High Blood Pressure / Hypertension

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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Understanding high blood pressure and hypertension

Hypertension is defined as blood pressure that is consistently elevated above what is considered an increased risk for an individual patient, or type of patient, over a considerable length of time. There is disagreement on the exact number for the definition of high blood pressure, but recent studies have set the figure at 140/90 mm Hg for patients that present with a 10-year risk of cardiovascular disease that is 20 percent or higher. For patients without significant cardiovascular risk assessment, the safe sustained blood pressure is higher than 140/90. In recent years, we have learned that women were largely excluded from clinical studies, and with a correction of the gender bias we have found that blood pressure levels are different for men and women, and that normal blood pressure is different for aging women with perimenopausal neurohormonal changes as well. This is difficult for most patients to really understand, as patient education of real cardiovascular risk has not been stressed, just medication protocols. In addition, blood pressure that is sustained consistently between 140/90 and 160/100 is considered to be mild to moderate, and the current advice from many medical institutions is to first try a conservative approach to achieve an optimum sustained blood pressure most of the time, between 120/80 and 140/90. Complementary and Integrative Medicine provides an array of proven therapies that are relatively inexpensive and easy to incorporate to achieve these goals, as well as abundant advice to help understand how diet and lifestyle choices can achieve this reduction of cardiovascular risk.

Some considerations of adjustment of this standard for hypertension apply to common variations in blood pressure for different age groups, as blood pressure is generally lower in the teenager, and higher in the aging patient population, which should be taken into consideration. The key to a diagnosis of hypertension is not whether the blood pressure is high at one moment or moments, but whether it is consistently higher than what is acceptable for each individual in relation to their degree of cardiovascular risk. If your medical doctor does not determine that your blood pressure is consistently high outside of the doctor's office, and does not make a thoughtful analysis of your cardiovascular risk, he or she is not doing their job. Prescription of hypertension medications should follow logical diagnostic guidelines and be individually tailored to the patient. Thoughtful patients are starting to question this process, understand their medications, and seek both the right course of drug protocol for themselves, as well as a therapeutic protocol to correct the underlying health problems that have led to the consistently sustained high blood pressure. Patients that are determined by analysis to be at risk are also looking for ways to reduce risk. This is where Complementary Medicine comes into play.

When a mild to moderate high blood pressure, defined as between 140/90 and 160/100, is detected during one or two visits to your physician, blood pressure monitoring should be conducted daily at home to see if true hypertension, not just "White Coat Syndrome" is occurring. If there is sustained high blood pressure, cardiovascular risk should be assessed and discussed before starting medications. To truly reduce the cardiovascular risks with aging, an individualized protocol to address the underlying health problems needs to be thoughtfully initiated. Simply taking blood pressure medication does not solve the problems of cardiovascular risks, and often does not even control the hypertension.

The issue of improper taking of blood pressure in the doctor's office has been a point of concern in the last decade. Not only diagnosis of hypertension based on just one or two blood pressure readings, and the overlooking of the widespread phenomenon of "White Coat Syndrome", but the routine habits of blood pressure readings by professionals that artificially elevate the reading is a cause of concern among experts. The use of too small cuffs is often cited, but a number of other problems in reading blood pressure that may cause the blood pressure to be read higher than it really is, have been studied. Placing the pressure cuff over clothing may raise the systolic pressure, or having the cuff not tightly bound before inflation. This may raise the systolic reading from 10-50 mmHg higher. The level of the arm in relation to the chest and heart, and the taking of the pressure on the left arm may be important. The right arm, away from the heart flow, should be used, and the placing of the arm below the heart level may result in a higher reading. Even crossing the legs during reading, or a tense posture by the patient is proven to be able to raise the blood pressure reading. If the reading is higher than expected in the clinic, or at home, correct these issues, and perhaps take another reading lying down, or relaxed against a comfortable chair back. Even a full bladder has been shown to be able to raise the systolic blood pressure by 10 mmHg. Of course, the diastolic blood pressure, or pressure in the arteries when the heart is at a resting point in its pumping, is the most important number to evaluate cardiovascular stress. Back tension is shown to be able to raise this diastolic reading by 1 to 7 mmHg. Insure that a sustained high blood pressure for at least 6 months is evident before resorting to more radical therapy.

