Dr Sukhjinder Nijjer
Expert in High Blood Pressure
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High Blood Pressure Explained
Why is Blood Pressure Important?
Hypertension is a major cause of death around the world. As a driving factor for heart attacks and stroke, hypertension or ‘high blood pressure’, is responsible for a great deal of suffering but it does so silently, without symptoms.
Recognising blood pressure early can prevent many health concerns. Having your blood pressure checked during health assessment or a routine visit to your Doctor can help identify this hidden problem.
Once identified, treatment should begin with a holistic assessment of you, your lifestyle and other health problems. Addressing lifestyle issues can lead to dramatic improvements. Exercise and weight loss are central tenets to the treatment. In this article, we will discuss the key issues surrounding this pressing medical problem that can often be neglected.
Why is treating blood pressure important
Elevated blood pressure is a major risk factor in developing both coronary and cerebrovascular artery disease. This is a progressive process, called atherosclerosis, that damages the arteries and narrows them with plaque deposition. Previously smooth arteries become craggy and closed-off, reducing blood supply to the brain or the heart. If a plaque ruptures, a small clot will form within the tiny blood vessel which manifested as a heart attack or stroke. Slow progressive closure of vessels causes angina (chest pains) and a slow deterioration of brain functions. The large leg arteries can also become clogged up by atherosclerosis causing pains in the legs when walking.
Elevated blood pressure also causes changes to the size of the heart muscle – it becomes thicker and less efficient (‘diastolic failure’). This leads to breathlessness and ankle swelling. Hypertension and diastolic change predispose to irregular heart arrhythmias such as atrial fibrillation. This is particularly troublesome as it elevates the risk of stroke and needs blood thinning medication.
Other organs are affected also, most commonly the kidneys which have very sensitive arteries. Once damaged by blood pressure, they cannot repair themselves and progressive deterioration can lead to dialysis.
What causes High Blood Pressure?
In young patients, in particular those below the age of 30, a number of underlying medical conditions can drive elevated blood pressure. Thyroid disorder, over active cortisol or over growth of special glands that secrete stress hormones can all explain hypertension. In others, there may be an abnormality of the kidney arteries or the aorta.
In the majority of patients, however, no clear cause can be found and we refer to this as ‘essential’ or ‘primary’ hypertension.
There may be a familial tendency and there is likely a strong genetic factor. It is not inherited in a traditional one-to-one way, and just because a parent has it, it does not mean a child will develop it.
In some cases, certain medications can be triggers: those who take strong non-steroidal pain killers for arthritis or those on the oral contraceptive pill, can find that their blood pressure rises.
Stress and dietary factors are important. Those undertaking shift work have altered hormone levels which can trigger high blood pressure. Stressful working conditions similarly can raise blood pressure. Those with a high salt intake are also more prone to hypertension. Recognising these factors can help improve the condition.
How is Blood Pressure Diagnosed?
Blood pressure is diagnosed by placing a sphygmomanometer on your arm; this has cuff that should fit neatly around the upper arm, and is connected to a console placed on a desk. Your blood pressure should be measured in a quiet environment, preferably after a period of 5 minutes rest.
Either arm will be suitable and there should not be a significant difference in blood pressure between the arms. If there is a difference, you may need scans to understand why this is happening. In general, we use the arm with the highest values to guide treatment decisions.
Modern automated devices are accurate and can store readings which makes it easier to follow your blood pressure trends. Blood pressure is easily measured in your General Practitioner’s office, but in some cases, readings can be artificially higher due to an underlying anxiety about being at the Doctors office. This is referred to as “white coat hypertension”. In the past, this was considered benign, but studies show that this can mask true blood pressure and if under treated, can be harmful in the long run.
If your Doctor recommends measuring your blood pressure at home, we advise measuring it three times in a row; you should ignore the first reading and take the highest reading. It should be checked at least twice a day for 7 days. We suggest writing down the blood pressure in a consistent place; some patients even choose to chart things on their computers.
In patients in whom results are borderline, or it is unclear if there is true hypertension, the gold-standard test is an ambulatory blood pressure monitor. This involves placing a small cuff that remains on your arm for 24 hours; the measuring device is clipped to your clothes and it will record the blood pressure around 40-50 times over the 24 hour period. This can give Doctors the truest assessment of your blood pressure values. On these monitors, we typically see that blood pressure is highest in the morning and during commuting hours; it comes down in the evening and should normalise over night if the arteries are still soft and pliable.
