Hypertension: A Growing But Often Hidden Problem
Hypertension, or high blood pressure, is relatively easy to diagnose, yet several studies find neither doctors nor patients are doing enough to fight it. Hypertension is the second leading cause of death in the United States — following tobacco — and a major risk factor for heart disease and strokes.
Out-of-control and undiagnosed hypertension is at epidemic proportions in the United States, according to an Institute of Medicine panel of medical experts. The panel cites studies that show more than two-thirds of people with hypertension do not have it under control.
An estimated 1 in 3 adults — 73 million people — in the United States has high blood pressure. As we get older, blood vessels stiffen, says cardiologist Thomas Lee, a professor at Harvard University School of Medicine. There's a resistance to blood flow, so the heart has to pump harder. As blood surges, those rigid blood vessels are weakened and may burst, which can lead to a stroke and heart failure.
Most people seem to have diastolic blood pressure under control — that's the bottom number, a measure of the heart at rest. It's the top number, systolic blood pressure — measured when the heart is pumping — that causes a problem for most people.
In 2003, a National Institutes of Health commission lowered the levels at which systolic blood pressure begins to pose a risk to health in their treatment guidelines for hypertension. The guidelines set a blood pressure of 120/80 as normal. A blood pressure consistently over 140/90 is considered hypertension.
There is some concern that physicians did not catch onto these changes. Prior to the guidelines, most doctors believed that the top number could be as high as 160 before the patient was thought to have hypertension.
Diagnosing The Problem
An Institute of Medicine report recently found that 85 percent of people who see doctors regularly have undiagnosed and uncontrolled high blood pressure. Research has shown that it takes years for doctors to follow new treatment guidelines.
Part of the problem is that a decade ago doctors just didn't pay much attention to that top number, says Lee, who graduated from medical school in 1979.
"There are some people out there that think it is all the bottom number," Lee says. "That's what I was taught: Focus on the bottom number."
Another issue is that even patients who are aware that they have a problem are not always doing their part, and many don't have the condition under control.
Lee Musick, 65, checks his blood pressure using a little portable home unit. Probably because he is talking to a reporter about his hypertension, his top number reads 163, which he says is unusual for him. He works hard at trying to keep his blood pressure under control.
"Usually, it's around 138 over 60 to 140 over 70," he says, checking his diary. "I'm looking back in February, there are some 128 numbers, another 128, 127 for a couple of days, 125."
It's a patient's average blood pressure level that is important, says Lee, especially given what is known as "the white-coat effect," or the tendency for a person's blood pressure to spike in the doctor's office. "It's not like you have any one blood pressure," he says. "Your blood pressure jumps all around from minute to minute, moves around 5, 10, 15 points. It is the average amount of wear and tear that you are subjecting your body's arteries to."
Lifestyle Factors And Medication
For 30 years, Lee has been Musick's doctor. The hypertension started creeping in about 15 years into the relationship, followed by diabetes and high cholesterol. They made a kind of deal that Lee wouldn't put him on medication right away, and Musick would change his lifestyle.
"There's an interesting little dance that goes on where both the doctor and the patient are in a little bit of denial as blood pressure goes up to 140, 150, 160," Lee says.
Like many patients faced with a high blood pressure diagnosis, Musick was trying to avoid being put on medication that he would probably have to take every day for the rest of his life if he couldn't change his ways. Lee says patients can lower their blood pressure by changing their lifestyle — exercising, losing weight, cutting back on salt and boosting potassium levels by eating more fruits and vegetables.
"Weight has been a creeping problem for me over time," Musick says. "I've got it stabilized over the last few years. He says he also avoids salt — the shaker is off the table — but he still favors processed meat and snacks.
Obesity is partly to blame for the epidemic of high blood pressure in the United States, but not entirely. Alcohol and smoking also add to the problem. Some people have inherited the condition. The main problem is metabolic syndrome, says Dr. Kathy Hebert, the director of disease management and outcome research at the University of Miami Miller School of Medicine.
"That just basically means you've got a big, thick waistline that causes your blood pressure to go up, your glucose to go up so you have diabetes, and causes your cholesterol to go up and you can get heart disease," she says.
You can avoid it, Hebert says, by making sure your waistline stays below 35 inches if you're woman and 40 inches if you're a man. She measures her patients' waistlines, and most are shocked by their measurements, especially the men, Hebert says. "They're always shocked. They're always just so surprised that their waistline isn't below 40 inches, that it is much bigger than that. That can cause their blood pressure to go up."
Hebert worries that physicians find it a lot easier to prescribe medication than to counsel patients who are dealing with a constellation of conditions, particularly in the 15 minutes physicians usually allot for office visits. Some things are going to get prioritized, she says. Some aren't.
"How is a physician supposed to address hypertension, diabetes, high cholesterol in 15 minutes?" Hebert says. "[That includes] taking a history, performing a physical exam, educating the patient, deciding on pills and writing out a prescription. It's absolutely unrealistic."
So if a patient's blood pressure is 142 and the guidelines say it should be below 140, Hebert says, that might not seem as important as a more pressing problem the patient is facing. When all else fails, there are a variety of medications, many of them relatively inexpensive. There are drawbacks for some patients taking the medicine, including feeling depressed or having dry mouth, erectile dysfunction or insomnia.
Side effects haven't been a problem for Musick. He put off taking medication as long as he could, but after two years, he accepted that he was going to have to take some. He continues to exercise and be careful of what he eats, though.
Dr. Lee says when a patient begs off taking medication to try to control blood pressure via lifestyle changes, physicians don't always respond as quickly to bad readings as they should.
"Physicians want to be heroes, they want to be nice guys," Lee says. "They say, 'OK, we'll give you another three months.' "
Patients don't always come back at the end of those three months, he says. "Some of them don't come back because they have strokes or heart attacks. And we can't tell which ones are going to be the ones who are unlucky, but some of those strokes and heart attacks could have been prevented, if we jumped right in and got their blood pressure under control."
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