Because of the failures of standard drug medication protocols to significantly reduce incidence of cardiovascular accidents or to reduce the deaths from heart failure, cardiologists have adopted an attitude that even mild hypertension may need to be heavily medicated to improve overall statistics. The research concerning the use of a multidrug protocol for patients with mild hypertension and no significant risk of cardiovascular disease, though, does not produce clear evidence that this drug protocol delivers significant benefits. The significant long-term side effects and risks from these medications has become a cause of concern in public health. The actual risk versus benefit assessment perhaps is being ignored in a desperate attempt to improve the statistical benefits from current medical protocol. The National Heart Lung and Blood Institute of the NIH states that a 2003-2006 national survey showed only about 45 percent of hypertensive patients (BP greater than 140/90 or on antihypertensive medications) had their condition under control. This has resulted in a push to medicate patients with lower blood pressures to achieve statistical goals, but has still not resulted in a significant drive to integrate Complementary Medicine into standard treatment protocol, despite the evidence of benefit.

By 2010, standard guidelines often indicated that an optimal blood pressure included a systolic pressure no greater than 120. There was a failure to communicate that systolic blood pressure varies considerably with immediate stress, both physical and emotional, and diurnally, and that the real concern was blood pressure that did not relax at all to a point below 120 systolic. For many patients, medication risks outweighed benefits. There is now a prevalent question of whether medication risks and side effects are enough to warrant this treatment to achieve an optimal blood pressure. Systolic blood pressure (the top number in the standard ratio) is the pressure that your heart is pumping at any given moment. The diastolic pressure is the pressure in the arteries at rest. Systolic pressure can vary considerably depending on the amount of stimulation, including anxiety, illness, and activity. For example, a study summary in 2010 of a large group of patients from a 2003-6 survey of adults with no prior history of hypertension (cited below), showed that a daily dose of high-fructose corn syrup almost doubled the risk of sustained systolic pressure over 160, so even diet may cause a higher systolic pressure. A large percentage of patients have an elevated systolic blood pressure whenever they are in a doctor's office (white coat syndrome). Studies have shown that 40-50 percent of patients had elevated blood pressure when in the doctor's office, but not at home. In addition, the prevalent use of a blood pressure cuff that is too small will show an elevated systolic pressure that is not accurate, and taking the pressure on the left arm (nearer the heart) will also likely result in a higher blood pressure for some patients. One study showed that 96 percent of primary care physicians habitually use a cuff size too small (Pickering T, 1994, Lancet 334(8914). In addition, primary physicians often choose the left arm. It is also well known from decades of study that systolic pressure is expected to be higher in the aging population. All of these considerations create a situation in which most patients as they age could be considered for anti-hyptertensive drugs, and most of these patients may not have true hypertension, much less a cardiovascular risk profile.

For some patients, the risks and side effects of medication are not a consideration when trying to control blood pressure, even when the sustained blood pressure is borderline or varies, and even when there is a low risk assessment for cardiovascular events. For an increasing percentage of patients, though, there is a desire to avoid these medication risks and side effects when possible by adopting a more conservative medical approach. It is highly recommended that the patient with a diagnosis of hypertension purchase a quality blood pressure monitor and make a record of the daily blood pressure when relaxed at home. In the past, the diastolic blood pressure was considered the primary indicator of cardiovascular risk when sustained consistently for at least 6 months in a patient with indicators of high risk. The emergent popularity of the prescription of beta-blockers and calcium channel blockers, which control spiking of systolic blood pressure, is considered a primary reason why these new standards that focus on systolic pressure are frequently discussed. A realistic assessment of risk, accurate record of blood pressure variance, and elimination of potential causes of high blood pressure before starting medication, are all essential components of a healthy approach to this problem of cardiovascular risk. When one starts medication to control blood pressure, adoption of a thorough and holistic approach to correcting the underlying causes of hypertension, and working to reduce cardiovascular risk, are ways to insure that greater protection from strokes and heart attacks in the future is achieved. In addition, Complementary Medicine can help protect the patient from the side effects and risks of the medications, and with sufficient improvement in health, the patient and their prescribing physician may decide to see if less medication can achieve sufficient results.