If you are diagnosed with hypertension, your Doctor may arrange for you to have other tests. An Electrocardiogram (ECG) and Echocardiogram (ultrasound scan of the heart) can be helpful to see if there has been any thickening of the heart muscle or any weakness. Urine and blood tests will help check kidney function, electrolyte and protein levels. Eye tests can assess for any damage to the small heart arteries.
What do the Blood Pressure Numbers mean?
Elevated blood pressure can be diagnosed after multiple blood pressure recordings over 140/90mmHg. If a 24-hour blood pressure cuff is used, the criteria are slightly different: 135/85mmHg is used because ambulatory pressures tend to be somewhat lower than seen in clinic.
The upper number, the systolic blood pressure, represents the pressure in the arteries when the heart is actively contracting – called systole. The second number, diastolic blood pressure, is when the heart is relaxing and filling up with blood – called diastole. This second phase is an active process, and there is natural tension within the blood vessels to maintain pressure. If this didn’t exist, we wouldn’t be able to do anything between heart contractions!
Both numbers are important. Early research focused on the importance of ‘systolic’ hypertension. However, diastolic hypertension also causes the same problems and should not be ignored.
How is Blood Pressure Treated?
Patients with persistently elevated blood pressure should be offered treatment, and holistic measures should be the first treatment offered. Those patients who have already had heart attacks or strokes may need medications straight away as they have already proved themselves at being at higher risk.
Improvements in lifestyle can have dramatic effects on blood pressure. Regular exercise makes a big difference as it encourages blood vessels to pliable; over time new blood vessels develop in your muscles causes blood pressure to fall. 10-20 minutes of moderate exertion per day, with enough speed to generate a light sweat, should be undertaken. Start with a brisk walk and build up your walking speed. In some cases, people try to take up excessive exercise but this can be difficult to sustain. Regular moderate exertion is sufficient and as you become healthier, you will need to do more to achieve that sweat.
An added benefit of exercise can be weight reduction. When combined with a healthy diet and calorie reduction, a sustained weight loss can lead to the normalisation of blood pressure. A sustained weight loss of 10kg can reduce blood pressure by 5-10mmHg, which can be a similar effect as a single blood pressure medication. We advise our patients to aim for 20kg weight loss over time aiming for a BMI 20-25kg/m2. Your diet should include fresh vegetables and reduction in red meat, and a healthy intake of unsaturated fats such as avocados, olive oil and oily fish as such salmon, mackerel, kippers and herring. Salt intake should be reduced to less than 5g per day, and certainly should not be added to food at the table. Cutting down processed or pre-prepared food will dramatically improve salt intake. Alcohol will similarly drive high blood pressure and no more than 3-4 units per day for men and 2-3 for women is recommended.
When are medications needed for Blood Pressure?
If blood pressure remains elevated despite good lifestyle changes and, in particular, if there are changes on tests on kidney or heart function, then medications will be needed. Those patients who have risk factors for having a heart attack or stroke (such as high cholesterol, smoking history or a family history of these conditions) may need medications earlier than those without.
There are many different blood pressure medications and there are now very clear guidelines for Doctors when choosing the medications. In the past, there was a ‘pick and mix’ approach – trying out different medications to see what suited. This has been replaced by a systematic approach depending on the age of the patient and other health issues. The medication should certainly achieve a blood pressure less than 140/90 mmHg, and ideally it should be less than 130/80 for younger patients. In older patients, a higher target may be set. To achieve targets, more than one medication may be needed and research has shown combination therapy (two or more medications that treat blood pressure in different approaches) achieve better results than excessive doses of a single drug.
Your Doctor will help you understand how to take the medication and what the potential side-effects are. Some medications require blood tests after starting them to observe for any adverse effects. Others have common side-effects such as mild ankle swelling or a dry cough at night. It is important to tell your Doctor if you develop a possible side-effect and they can help choose an alternative medication. This is preferable over stopping the medication suddenly as this can cause a rebound in blood pressure. Your blood pressure should be monitored over time. With the right combination of medications and holistic measures, your blood pressure should improve and so reduce the risk of major complications in later life.
Help Your Heart
If you have any concerns regarding your heart health, then please seek a referral to Dr Nijjer.
Call the Team: Monika, Amy, Charlotte, Erin or Grace:
0203 9838 001
Dr Nijjer can be seen at :
68 Harley Street, London, W1G 9QP
He also practices at Cromwell Hospital, Wellington Hospital, BUPA Clinics, BMI Syon Clinic as well as Imperial Private Healthcare.