart attack Chest pain |
Asthma |
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Calcium antagonists |
Angina Elderly |
Swollen ankles |
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Thiazide diuretics |
Elderly |
Gout |
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help and info
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organisations
Blood Pressure Association
60 Cranmer Terrace
London SW17 0QS
Tel: 020 8772 4994 (Mon-Fri 9am-5pm)
Website: www.bpassoc.org.uk
Acts as a forum for individuals whose lives are affected by high blood pressure, drawing attention to the importance of better detection, management and treatment. Aims to help people to manage their blood pressure better themselves by providing information and support. Website contains facts and information on medication, lifestyle and general issues related to high blood pressure, and outlines BPA services and activities.
British Heart Foundation
14 Fitzhardinge Street
London W1H 6DH
Heart Information Line: 08450 70 80 70 (Mon-Fri 9am-5pm)
Website: www.bhf.org.uk
Plays a leading role in the fight against heart disease and provides a range of information about the causes, prevention and treatment of the problem. Website contains a glossary, details of publications, plus practical advice on how to protect yourself from heart disease.
Stroke Association
240 City Road
London EC1V 2PR
Stroke Information Service Helpline: 0845 30 33 100 (Mon-Fri 9am-5pm)
E-mail: info@stroke.org.uk
Website: www.stroke.org.uk
Provides information and support for people affected by stroke and funds research into stroke prevention, diagnosis, treatment, rehabilitation, and care. Also produces a wide range of publications.
websites
Action on Pre-eclampsia
www.apec.org.uk
Explains what pre-eclampsia is, the importance of checking the blood pressure of pregnant women, outlining who is most at risk, and signs and symptoms. Contains details of the services offered by APEC including information, helpline, publications and research.
British Cardiac Patients Association
www.bcpa.co.uk
The independent voice of patients and carers. Offers help, support, advice and reassurance to all cardiac patients, their families and carers, and advice on how to prevent heart disease and stay healthy.
The British Hypertension Society (BHS)
www.hyp.ac.uk/bhs
Provides a forum to bring together research workers in the UK and the Republic of Ireland, including clinicians, physiologists and other scientists. Information leaflets such as Understanding High Blood Pressure and Self Help Measures are available on the website.
CASH: Consensus Action on Salt and Health
www.hyp.ac.uk/cash
A group of specialists concerned with salt and its effects on health. It is working to reach a consensus with the food industry over the harmful effects of a high salt diet, and aims to bring about a reduction in the amount of salt in processed foods. Features general dietary guidelines.
Database of Individual Patient Experiences (DIPEx)
www.dipex.org
Contains extensive information about high blood pressure, looks at individual experiences, and has a range of links.
High Blood Pressure Foundation
www.hbpf.org.uk
Aims to improve the basic understanding, assessment, treatment and public awareness of high blood pressure, and, in so doing, help promote the welfare of people with high blood pressure.
Irish Heart Foundation
www.irishheart.ie
Answers frequently asked questions about heart disease and risks. Outlines how to reduce stress, blood pressure and cholesterol, and stop smoking. Emphasises the importance of exercise and eating well. Features healthy recipes.
Patients Talking
www.patientstalking.com
A website for people to read and write diaries about a wide range of medical conditions and, if requested, confidentially make contact with others. It can also help people who may not directly have a condition but have concerns for a friend or relative with an illness.
reading
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The Blood Pressure Book by Stephen P Fortmann and Prudence Breitrose (Bull Publishing, 2001) |
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The Hypertension Sourcebook by Mary P McGowan and Jo McGowan Chopra (Contemporary Books, 2001) |
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Outsmart High Blood Pressure: Expert-Endorsed Solutions for Lowering Blood Pressure Quickly and Safely (Saint Martin's Press, 2003) |
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(October 2001, resources updated January 2005)