Assessing the actual cardiovascular risk of each patient

The American Society of Hypertension (ASH) recommended in 2005 that overall risk assessment is very important in diagnosis and treatment protocol. If you are prescribed hypertensive medication without evidence of sustained high blood pressure meeting the above criteria (repeated measurement at the clinic and at home over several months), and are prescribed medication without a thorough risk assessment, these experts agree that your doctor is not doing his or her job. These risk factors include age, gender, high-density lipoprotein cholesterol count (HDL-C), history of smoking, diabetes, level of C-reactive protein (CRP), laboratory analysis of proteinuria and hyperuricemia, as well as glutathione metabolism (and circulating homocysteine levels). You may refer to the article on this website entitled C Reactive Protein and other markers of cardiovascular risk to better understand which markers are more important, and why. In evaluating age as a risk factor, it is important to note that blood pressure is normally higher in the aging population, and age alone does not present significant risk. Other important risk factors to consider include evidence of atherosclerosis, history of transitory ischemic attacks, and evidence of genetic predisposition. Any or all of these risk factors can be treated with a holistic approach. The patient may take blood pressure medications while treating these risk factors, and when sufficient progress is made, try going off of the blood pressure medications while monitored by the prescribing physician. Since the standard medication protocol does not address underlying health problems and dysfunctions, addition of Complementary protocols to address these concerns is sensible, and may eventually reverse the progression of cardiovascular disease. Since rebound effects may happen with some of these medications, decreasing dosage slowly is often recommended.

Fluctuating blood pressure, and now widely fluctuating blood pressure, has become a subject of concern, with some studies showing that widely fluctuating blood pressure may increase the risk of stroke in patients with high cardiovascular risk. This subject, fluctuating blood pressure, was dismissed in standard medicine for decades, as if it did not really exist, or did not matter. Clear studies have shown that evidence existed that many, if not all, patients with hypertension react to stress and anxiety with significantly increased blood pressure, and evidence that this anxiety-driven rise in blood pressure existed, now termed 'white coat hypertension', as many patients experience a significant rise in the blood pressure when doctors and nurses are taking their blood pressure, has been documented since 1896. Serious study of this phenomenon only was published in 1983, though, when constant monitoring of hospitalized patients showed that their blood pressure rose with the appearance of a physician. Further research found that these patients reacting with an immediate dramatic rise in blood pressure when a Medical Doctor entered the room usually did not react with a rise in blood pressure to all types of emotional stimuli. Many experts stressed that this should be called "White Coat Syndrome" instead of hypertension, because it does not appear to be sustained high blood pressure, but this classification has met with much resistance. In response to this acknowledgement that blood pressure readings that Medical Doctors relied on to prescribe medication, often a combination of medications, presented false evidence of actual hypertension existed, the standard medical community has proceeded to just declare that this fluctuating blood pressure was an added cardiovascular risk and thus just needed more blood pressure medication. Instead of offering objective assessment that for most patients mild to moderate hypertension presented little immediate risk and was not a cause for anxiety, and to apologize for past prescribing and diagnostic behavior and assure patients that they did not need to be concerned when the blood pressure reading in the hospital or clinic was high, only that they needed to monitor the blood pressure accurately at home for awhile and chart the readings, standard medicine has done the opposite and resorted to a 'spin' on the subject that now generates more anxiety about their high blood pressure. Numerous studies have now followed patients where this White Coat Syndrome occurs regularly and found that a much higher percentage of these patients actually do end up with hypertension within 10 years, than in patients that do not respond with unrecognized fear and anxiety to the Medical Doctor. Obviously, this pattern of creating fear of hypertension has caused much harm and cardiovascular risk, and has led to gross over-prescription of blood pressure medication. To see a history and assessment of this subject by experts at the Texas State University School of Medicine, Department of Psychology, in the United States, just click here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4427265/ . It is very obvious that we need to change the public perception of what they need to do to take positive steps to decrease cardiovascular risk. This long article provides the evidence that the standard protocol is misleading and full of problems, and that a simple individualized and holistic response to actual cardiovascular risk, integrating Complementary Medicine with simple dietary advice, healthy changes in daily habits, short courses of frequent acupuncture, herbal and nutrient medicine, will achieve this goal in a proactive manner. Only when this is finally endorsed by standard medicine will we see a significant number of patients following this healthier path, and only when the patient population demands change will we see this occur in standard medicine.

