Theresa’s story began in 2009 when she was diagnosed with anxiety. By 2011, she was suffering from a lot.
Palpitations, severe headache, nosebleeds and shortness of breath were a part of daily life for the 36-year-old store manager from Ohio. These symptoms were regularly interfering with her normal life and she had to change her job thrice after she failed to show up during her assigned shift hours due to headaches or anxiety attacks.
Things took a turn for the worse when she fell in Walmart’s parking while shopping for her groceries. She hurt her back and was rushed to the hospital. The nurse inspected her and came back and announced that, thankfully, Theresa was perfectly fine and her sister, Cindy, who was called in by the hospital, could take her back home.
However, a week had past and Theresa was still unable to get up from her bed.
Cindy was beginning to worry now.
She discussed Theresa’s condition with Harry, a friend of hers and a cardiologist.
She didn’t know that this decision would change her sister’s life forever.
Harry promised to visit the next day and check up on Theresa. While listening to her chest, Harry asked if Theresa had a heart murmur, to which she replied in a negative. He said he had her doubts and booked an appointment for her at the hospital immediately.
At the hospital, Harry carried out an echo cardiogram which lasted an hour and a half. Much to Cindy’s and Theresa’s dismay, Harry announced that Theresa was suffering from hypertension and her lungs were working at full capacity.
He said Theresa only had eight more months to live if she didn’t start her medication immediately.
The sisters were shell-shocked.
What Is Hypertension?
Hypertension, commonly known as blood pressure, is a lifelong condition. Systolic pressure is measured when the heart beats while diastolic is measured when the heart is at rest. The normal range for both these pressures is below 120 mmHg and below 80 mmHg respectively. Anything consistently higher than these values is considered hypertension.
Theresa’s BP was consistently way over the normal limits but she had not been taking it seriously.
But she is not alone.
Hypertension is highly prevalent in the United States and costs the country $46 billion each year. Nearly 70 million people (29 percent of the population) have high blood pressure.
One in every three adults is hypertensive today. The same statistics stand for prehypertension. Every one out of three individuals in US is also potentially at risk for the disease.
Only 50 percent of the patients suffering from this disease have it under control.
If Theresa doesn’t do anything about her disease she would join nearly 35 million people in the country have no control over a potentially life threatening condition.
What is Hypertension?
If not managed properly, hypertension is a killer.
Hypertension causes almost 1,000 deaths each day in the US. Though the condition develops over years with consistent damage to the blood vessels and organs, it is possible that a person can suffer from sudden Hypertensive crisis.
The crisis can present itself as either hypertensive urgency or hypertensive emergency. In hypertensive urgency the blood pressure is severely elevated (180 for systolic pressure and 110 for diastolic pressure) but there is no organ damage
The condition can be treated immediately with oral medications and shows symptoms like severe headache, nosebleeds, severe anxiety, and shortness of breath. Hypertensive emergency on the other hand can cause additional organ damage with consequences like fatal stroke, heart attack, memory loss, loss of kidney function, aortic dissection, pulmonary edema, eclampsia, angina, damage to eyes, and unconsciousness.
According to Centers for Disease Control and Prevention (CDC), 7 of 10 people who have had their first heart attack or chronic heart failure also have high blood pressure. Every 8 out of 10 people experiencing their first stroke have hypertension.
Through the course of her treatment, Theresa found out that hypertension has no treatment and reversal for primary high blood pressure is not possible. The only way to control this disease is to manage it on day to day basis.
In order to improve her disease, Theresa decided to change her way of living.
Getting To know The Disease: What Is Hypertension?
Theresa found out that she is among the 20 percent of the people who have high blood pressure are not aware of this condition. This group is especially at risk to suffer from potential adverse health consequences associated with hypertension.
The American Heart Association recommends getting regularly tested. Starting at the age 20, a person should get screened for high blood pressure once every two years. The test is quick, simple, and painless. The healthcare personnel like a doctor or nurse uses an instrument named sphygmomanometer, commonly known as a blood pressure monitor. Out of all types of monitors, the bicep cuff monitor gives the most accurate readings.
Theresa immediately decided to get one.
She learnt how to perform the test by placing the rubber cuff on her arm and inflating it. When inflated, the cuff restricted the blood flow through the larger artery in the bicep and when deflated, the reading shows up on an electronic monitor. When the blood starts to pulse through the artery, it registers sounds that continue until pressure in the artery exceeds the pressure in the cuff. The measurement can then be recorded.
Cindy also learnt how to measure BP and asked Theresa to start a log for effective management of her disease.
