IN 1945, THE MOST IMPORTANT patient in the world, President Franklin D. Roosevelt, died of a stroke caused by high blood pressure. The sorely pressed physicians attending the Chief Executive had nothing to offer their patient except rest and a salt-free diet.
Dr. Howard G. Bruenn, the Navy cardiologist who cared for FDR during the last year of Roosevelt`s momentous life, recently told Navy Medicine, ”If I had had the modern drugs we now have to control high blood pressure, I might have been able to perform a miracle. In the last 10-15 years, we have been able to bring down the blood pressure of practically everybody.”
Well, bring it down, maybe, but not necessarily keep it down.
Chicagoans need look no further than the medical example of their late mayor, Harold Washington, who died of a massive heart attack on Nov. 25, 1987. In a 1988 article in the Tribune Magazine, Cook County Medical Examiner Robert Stein described the mayor`s autopsy this way:
”Harold Washington was a victim of his hypertensive heart disease
(resulting from high blood pressure), his lifestyle and his diet. The message is that we all have to find the time to take better care of ourselves physically.”
Washington was an accident waiting to happen. He had been a heavy smoker for 30 years, was obese (weighing 284 pounds at autopsy, almost 100 pounds over the recommended weight for his 5-10 frame), had high cholesterol, and had not taken a day of vacation since being elected mayor in April 1983. And, most significantly, he had high blood pressure, for which he often forgot to take his medication.
These two famous politicians personify a very common problem. High blood pressure, or hypertension, is one of the most neglected-and deadliest-health problems in America.
In 1990, according to the National Institutes of Health (NIH), more than 50 million Americans have uncontrolled high blood pressure. And uncontrolled high blood pressure is a ticking time bomb, worsening over 15 to 25 years to attack the body`s vital organs and cause heart attack, stroke, kidney failure, blindness and death.
The time from the onset of uncontrolled fixed hypertension to death is about 20 years. However, for the first 14 years or so, there are no warning signs other than a high blood pressure reading. This is why hypertension is aptly called the silent killer.
By the late 1950s, the monumental research study begun in 1948 in Framingham, Mass., had clearly demonstrated the role high blood pressure plays in causing heart attacks and strokes and kidney disease. Accordingly, by the late 1960s and early 1970s, the U.S. pharmaceutical industry had developed an arsenal of medications, and physicians had begun to aggressively treat hypertension.
However, millions of Americans-such as former Mayor Washington-are still foolishly refusing to take their medicine. Dr. Robert S. Eliot, director of the Cardiovascular Center at the Swedish Memorial Center in Englewood, Colo., and a member of the Prevention Committee of the American College of Cardiology, pointed out in the article on Washington`s death:
By itself, high blood pressure doubles your risk of heart attack. If, in addition, you smoke or have high cholesterol, your risk is eight times higher. If you have high blood pressure and you smoke AND you have high cholesterol, your risk is up to 12 times higher. If you have all three of these factors plus being obese, the risk doubles again. So Harold Washington`s risk was 24 times the average.
What Roosevelt couldn`t do and what Washington wouldn`t do is what you should do if you have high blood pressure: Take the medications your doctor tells you to take and motivate yourself to lose weight, exercise more and adopt a healthy diet.
First, though, let`s start with the basics.
Our circulating blood is a sea of of life-sustaining fluid that delivers oxygen and nutrients to the body`s cells and removes waste material, just as the ocean did for the first animal, the single-celled amoeba. In place of waves, the continuous bathing of each cell in refreshed fluid is
accomplished by an internal pumping system-the heart and blood vessels-that keeps the fluid recirculating, full and fresh, and maintains the pressure.
Blood pressure is the force with which blood pushes against the walls of the blood vessels.
Everyone has a blood pressure, and the NIH estimates that for one of every four Americans, or 60 million people it is either too high (35 million) or borderline high (25 million).
That`s half the story. The other half, the NIH points out, is that in 1990 only 17 million American hypertensives, roughly one of every four, is under medical supervision to control this lifelong and potentially fatal condition. And only half of those under medical supervision are regularly taking their drugs as prescribed. In other words, about 51.5 million Americans have uncontrolled high or borderline high blood pressure.