Often the Complementary and Integrative Medicine protocol will address individual risk factors with individually tailored treatment, thus helping to control high blood pressure indirectly as well as directly. The degree of knowledge of the Complementary and Integrative Medicine (CIM/TCM) physician, such as the Licensed Acupuncturist and herbalist, is very important in designing the right individual protocol. There may be a significant difference in approach between one Licensed Acupuncturist and another, and the individual patient may try another practitioner if results are not as good as expected, or if individual risk factors are not sufficiently addressed. Of course, we need to look at long-term outcomes and a variety of measures, not just whether visits to the Medical Doctor quickly result in a decreased risk assessment by the M.D. after a couple of acupuncture visits. Obtaining a clear and individualized assessment of cardiovascular risk is very important in this regard, and most patients today do not have a clear and thorough individualized idea of their actual cardiovascular risk. Family history of cardiovascular disease and a personal history of stroke, heart attack or atherosclerosis, are important risk factors, as well as Kidney disease, and certain medications may also increase your risk of cardiovascular disease significantly, as well as a history of diabetes or metabolic syndrome. Hormonal changes, such as menopause may pose a significant risk of cardiovascular disease and hypertension, and some studies have found that the perimenopausal woman is more prone to White Coat Syndrome that any other group. We have found that most types of essential hypertension are not directly inherited, but have a multifactorial cause, although genetic propensity is a significant and complicated factor in your assessment. In the last decade, extensive genetic mapping and research has revealed that multiple genetic traits may be associated with specific disease mechanisms, and these gene expressions that are related to disease may be modulated by a variety of factors, including other genetic expressions, epigenetic expressions, and even the biochemistry of the patients. Genetic propensities for disease do not doom the patient to the disease, and may be altered by a healthy holistic health regimen.

When you work with your Complementary Medicine physician, such as a Licensed Acupuncturist and herbalist, it is important that you bring knowledge of your individual cardiovascular risk to the physician so that treatment and preventive medicine can be applied more efficiently. A list of the cardiovascular risks described above could be made by the patient, and of course, copies of all laboratory and cardiovascular test results and assessments should be provided by the patient to the Licensed Acupuncturist and herbalist. There is almost no cooperation and exchange of these test results between standard doctors and Licensed Acupuncturists in private practice, and a pro-active patient insures better results by personally obtaining health records and bringing them to the treatment in Complementary Medicine. There is no one-size-fits-all approach to hypertension and the underlying causes, and integration of Complementary Medicine by the patient will help to insure that an individualized and thoughtful approach to this health concern is achieved. A pro-active approach by the patient achieves a better utilization of the various physicians in an integrative setting, defines treatment goals effectively, makes for better utilization of a team of health providers, and achieves realistic goals in the most efficient manner. A pro-active approach to hypertension and cardiovascular risk also is important in mind-body medicine. Patient understanding and focus helps the mind and body work together to achieve a healthy homeostasis.

The Pathophysiology of Hypertension

Almost all cases of hypertension fall under the category of idiopathic primary hypertension. Hypertension caused by another health problem, or secondary to another disease, indicates that the primary disease should be treated to cure the secondary hypertension. The term idiopathic means that the cause is unknown, but here the failure to identify a single underlying cause implies that a number of health factors may be involved, making the identification of a single comorbid condition responsible for the hypertension impossible. In a holistic approach, the hypertension is assumed to be multifactorial in underlying cause, and these various health problems are addressed as a whole to achieve success. To construct a treatment protocol that addresses the underlying health problems, though, requires us to look at the potential physiological causes of hypertension, and to work on these health problems, preferrably in an integrative manner, utilizing a complete package of care. Complementary Medicine offers various treatment modalities that are safe and without side effects. The first step is to make sure that your M.D. discusses what type of hypertension you have, and clarifies what is known about your individual underlying pathology.

