High Blood Pressure and the Hyper Tense Person

Many people expect their blood pressure to be high in the doctor's office. After all, "it's the doctor's office, of course my blood pressure is high," implying that the numbers simply reflect anxiety. What most people don't realize is that the studies linking high blood pressure with heart attack, stroke, kidney failure or blindness are based on in-office measurements. While you don't want to commit yourself to lifestyle change or ongoing medication based on one blood pressure measurement, you don't want to disregard it either. How should an elevation in blood pressure be evaluated?

After reviewing the literature, I now consider the best follow-up to be ambulatory blood pressure monitoring -- wearing a blood pressure cuff that takes repeated measurements over a 24-hour period. We call this diagnostic tool ABPM for short.

While the effort involved in APBM may sound daunting, it offers tremendous value:

• Studies have shown that ambulatory blood pressure (during work or sleep) is a better predictor of organ damage (heart, brain, kidney) than blood pressure measured in the doctor's office.
• Evaluation over a 24-hour period shows whether or not you have "white coat hypertension" meaning your pressure is elevated just in the doctor's office and normal during a typical day and night. If you have "white coat hypertension," studies show that your risk of cardiovascular disease is the same as those with normal blood pressure (over the short term) and - here's the key - you won't need medication.
• Women, especially African Americans and Latinas, are more likely to have "white coat hypertension" than men. Women's cardiovascular systems seem to be more "reactive" to the stress of the doctor visit. Interestingly, psychosocial stress has been found to lead to hypertension over time, but stressors vary between men and women. In men, concerns about job performance and the threat or reality of unemployment predicts the development of high blood pressure. In women, the stressors that drive high blood pressure are depression or social alienation.
• Hypertension is common. Someone with a normal pressure at age 55 still has a 90% chance of becoming hypertensive in their lifetime. So, people with white coat hypertension" will, over time, develop sustained hypertension. It pays, over time, to continue monitoring with ABPM or a regular blood pressure device used at home.
• ABPM can also show if your pressure lowers during sleep, reflecting a normal biorhythm. "Non-dippers," or people who fail to lower their pressure during sleep, have higher risk of organ damage (heart, brain, or kidney) than "dippers." This is especially true in women. In a study of people with thickened heart muscle due to hypertension, women "non-dippers" had a 7 times greater risk than other women of a deadly heart attack; but men "non-dippers" did not show any elevated risk.
• Fifty percent of people with hypertension also have insulin resistance. These people may benefit from specially-designed nutritional strategies and may be able to avoid medication.

Specific elements of the strategy include:

• Avoid salt (sodium) intake
• Limit alcohol use (less than 2 ounces/day)
• Increase intake of calcium, potassium and magnesium
• Be more physically active
• Lose weight, if you are overweight

So, if you have an elevated blood pressure at a doctor's office (especially at mine, since I never wear a white coat), you should arrange for an APBM study. Also be aware that there are new guidelines for classifying blood pressure as normal (less than 120/80) and high
(over 140/90). Pressures between 120 - 139/ 80 - 89 are now referred to as "pre-hypertension." So, if your blood pressure has been in this gray zone it also requires a better evaluation. With accurate and complete information we can make better decisions about how to stay healthy and avoid chronic disease.