Nov 20, 2018
Lifestyle modifications are key to treating hypertension, especially for people at high risk. Dr. Valeriani Bead discusses who is at risk and which treatments are most effective.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We’re speaking with Dr. Valeriani Bead, a board-certified cardiologist at the MedStar Heart and Vascular Institute, with extensive expertise in nuclear cardiology and echocardiography. Welcome, Dr. Bead.
Dr. Valeriani Bead: Thank you for having me.
Host: Today we’re discussing how the 2018 hypertension or high blood pressure guidelines apply to African Americans, the elderly and other at-risk populations. The guidelines lower the target rate of a healthy blood pressure for average risk individuals, thereby increasing the number of U.S. adults who are considered to have hypertension. Dr. Bead, what is the optimal blood pressure target for a person at average risk for hypertension under the new guidelines?
Dr. Bead: Well, you mentioned that the new guidelines that were just released in November 2017 - well, these were the most recent guidelines in almost fourteen years that were published - and they were treating high blood pressure in adults and they’re really the first guidelines that we’ve had that’s based on extensive research, using the highest quality clinical research and drug trials. And, based on these new guidelines, really the goal blood pressure is anything less than 120/80 millimeters of mercury. And really where the controversy started is now stage 1 hypertension is considered in individuals who present to their healthcare provider’s office with a blood pressure of 130/80 millimeters of mercury. Well, what that means is that more American adults will be told they have high blood pressure because of these newest thresholds. And those who are already being treated will need to really talk with their healthcare providers about whether or not their target blood pressure readings need to be adjusted. And, in some cases, whether or not lifestyle changes and their medication will need to be intensified.
Host: What are some of the symptoms of hypertension?
Dr. Bead: The most common symptoms we experience, which is scary, are none. Some people don’t even know it. They don’t feel it. Which is just fascinating. Outside of that, the most common symptom is headache, fatigue, dizziness, lethargy and at times, but not quite often, they can get chest pain and shortness of breath.
Host: When it comes to hypertension, African Americans are at greater risk, in general, than other nationalities. Why is that?
Dr. Bead: Well, in the United States, in any decade of life, African Americans have a higher prevalence of hypertension than that of Hispanic Americans, whites, Native Americans and really any other subgroup defined by race and ethnicity. And the ideology remains obscure and we really don’t know. But, we do know that hypertension control rates are lower for blacks. That also hypertension, when it’s diagnosed, is more severe and that sometimes the medicines we use to treat high blood pressure are less effective at controlling blood pressure. And with all this, the morbidity and mortality attributed to hypertension is more common in blacks than it is in white Americans and any other ethnic group - which is why identifying and treating hypertension can have such a significant impact on health and morbidity in the African American community, which is why it should be identified much earlier.
Host: When we’re thinking about high blood pressure, regardless of nationality, the risk increases as we age. Could you explain why older adults are at a greater risk than younger adults?
Dr. Bead: That’s a very good question because there really is an extremely high prevalence of hypertension in older adults. And, hypertension is not only a leading cause of preventable morbidity and mortality, but, more importantly, it’s under-recognized and it’s considered a major contributing factor to premature disability and why many elderly adults get institutionalized, such as nursing homes. And, it is worthy to note that after the age of 69, the prevalence of hypertension rises to greater than 50 percent. And so, it’s linear with age. Now, the exact cause is unknown, but we have postulated that as we get older our blood vessels do get stiffer and then that can lead to elevated blood pressure. But, I’ve got to tell you that that’s not entirely elucidated and a lot more research is warranted to help figure that out.
Host: So, we’ve talked about African Americans. We’ve talked about older adults. Are there other patient populations who are at increased risk for hypertension?
Dr. Bead: More often times than not, in my clinic practice, I see pregnant women who come in with elevated blood pressure and that is certainly a population that cardiologists, in general, need to be aware of. Because, blood pressure, while it usually declines during the first trimester of pregnancy, it can slowly rise in either the second or third trimester of pregnancy. And we usually need to be aware of those mothers who have newly diagnosed hypertension, or whether or not they have incident hypertension during clinical conditions such as something called preeclampsia, which is a dangerous form of hypertension, that leads to increased protein and other consequences with the mother’s health. And the reason that this really is important for us to identify earlier is because we have found out through research studies that mothers who are diagnosed with high blood pressure during pregnancy eventually have high blood pressure later on in life. And so, it’s important to identify it earlier so that we can treat it and have it under control.
Host: These women who are diagnosed during pregnancy with high blood pressure, what are some of the risks for them and for, perhaps, their babies if they don’t get that treated?
Dr. Bead: The most important risk we always worry about is the health of the mother and the baby. With high blood pressure, that can put the baby at risk. With high blood pressure, that can put the mother at risk and lead to bad consequences such as congestive heart failure. And so, there are actually very serious consequences to worry about if blood pressure is not controlled during pregnancy.