Dr. Murray Levin, director of nephrology (the study of kidney disease)
and hypertension at Chicago`s Northwestern Medical Center, says: About 10 years ago, we called it the `one-half rule.` Only half of all the people with high blood pressure even knew it; only half of those who knew were under medical supervision; and only half of those under treatment had their condition controlled.
”This meant that only one of every eight hypertensives had his high blood pressure under control. I believe that more people are aware of the problem today, but the percentage who seek treatment and have their high blood pressure under control is about the same.”
ALTHOUGH HIGH BLOOD PRESSURE is the No. 1 reason for patient visits to physicians, and although anti-hypertensive medications are the No. 1 selling class of drugs, there is an epidemic of non-compliance with the doctor`s advice to control this silent killer. Ironically, although high blood pressure is both easy to detect and relatively easy to treat, half of all people treated discontinue drug therapy within one year and at least as many also refuse to make the necessary changes in their lifestyles.
For most people, high blood pressure is usually detected during a routine physical examination. In 5 to 10 percent of the cases, the condition can be traced to an underlying disorder. If these disorders are corrected, the blood pressure usually returns to normal.
The other 90 to 95 percent of people with established, or fixed, high blood pressure are said to have essential hypertension For these people, the key contributors appear to be genetics, obesity and excessive salt intake. Also, for reasons imperfectly understood, excessive alcohol intake and excessive stress (notably anger and frustration) can also raise blood pressure. Still, science does not know what causes essential hypertension.
IT HAPPENS MILLIONS OF TIMES EVERY day. A doctor or nurse wraps a cuff around the upper arm. The cuff is attached to a barometer that contains a column of mercury or its equivalent. The physician gently inflates the cuff, sqeezing the main artery in your arm until the flow of blood stops. Then the physician slowly deflates the cuff, reducing pressure on the artery. He or she places a stethoscope over the artery and notes the barometer reading when the pulse starts again. This gives the systolic pressure (maximum pressure in the artery when the heart is beating). The reading when the pulse sound disappears gives the diastolic pressure (minimum pressure in the artery between heart beats).
The physician records the numbers as, let`s say, 120 over 80, meaning a reading of 120 millimeters of mercury systolic and 80 millimeters of mercury diastolic. The numbers are based on a universally recognized measurement of the force required to move a column of mercury to a specified height.
On a continuum of possible readings, 120/80 is considered average for adults, and 140/90 is considered the beginning or borderline of high blood pressure. As with all human measurements, there is variability within the range of normal, and blood pressure rises with age.
A 12-year-old with a reading of 140/90 would have the same high-risk profile as an adult at 200/130; a teen-ager with a reading of 120/80 would have definite high blood pressure.
Most physicians are familiar with white-collar hypertension, the phenomenon in which many people experience a rise in blood pressure simply by entering a physician`s office. However, repeat reliable readings above 140/90 are considered abnormally high and carry increased risks.
The higher the pressure, the higher the risk, and readings of 200 or higher systolic and 115 or higher diastolic are extremely serious medical conditions. Except in rare cases of shock, low readings (low blood pressure)
are not harmful and often mean a longer life. Healthy adults and teenagers may have normal readings as low as 95/55.
Your blood pressure can rise for three reasons:
1. The heart increases its output of blood by beating faster and/or harder.
2. The arteries narrow and allow less room for the blood to flow.
3. Both of the above. Eliot refers to this as driving a car at high speed with the brakes on.
To understand the effect of narrowing, or constriction, think of a garden hose. Water from the same spigot will push harder and exert more pressure on the insides of a narrow hose than on the insides of a wide hose. In the same way, if your arteries constrict into narrow tubes, the blood trying to get through will have to push harder, and your blood pressure will rise.
NORMAL BLOOD PRESsure suggests that the heart is working properly; high blood pressure is a sign that the heart is working extra hard to keep the blood moving. Thus, the level of your blood pressure is one important way of measuring the efficiency of your cardiovascular system (heart and blood vessels).
