Hypertension or High blood pressure is a very common cardiovascular problem all over the world. It is responsible for 50% of the strokes and at least 25% of the heart attacks. WHO ranks it as the most frequent cause of premature deaths worldwide? According to a recent survey carried out in population > 18 years of age (n = 1,320,555) in Fourth District Level Household Survey hypertension was reported in 25.3% with greater prevalence in men (27.4%) than women (20.0%) when 140/90 mms Hg was taken as the cut off. This translates into 207 million persons (men 112 million, women 95 million) with hypertension in India. The numbers would increase substantially if the American guidelines of 130/80 as cut off are used. The figures from the Kashmir valley also are in agreement with these figures. High salt intake, bad life style and genetic factors along with mental stress are important contributors.
This issue is further complicated by the fact that of the people with hypertension only 42% are aware of it in the urban and 25% in the rural milieu. The treatment is woefully inadequate with only 38% taking it in cities and 25% in rural India. Only 20% of the urban and 11 % of rural hypertensive population have acceptably controlled BP in the reported studies. These figures are very concerning from public health point of view.
What is normal Blood Pressure?
Optimal BP is a pressure less than 120/80 mm Hg. Any rise in BP above 110/75 mm is associated with a linear increase in stroke and heart attack rates. This has been proven by several epidemiologic studies and life insurance statistics. An increase of 10 mm in systolic or diastolic pressure is associated with a doubling of the risk of a vascular event. Unfortunately, high BP is invariably not accompanied by symptoms and therefore its detection and management is a challenge. This is in fact, why, it has been described as a “Silent Killer”. Blood pressure levels between 130/80 to 140/90 are often termed as high normal. The blood pressure cut offs do not change with age in adults and BP more than 140/90 is classified as hypertension at all ages. Some authorities recommend cut off for people more than 80 years to be more than 150/90 mms Hg.
Life Style Modification as Treatment strategy
Everyone who has high blood pressure should adopt measures to stay healthy. The lifestyle changes advised will bring down the dosage of drugs and number of medicines that need to be taken. All healthy individuals too, should adopt these non-drug measures, so their pressure remains below 120/80 mm Hg. These measures consist of Keeping Weight Healthy – Exercise Regularly (average of 30 minutes a day and Yoga) – Eat plenty of fruit and/or vegetables every day – Cut down on salt and reduce intake of fried food – Cut down on fat and sugar – Stop smoking tobacco- Reduce your caffeine intake – Don’t drink too much alcohol. Make sure to minimize the consumption of following: Painkillers, nasal drops, cough syrups, anti-depressants and mood elevating drugs.
Points to remember before getting labeled as a hypertensive
• Get the BP measurement done after sitting for several minutes in a quiet room
• Take at least 2 measurements spaced by one to two minutes and additional readings if the two are quite different
• An appropriate BP apparatus which has been calibrated periodically.
• If the BP in two arms is different, take the higher value as the reference
Drug treatment for high BP is a very long term affair. Once it has been recommended that medicines (very often 2 drugs if the BP is more than 160/100 mm) are needed, they are not to be stopped even after BP comes down to target levels. This is a common mistake committed even by very educated people. The aim of medication is to keep patients free of the risk of complications like heart attacks, stroke and kidney failure. It is to ensure that the patient remains free of catastrophic problems as years go by. The currently used drugs are very safe and need very little monitoring for side-effects. Most are well-tolerated. For every patient, the treatment has to be individualized. No one should try self-medication.
The agents used and dosage of medicines depend on several variables. Broadly, the agents used are ACE inhibitors and angiotensin receptor blockers, calcium blockers, beta-blockers and diuretics or water pills in various combinations. Several studies have shown that a combination of amlodipine and an ACE inhibitor/Receptor blocker combination is a very well tolerated and efficacious combination for most persons requiring drug treatment. This combination can result in reduction of death by more than 15%. The combination of diabetes and high blood pressure is a very frequently seen association in our milieu. This is also called the twin epidemic which is an important cause of a very high cardiovascular disease in South Asia. The aim is to not only keep your BP in normal range but also to take care of all the risk factors, which lead to heart attacks and strokes. The target of drug treatment is to go to levels below 140/90 mms Hg and having achieved that then try for 130/80 whenever possible without adding too many drugs.
“Observing the Rule of 100” goes a long way. Keep your blood sugar and cholesterol and triglyceride levels close to 100 mgs. The emphasis is on keeping all round risk very low instead of concentrating on one risk factor. Patients needing BP lowering drugs are also often in need of agents to keep cholesterol and triglycerides very low. The management should be holistic and not just treating numbers.
Hypertension is a very common problem seen all over the world. In South Asia we are seeing its increase much more than industrialized countries, which have started showing decline. Early recognition and its management are extremely important. Despite a large number of safe medicines with low side effects being available the number of patients with uncontrolled BP is steadily increasing. This trend is very alarming. Adverse life style is the most important cause for this and we need to recognize it and take corrective measures.
Upendra Kaul is Executive Director & Dean, Batra Hospital and Medical Research Center, New Delhi