Hypertension Treatment: Take Medication Seriously
Theresa decided to take her medication and doctor’s appointments seriously. Medication is prescribed according to age, cause, and severity of the condition. According to the latest Clinical Guidelines for the management of high blood pressure in adults given by the Eighth Joint National Committee (JNC 8), the pharmacological treatment can differ on the basis on co-morbid conditions, age, and ethnicity.
For a person aged 60 or above treatment is aimed to lower the systolic blood pressure to 150 mmHg and diastolic pressure to 90 mmHg. If the treatment works the medications is not adjusted. For people younger than sixty years, like Theresa, the focus is to lower the systolic pressure to 140 mmHg and diastolic blood pressure to 90 mmHg. In people aged 18 or more if a chronic kidney disease or diabetes is diagnosed, the aim for systolic and diastolic pressures is 140 mmHg and 90 mmHg respectively.
In non-black population, including those with diabetes, initial treatment includes a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). For black populations only thiazide-type diuretic or CCB is given. People over the age of 18 and with Chronic Kidney failure are treated with an ACEI or ARB. This is followed for everyone with kidney failure regardless of diabetic status or race.
If the set goal is not achieved within a month, the drug dose is increased or a second drug from another class is added and it is adjusted till the target BP is not achieved. If the two drugs fail to help, a third drug may also be prescribed. However an ACEI and ARB should not be mixed. Additionally, antihypertensive drugs from other classes are also used if need arises.
Previously, the JNC 7 recommended five classes of hypertension drugs to be used as initial therapy with thiazide-type diuretics for most cases. However, the JNC 8 recommends only four classes of drugs for the initial therapy.
ACE Inhibitors helped Theresa by relaxing her blood vessels and included drugs like Enalapril, Lisinopril, Perindopril and Ramipril. She did face some common side effects, including dry cough, headaches, dizziness, and rash. ARBs also work in a similar way. Common examples are Candesartan, Irbesartan, Losartan, Valsartan and Olmesartan, side effects for which include cold or flu like symptoms, dizziness, and headaches. Calcium channel blockers also help by widening blood vessels with side effects like headaches, swollen ankles, and constipation. Common drug names include Amlodipine, Felodipine and Nifedipine.
Thresa was also prescribed diuretics, also known as water pills. These drugs helped by flushing excess salt and water from the body in the form of urine. They are also used if CCBs do not work properly and cause side effects. Diuretics may cause dizziness when standing up, rash, increased thirst, and a frequent need to go to toilet. Long term use may also cause hypokalaemia (low potassium level) and hyponatraemia (low sodium level).Common examples of thiazide diuretics include indapamide and bendroflumethiazide.
The fifth class; Beta blockers not included in Theresa’s current recommendations, reduce blood pressure by decreasing heart rate and force with which it beats. These drugs are less effective than other medications and are only used when other treatments do not work properly. Common examples include Atenolol and Bisoprolol. Side effects of Beta-Blockers include headaches, dizziness, tiredness, cold hands, and feet.
To ensure that Theresa was taking her medications on time, Cindy adopted several tips which are frequently given by the Department of Health and Human Services (HHS). These included:
- Putting a reminder note on the refrigerator
- Keeping the medicine on the nightstand next to her bed
- Keeping the medication with her tooth brush
- Putting reminder notes or sticky notes at visible places like bathroom mirror and doors
- Setting a buddy system with a friend to remind each other to take the medication
- Asking a loved one to remind you
- Placing the drugs in weekly pill boxes easily available at most pharmacies
- Setting reminder alarms at personal computers, phones or setting up a reminder e mail service
- Remember to refill the prescription one week before you run out, by making a note on the calendar in advance.
Making The Much-needed Changes In Diet
Theresa also looked at the recommendations from the National Heart, Lung, and Blood Institute (NIH) to make serious lifestyle changes to help manage blood pressure. She changed her diet to make it rich in natural and raw foods like fresh vegetables and fruits. Whole grains, high fiber foods, fat free or low fat products became a part of her daily diet and she included lean meat, fish and beans to fulfill her protein need. She reduced salt and Trans fats which increase BP. She also decided to cut down on sugar.
To make things easy for hypertension patients, the institute details a DASH eating plan (Dietary Approaches to Stop Hypertension) on its website. The plan for 2000 calorie a day diet suggests taking 6-8 daily servings of grains, 6 or less servings of meats, poultry, and fish, 4-5 daily servings of vegetables and fruits, 2-3 daily servings of low fat products, fats, and oils.