Host: And, if we take a step back and think about all these other individuals - African Americans, older adults, adults of any age, really, who don’t take care of their hypertension - what are some of the risks for them if they don’t seek treatment?
Dr. Bead: Not to be too grim, the risks for uncontrolled high blood pressure are significant. Meaning, with uncontrolled high blood pressure, it can lead to strokes, heart attacks, abnormal heart rhythms, congestive heart failure, kidney problems, and death. This is typically something that happens over time, which is why you may sometimes hear hypertension referred to as “the silent killer.” Meaning, hypertension can be prevented. And usually, when you have consequences related to hypertension such as the ones I just mentioned, it’s something that could have been identified much sooner and treated earlier, without the bad consequences.
Host: The 2018 guidelines lower that target rate of a healthy blood pressure for average risk individuals. What does that mean for lowering the blood pressure targets for high risk individuals?
Dr. Bead: The implications are essentially the same. To identify high blood pressure individuals, whether they have it average or high risk, it really helps us treat it earlier and potentially reduce future cardiovascular events.
Host: How can high risk patients proactively manage their blood pressure?
Dr. Bead: The lifestyle measures can be effective in treating hypertension. So, there is something called the DASH lifestyle eating plan and the DASH diet stands for Dietary Approaches to Stopping Hypertension. and that has been a long term, randomized clinical trial that actually shows that following this eating program, which reduces the amount of salt in our diet, can reduce the blood pressure by an average of 10 to 15 points. And, using that, in combination with restricting dietary sodium and increasing dietary potassium, can really result in a good effect on the blood pressure. So, in addition to that, weight reduction, regular aerobic activity, not smoking, and limiting alcohol really also go a long way in terms of managing blood pressure.
Host: When those lifestyle methods aren’t enough, what treatment options are available for patients with high blood pressure?
Dr. Bead: So, first line treatment will always be lifestyle changes, such as the ones I’ve mentioned. And then we can go on to second line treatment which usually includes prescribed medications, and sometimes it may require starting two medications at the same time in order to achieve that goal blood pressure of less than 120/80 millimeters of mercury. Also, ruling out any other potential causes such as obstructive sleep apnea, which is when someone doesn’t get enough oxygen when they sleep, can really go a long way in terms of keeping the blood pressure under control and treating that. And, in extreme cases, for patients who have something called resistant high blood pressure, which is basically blood pressure that is difficult to control, we have invasive procedures that are available but that’s something for another discussion.
Host: Could you share a treatment success story from your practice?
Dr. Bead: This is my favorite part! I love my practice and, I’ve only been doing this for about 8 years. And, I’ll never forget one of my first patients, who I met about 7-½ years ago. She was a middle-aged woman who I initially met during a normal EKG. And, at the time, she was dealing with high blood pressure, requiring at least 3 or 4 different medications. She was morbidly obese, and she had problems with arthritis. And, we did a comprehensive cardiovascular workup. And, it turned out that her heart status was actually pretty good. And so, we adjusted some of her medications and, with time, nothing really changed. And at one of her follow-up visits, I sat down with her and looked her in the eye and basically, with as much encouragement as I could, I asked her...that she just has to start moving. Literally, to start doing 2 minutes a day and then, after that, doing 5 minutes a day and then, after that, getting up to about 30 minutes a day. And, I kid you not, when I saw her back in a 6-month follow-up visit, she had lost 50 pounds just by walking. And, she was motivated enough to start changing her lifestyle in terms of what she ate. She followed the DASH eating program and joined a gym and lost another 50 pounds, to the point that her blood pressure was actually too low, and we actually stopped the majority of her medications to the point that she was on one low dose medication to keep her blood pressure under control. And also, she didn’t have any more knee problems. So, she was able to share that success story with me and she spread it to her family, and she’s also been able to do some exercise programs at the local YMCA. And, she’s happy and she’s here to tell the story and she actually had a poster that she shared with me. And it’s something that I share with my other patients as well.
Host: What was the poster that she shared with you, if you don’t mind sharing with us?
Dr. Bead: It was a before and after of herself and basically, it showed pictures of her when she was at her highest weight. It showed pictures of her when she started walking. And it showed current pictures of her at her current weight. Because she had lost over a hundred pounds just by moving and watching her salt intake. So, all of the poster of her - really a before and after. I mean, the picture was worth a thousand words just to see how she transformed by making literally small steps.
Host: That was really amazing and I’m sure that’s really inspirational for a lot of your other patients and maybe even for you every day to remind yourself to get in there and do your exercise and just keep going forward. Why is MedStar Heart and Vascular Institute the best place for people at high risk for hypertension to seek care?
Dr. Bead: Because the MedStar Heart and Vascular Institute really offers comprehensive, state-of-the-art care. And the compassionate environment that is patient centered and really evidence based. And what I really like about MedStar Heart and Vascular Institute is there really is a physician for every type of patient and for every type of medical illness that hits our door. So, there is something for everyone.
Host: Thanks for joining us today, Dr. Bead.
Dr. Bead: Thank you for having me.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.