One of the most respected experts on pathophysiology is Dr. Arthur C. Guyton. Dr. Guyton finds that the role of altered sodium excretion by the kidney, which is largely controlled by the endocrine system and hypothalamus/pituitary regulation, and also by the renin/aldosterone response, which is tied to adrenal hormonal responses, is the central mechanism in the development of hypertension. When the body struggles to maintain a sodium and water homeostasis, the body ultimately develops responses that increase the blood pressure to compensate. Several factors may affect the health of the kidney and ultimately create injury of the renal tubules and epithelium. These include sympathetic nervous overstimulation, or autonomic imbalance, toxins, and the effects of aging. In more recent study, the role of insulin resistance and metabolic syndrome, with fluctuating excess of the insulin hormone, has been found to lead to increased sympathetic autonomic nerve response and subsequent high blood pressure. This is also associated with sleep apnea, often the result of excess tissue growth in the airway due to metabolic syndrome, causing airway obstruction. This too may result in sympathetic overstimulation and chronic activation of the renin angiotensin response. Although we have these various pathophysiological explanations, there is still no clear single explanation for most cases of hypertension, only a multifactorial presentation involving these various systems.

The more proactive and intelligent patient understands that to correct this pathology of hypertension, that restoration of a healthy homeostatic function needs to be achieved. This requires some work to reduce physiological stress, improve kidney and liver health and function, achieve a balance hormonal response, and possibly correct metabolic disorder and insulin resistance. While each individual presents with a unique set of these problems, for some, the task might seem complicated. The good news is that by working on these various underlying problems, general health and well being will be restored as the blood pressure is normalized. For most patients, hypertension is still in a mild stage, and for most, there is no history of cardiovascular risk. These patients may be diagnosed with hypertension, but have no immediate threat to the health from mild high blood pressure. There is usually time to resolve the underlying health problems before going on a harsh medication protocol. For those on medication, correction of the uderlying problems and restoration of health will lead to the ability to reduce or eliminate these medications. Your cardiologist will agree that this is the most desirable outcome.

A New Understanding of Primary Idiopathic Hypertension

Standard medicine has failed for decades to properly explain the pathophysiology of primary hypertension, or high blood pressure without an apparent other disease that is causing it. In recent years, experts have narrowed the debate to two areas of concern, 1) chronic activation of the sympathetic nervous system, and 2) chronic activation of the intrarenal renin-angiotensin system, as the dominant contributors in the multifactorial pathogenesis of this common symptom. Many experts believe that the interactions between these two systems, the sympathetic portion of the autonomic nervous system, and the kidney adrenal (intrarenal) renin-angiotensin system, are what is important. Further scientific study has discovered that the blood pressure during sleep, where the renin-angiotensin system is more important, is more predictive of future outcomes and risks (Expert Rev Cardiovasc Ther 2010 Jun:8(6);803-9; Morgan TO; Univ of Melbourne, Victoria, Australia). If the blood pressure does not relax in sleep, the outcome measures in large studies are worse. Of course, most patients do not record their blood pressure during sleep, so this is a problematic assessment. What this research points out, though, is that a holistic protocol to achieve a healthier sleep cycle, as well as improved autonomic health, and better function of the renin-angiotensin system of the kidney and adrenals, is important to reversing this pathology.

The findings of poor relaxation of blood pressure during sleep due to sustained renin-angiotensin response explains why sleep apnea and other sleep disorders are so highly associated with cardiovascular risk. Both the normalization of sleep cycles and the circadian rhythms have assumed increased importance in the correction of chronic sustained primary idiopathic hypertension. Circadian rhythms, or the diurnal changes programmed into the homeostatic mechanisms of the human organism, are neurohormonal responses that change according to the time of day or night. While allopathic medicine is exploring whether the time of taking certain medications may be of help, this narrow allopathic solution is not perceived as the most sensible course of action to correct these problems of circadian rhythms. An array of hormones and neurotransmitters insure that healthy diurnal changes occur. These include melatonin, adrenalin, and cortisol, all within a feedback system that demands a healthy balance and bioavailability of hormones and neurotransmitters. Restoration of the neurohormonal health may be needed, and integration of a more complex restorative treatment protocol with Complementary Medicine is the key to success.