Sodium consumption should be kept between 1,500 to 2,300 mg per day to lower the blood pressure. Table salt or sodium chloride is 40 percent sodium. According to rough estimates, to see how much sodium is being consumed, the following can be considered:
- 1/4 teaspoon salt = 575 mg sodium
- 1/2 teaspoon salt = 1,150 mg sodium
- 3/4 teaspoon salt = 1,725 mg sodium
- 1 teaspoon salt = 2,300 mg sodium
Theresa started looking at the labels of the products she was buying and realized that words like “soda”, “sodium”, “Na” also signified the presence of sodium. Natural foods like seafood, cheeses, olives, and some legumes also carry large amount of salts. Some medications also carry high amounts of sodium.
She also added physical activity, maintaining healthy weight and BMI, stress management, avoiding tobacco and alcoholic products to her to-do list.
The list also advises daily physical activity of half an hour. Losing weight is also advised if needed through cardiovascular exercises, strength training, weight training, and stretching exercises. These activities decrease BP by nearly 5-7 mmHg. Maximum decrease in blood pressure is seen in individuals with highest baseline, after an endurance exercise bout (post exercise hypotension).
New data has also shown genetic links to blood pressure reduction associated with chronic and acute exercise sessions. Men over 45 years of age and women over 55 years may need to get tested, to see whether they experience any adverse effects related to exercise. Theresa met with her doctor to decide an exercise regimen.
Current recommendations suggest primarily endurance building physical activity for 30 minutes each day, for all days of the week.
Stress management is a vital part of blood pressure management and Theresa considered it to be the most important aspect of her treatment. She decided to deal with her anxiety and stress issues with the help of biofeedback, mediation, breathing exercises, behavioral training, relaxation techniques, and yoga. Harvard health also suggests some key strategies to lower stress in daily life. These strategies can include:
Getting adequate sleep is important. National Sleep Foundation suggests 7 to 9 hours of sleep for individuals aged above 18 years. Sleep can help you stay alert, increase your energy level, physical health and decrease your stress levels. Learning relaxation techniques can help lower stress and also boost morale. Strengthening social network can decrease feeling of loneliness and help with mental health of an individual. Other strategies include enhancing time management skills, nurturing one’s self, and asking for help.
Using Sauna And Hot Tubs Carefully
People with hypertension have to be especially careful when using hot tubs and saunas. As long as they are used with care they do not pose any serious threat. However, people experiencing a hypertensive crisis may not be able to tolerate saunas and hot tubs.
Heat from such places can cause the blood vessels of an individual to expand (vasodilatation) which can be harmful if one is hypertensive. Vasodilatation can also occur during normal physical activities. Moving between extreme temperatures that is cold and hot water can trigger the rise in blood pressure.
Managing Treatment-Resistant Hypertension
Resistant hypertension is the type of hypertension disease where individuals cannot control their blood pressure despite the use of diuretic and at least two blood pressure medicines. Resistant hypertension can be due to multiple reasons such as abnormalities in hormones which control blood pressure, accumulation of artery clogging plaque in blood vessels in a condition called renal artery stenosis, sleep problems such as sleep apnea, obesity, heavy alcohol intake, and other harmful substances.
Treatment of resistant hypertension involves the understanding of patterns that exist in individual’s blood pressure level. These patterns can be fully charted with the help of an automatic blood pressure recorder that can be worn for 24 hours. Treatment involves continuous revision of medications till a suitable combination is found, along with investigation of any other underlying medical conditions, and changes in the lifestyle of an individual.
Usually a thizide diuretic may be used that can help flush extra water and salts out of the body. Doctor may also prescribe angiotensin-converting enzyme (ACE) inhibitors, beta blockers, calcium channel blockers or others that can help lower blood pressure. Literature on the subject suggests that one should not:
Keep on adding medications– as adding more drugs to regimen may actually cause more harm than benefit. The focus should be on identification of the underlying cause that is causing the resistance.
Keep on combining an ACEI, an ARB, or a direct rennin inhibitor- because studies in specific populations such as people with diabetes, and proteinuric renal disease show serious complications and sever morbidity in patients on dual RAAS blockade therapy.
Accept any blood pressure level that is less than the target- because there is always some way to manage the disease better.
By making changes in her lifestyle and approach towards her disease, Theresa expects to slow the progression of her disease. She has learnt to look at life differently and hopes, like many others, there can be a permanent treatment for her condition. Cindy has moved closer to her sister’s place so that she can be at her beck and call in case of any emergency, which both of them hope never happens.