Understanding Hypertension and how to manage hypertension.

Introduction

The understanding of hypertension has changed tremendously over the last 50 years. When I was in medical school, The change in understanding is so severe as if we were all cheated 50 years ago. All to support the pharma industry.

The old paradigm

For a century,  our understanding of essential hypertension was guided by that important paper by Dr Allbutt on " Hyperpiesis". He called that essential hypertension ( or hypertension with unknown causes ) as contrasted with secondary hypertension ( hypertension with known causes ). The understanding that essential hypertension formed about 80% of the hypertension population and secondary hypertension formed about 20% of the population.

New paradigm.

Closer inspection of the evidence seem to suggest that most of so called essential hypertension, occurring in mid-life could in fact be due to a nervous stresses and strains of everyday living causing wide fluctuations in blood pressure as we run the "rat race". And it is no wonder that this "nervous hypertension" does run in families. Nervous dad and mum breeds a nervous family, always living on the edge. White coat hypertension is another example of this. How can a patient coming to see me, for an appointment after battling through traffic jams and no parking bays, have a normal blood pressure? What should be the normal blood pressure in a busy government outpatient ( waiting time 2 hours ), full of noise and hot and sweaty. I am sure by now you get my drift. That means that for years, we are over treating labile, nervous, stress provoked " hypertension"? The only benefactor from this strategy are the pharmas who find an easy accomplice in doctors and physicians who are "pharma friendly" in many ways.due to many reasons? 

On the other hand, we also do not wish to miss those patients who are really hypertensives, who may end up in life-changing strokes. These patients must be identified early and treated early. There are almost 20% of hypertensives out there who may have secondary causes like renal disease, endocrine diseases, pheochromocytomas, coarctations, primary arteritis, renal disease, etc etc. who do need early treatment.

Management.

I would like to introduce the strategy of  " Home BP Monitoring " for all above 40-50 whether symptomatic or not. A digital BP monitor costs about RM 100 - RM 150. Teach all patients to check their BP regularly on a scheduled basis ( Sunday, Tuesday, Friday ) at 7.30 am in the morning and 10pm at night and keep a chart for the next GP/consult visit. Let them show to their practitioner and identify what is the real BP situation?. 

The digital monitors are good enough for wide spread use. The only safe guard is to make sure that the energy level in those meters are adequate and stable. There are 2 types of those digital monitors. There is one type that only uses battery power. When the battery level weakens, it will take longer to read and may give rise to errors. The second type uses dual power source, a battery source usually for travelling and a AC plug in source for home use. This type is slightly more expensive but probably more reliable.

Nowadays, in our effort to "empower our patients", there are many heart watches that we can wear on our wrist. Not very accurate, but adequate to give us a trend. It is very convenient. Make sure that the watch energy level is always charged up and once a week or two weeks, calibrate it against the digital monitors, because these health watches uses a laser pulse beam to sense the skin capillaries, so a smaller blood vessel, less sensitive but does allow you to see the trend, which is what we are interested in. NOT INDIVIDUAL READINGS.

Use these simple gadgets to monitor your BP profile daily or weekly. 120/80 mmHg is ideal. 130/80 mmHg is the upper limit of normal and any reading persistently above this, show be lowered. However, lowering it does not mean drug therapy. There is much that can be done to help without drugs.

The first step should be to exclude secondary cause. A good physical examination with basic lab test would be a good first step, together with an ECG and if possible a CXR. Remember Obstructive sleep apnea is also associated with hypertension, and relieving OSA can "cure" the hypertension.

Sit down and chat with the patient for a while to be what kind of psychological profile he/she is? Do he/she have a type A personality, OCD, work stress, family stress, financial stress etc etc. Try and help him/her understand the role of stress to the BP and these counselling session may also serve as therapy. If the patient is obese or overweight, weight reduction is also good BP lowering therapy. Regular exercise, green vegetables and fruits, no added salt, also lowers blood pressure.

Try these initial  non pharmaco steps first.

Sometimes patients' anxiety cannot be relieve without the use of a drug ( for their placebo effects ). Please choose a drug that you are familiar with, mild with a very safe drug profile. Use it but do tell the patient to continue home BP monitoring and should the Home BP profile improve, there is a possibility of gradual withdrawal of the drug, while using non-Pharmaco  therapy and home BP monitoring. I do not like drugs for evermore, except when there is no choice.

I will stop here. Getting too long.

Let us comment and ask the questions.