Hypertension or High blood pressure is a very commoncardiovascular problem all over the world. It is responsible for 50% of thestrokes and at least 25% of the heart attacks. WHO ranks it as the most frequentcause of premature deaths worldwide? According to a recent survey carried outin population > 18 years of age (n = 1,320,555) in Fourth District LevelHousehold Survey hypertension was reported in 25.3% with greater prevalence inmen (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 theAmerican guidelines of 130/80 as cut off are used. The figures from the Kashmirvalley also are in agreement with these figures. High salt intake, bad lifestyle and genetic factors along with mental stress are important contributors.
This issue is further complicated by the fact that of thepeople with hypertension only 42% are aware of it in the urban and 25% in therural milieu. The treatment is woefully inadequate with only 38% taking it incities and 25% in rural India. Only 20% of the urban and 11 % of ruralhypertensive 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 inBP above 110/75 mm is associated with a linear increase in stroke and heartattack rates. This has been proven by several epidemiologic studies and lifeinsurance statistics. An increase of 10 mm in systolic or diastolic pressure isassociated with a doubling of the risk of a vascular event. Unfortunately, highBP is invariably not accompanied by symptoms and therefore its detection andmanagement 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 areoften termed as high normal. The blood pressure cut offs do not change with agein 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 morethan 150/90 mms Hg.
Life Style Modification as Treatment strategy
Everyone who has high blood pressure should adopt measuresto stay healthy. The lifestyle changes advised will bring down the dosage ofdrugs and number of medicines that need to be taken. All healthy individualstoo, should adopt these non-drug measures, so their pressure remains below120/80 mm Hg. These measures consist of Keeping Weight Healthy – Exercise Regularly (average of 30 minutes a day andYoga) – Eat plenty of fruit and/or vegetables every day – Cut down on salt andreduce 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 tominimize 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 severalminutes in a quiet room
• Take at least 2 measurements spaced by one to two minutesand additional readings if the two are quite different
• An appropriate BP apparatus which has been calibratedperiodically.
• If the BP in two arms is different, take the higher valueas the reference
Drug treatment for high BP is a very long term affair. Onceit has been recommended that medicines (very often 2 drugs if the BP is morethan 160/100 mm) are needed, they are not to be stopped even after BP comesdown to target levels. This is a common mistake committed even by very educatedpeople. The aim of medication is to keep patients free of the risk ofcomplications like heart attacks, stroke and kidney failure. It is to ensurethat the patient remains free of catastrophic problems as years go by. Thecurrently used drugs are very safe and need very little monitoring forside-effects. Most are well-tolerated. For every patient, the treatment has tobe individualized. No one should try self-medication.
The agents used and dosage of medicines depend on severalvariables. Broadly, the agents used are ACE inhibitors and angiotensin receptorblockers, calcium blockers, beta-blockers and diuretics or water pills invarious combinations. Several studies have shown that a combination ofamlodipine and an ACE inhibitor/Receptor blocker combination is a very welltolerated and efficacious combination for most persons requiring drugtreatment. This combination can result in reduction of death by more than 15%.The combination of diabetes and high blood pressure is a very frequently seenassociation in our milieu. This is also called the twin epidemic which is an importantcause of a very high cardiovascular disease in South Asia. The aim is to notonly keep your BP in normal range but also to take care of all the riskfactors, which lead to heart attacks and strokes. The target of drug treatmentis to go to levels below 140/90 mms Hg and having achieved that then try for130/80 whenever possible without adding too many drugs.
"Observing the Rule of 100" goes a long way. Keepyour blood sugar and cholesterol and triglyceride levels close to 100 mgs. Theemphasis is on keeping all round risk very low instead of concentrating on onerisk factor. Patients needing BP lowering drugs are also often in need ofagents to keep cholesterol and triglycerides very low. The management should beholistic and not just treating numbers.
Hypertension is a very common problem seen all over theworld. In South Asia we are seeing its increase much more than industrializedcountries, which have started showing decline. Early recognition and itsmanagement are extremely important. Despite a large number of safe medicineswith low side effects being available the number of patients with uncontrolledBP is steadily increasing. This trend is very alarming. Adverse life style isthe most important cause for this and we need to recognize it and takecorrective measures.
Upendra Kaul is Executive Director & Dean, BatraHospital and Medical Research Center, New Delhi