Northwestern`s Levin says, ”High blood pressure is not a disease in the usual sense. It is a measure of disturbed physiology. The definition of high blood pressure is totally arbitrary. Defining 140/90 as the beginning of high (blood pressure) simply means that the top 20 percent or so of humanity exceeds this measurement
He adds, though, that while the numbers are arbitrary, high blood pressure is a much more established risk factor for heart disease than is cholesterol (for which the recommended desirable ranges have also been lowered).
Recently, experts agreed on a consensus definition of high blood pressure. The Joint National Committee on the Detection, Evaluation and Treatment of High Blood Pressure has stated that a reading greater than 95 diastolic (the average of two or more readings on at least two subsequent visits) is the beginning of high blood pressure, and that a reading of 90-95 is considered borderline high. (Experts consider the diastolic, or resting blood pressure, to be the more significant measurement.)
Levin`s colleague, Dr. Daniel Batlle, who is doing cutting-edge research into the causes of hypertension, says, ”High blood pressure does not respect anyone, and it can strike anyone at any time, but it also discriminates against certain people. It usually occurs among older people, among the relatives of hypertensives, among men, and, especially, among black men.”
Half of all Americans over 65 have high blood pressure. In general, hypertension occurs more often and with more severe consequences among men than among women; and among blacks, especially black men, than among whites. Also at increased risk for hypertension are pregnant women; women taking birth control pills; short, heavy people; and overweight people in general.
You should be especially concerned if your parents have hypertension. If one of your parents has essential hypertension, there is a 50 percent risk that one child in the family will develop it also (usually between 40 and 50). If both parents have it, the chances that one child in the family will develop it rises to 90 percent. In that case, it usually begins earlier.
Uncontrolled high blood pressure is a killer. The extra pounding and work created by high blood pressure can damage and destroy the heart and blood vessels, the brain, the kidneys the eyes. In fact, according to a recent study published in the Journal of the American Medical Association, one needn`t even be classified as hypertensive to be vulnerable. The study found that above-normal blood pressure can be harmful and can permanently damage heart and blood vessels and increase coronary risk.
That`s the bad news. The good news is that in the last 20 years there has been a revolution in the ways medicine can control hypertension, and this has contributed to a 50 percent decline in deaths from strokes and a 35 percent decline in deaths from heart disease in the U.S. since the early 1970s. Even after organ failure begins, effective treatment can add years to your life. In one study, patients who did not follow their doctors` advice lived an average of less than five years, while patients who controlled their blood pressure survived an average of more than 12 years.
The advice from physicians is as simple 1-2-3:
1. Have your blood pressure checked.
2. If it is high, have the tests repeated on at least two subsequent occasions.
3. If it is determined that you have established high blood pressure, do what you have to do to control it. The physician can prescribe medication to slow the heart`s output and/or widen narrowed blood vessels; the patient can provide motivation to lose weight, exercise more, stop smoking, reduce excess alcohol and salt intake and learn how to manage stress better.
ALTHOUGH MEDICATION IS THE answer for the overwhelming majority of hypertensives, research indicates that nondrug therapies, especially exercise and diet, can control mild high blood pressure and supplement medication for more serious cases. The overwhelming majority of hypertensives have mildly high blood pressure.
A study published this year in the Journal of the American Medical Association, reports that regular physical exercise can be as effective as medication in treating mildly high blood pressure. The findings show that 52 previously sedentary men who belong to a group health plan in Maryland were able to safely bring their mildly high blood pressure under control by exercising vigorously for 50 minutes three or four times a week. As an added benefit, the 10-week exercise program lowered total cholesterols and increased the protective high-density-lipoprotein cholesterol, which helps to clear the body of excess cholesterol.
The men did weight training and aerobic exercises such as walking, jogging, and cycling. The blood-pressure reductions occurred, even though the men lost little or no weight and continued their normal diets. However, the principal researcher, cardiologist Michael H. Kelemen, cautioned, ”A lot of people find it easier to take medication on a long-term basis than to get to a health club regularly.”
