The Hypertension Sourcebook

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The Hypertension Sourcebook

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THE HYPERTENSION SOURCEBOOK

Mary P. McGowan, M.D. and

Jo McGowan-Chopra

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abc Copyright © 2001 by Mary P. McGowan. All rights reserved. Manufactured in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. 0-07-139202-5 The material in this eBook also appears in the print version of this title: 0-7373-0539-8.

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TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS”. McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise. DOI: 10.1036/0071392025

For Sheila Joy: You make my heart sing —MPM For Uncle Clem, whose life sparkles and instructs —JMC And in memory of Aunt Sheila Callahan and Aunt Rita Doherty

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Contents

ö

List of Tables xi List of Figures and Exhibits xiii Preface xv Acknowledgments xix

PART I: HIGH BLOOD PRESSURE_WHAT IS IT?

CHAPTER 1: DO I HAVE IT?

3

CHAPTER 2: WHAT CAUSES IT? AND WHY SHOULD I WORRY? 13 Salt Intake Kidney Disease Stress Aging Being Overweight Excess Alcohol Genetics Who Will Get High Blood Pressure? Medications

PART II: TREATMENT

CHAPTER 3: DIET AND BLOOD PRESSURE_THE CRITICAL LINK

33

vii McGraw-Hill's Terms of Use

viii • CONTENTS

CHAPTER 4: DEVELOPING PROGRAM 57

AN

EXERCISE

Benefits of Exercise Developing Your Exercise Program The Maintenance Stage Warm-Up and Cool-Down Be Patient

CHAPTER 5: WEIGHT LOSS

69

Weight Loss Aids

CHAPTER 6: YOU CAN QUIT SMOKING! 83 CHAPTER 7: AN OVERVIEW PRESSURE MEDICATIONS

OF

BLOOD

97

Choosing the Correct Medication Choosing the Correct Dose Getting to Your Blood Pressure Goal Diuretics Beta-Blockers Calcium Channel Blockers Angiotensin-Converting Enzyme Inhibitors Angiotensin-Receptor Antagonists (Sartans) Alpha-Adrenergic Blockers Alpha-Beta Receptor Antagonists Central and Peripheral Sympatholytics Direct Vasodilators

CHAPTER 8: HOME BLOOD PRESSURE MONITORS 157 Evaluating Home Monitor Cuffs

CONTENTS • ix

PART III: MANAGING BLOOD PRESSURE IN SPECIAL SITUATIONS

CHAPTER 9: WHEN NOTHING SEEMS TO WORK 167 Renal Hypertension Renovascular Hypertension Primary Aldosteronism Secondary Hyperaldosteronism Hypercortisolism: Cushing’s Syndrome Enzyme Deficiencies of the Adrenal Zona Reticularis Pheochromocytoma Hypothyroidism Hyperthyroidism Hyperparathyroidism Obstructive Sleep Apnea Morbid Obesity

CHAPTER 10: HYPERTENSION POPULATIONS 203 Heart Disease Syndrome X or Diabetes High Cholesterol Cerebrovascular Disease Peripheral Vascular Disease Pregnancy Children and Adolescents Older People

Epilogue 239 Glossary 241 Bibliography 257 Resources 267 Index 269

IN

SPECIAL

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List of Tables

ö

Table 1.1 High Blood Pressure Awareness, Treatment, and Control in U.S. Adults 4 Table 1.2 Healthy versus High Blood Pressure 6 Table 1.3 Determining Heart Disease Risk 8 Table 2.1 Body Mass Index (BMI) 22 Table 3.1 Potassium Levels of Salt Substitutes 36 Table 3.2 DASH Comparison Diets 38 Table 3.3 Calories, Fat, and Sodium in Fast Foods 48 Table 4.1 Target Heart Rates 62 Table 4.2 Developing an Exercise Plan: The Initial Conditioning Stage 64 Table 4.3 Target Heart Rates for the Initial Conditioning Stage 65 Table 4.4 Developing an Exercise Plan: The Improvement Stage 66 Table 4.5 Target Heart Rates for the Improvement Stage 66 Table 5.1 Determining Ideal Weight 69 Table 5.2 Numbers of Daily Servings 73 Table 7.1 Diuretics and Dosages 105 Table 7.2 Beta-Blockers and Dosages 116 Table 7.3 Calcium Channel Blockers and Dosages 123 Table 7.4 Side Effects of Calcium Channel Blockers 124 Table 7.5 Drug-Drug Interactions with Calcium Channel Blockers 127 Table 7.6 ACE Inhibitors 135 Table 7.7 Angiotensin-Receptor Antagonists (Sartans) 141 Table 7.8 Alpha-Adrenergic Blockers 144 Table 7.9 Alpha-Beta Receptor Antagonists (Blockers) 145

xi

xii • LIST OF TABLES

Table Table Table Table

7.10 7.11 10.1 10.2

Central and Peripheral Sympatholytics 149 Direct Vasodilators 153 Normal Blood Fat Levels 213 Effects of Medication on Triglycerides and Cholesterol 216 Table 10.3 Normal Blood Pressure in Children 232

List of Figures and Exhibits

ö

Figure 2.12 Exhibit 3.1 Exhibit 3.2 Exhibit 3.3

Kidney Disease and High Blood Pressure 17 Serving Sizes 39 Spice Up Your Food 44 Approximate Sodium Content of Common Foods and Condiments 45 Exhibit 5.1 Sample Meal Plans 73 Exhibit 6.1 Fagerstrom Nicotine Dependency Assessment 85

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Preface

ö

One year ago I was sitting at our community pool with my sons Patrick and Liam when my cell phone rang. I had expected it to be my husband, Tom, telling me how much longer it would be before he would be leaving the hospital. He had just admitted a fifty-year-old woman who had had a massive stroke. She hadn’t seen a doctor in years and by her grief-stricken husband’s account, she had terribly high blood pressure but refused to do anything about it. She was on life support, but there was no hope of a recovery. The life support allowed Tom to keep her alive while her family and close friends assembled and processed (or tried to process) the shocking news that a wonderful mother, a best friend, a wife and lover, a dancer, a dreamer was no more. Tom had called me earlier in the day and told me the story. He had never met Mrs. G. before, but as the on-call physician it was his job to admit anyone without a doctor that day. Just before he hung up he had said, “You know, Mary, I really wish I had known Mrs. G. She must have been a wonderful person.” I thought later that if he had known her, he would have convinced her to get her blood pressure under control, and she wouldn’t be where she was today. He had promised to call me back as soon as he had spoken to everyone in her family, to let me know when to expect him. When I answered my phone it was Susan Cohen, my literary agent. I told Susan what had been happening. She responded by telling me that high blood pressure was exactly what she wanted

xv

xvi • PREFACE

to talk to me about. She had just received a call from L. Hudson Perigo, an editor and friend at Lowell House. Hudson was looking for a physician to write a book on hypertension (high blood pressure), and Susan wanted to know if I was interested. My first response was: “Hypertension is not exactly my field (by training I am a cholesterol specialist).” “But don’t high blood pressure and high cholesterol go hand and hand?” Susan asked. I had to admit that it was very common for me to see a person for his high cholesterol and proceed to treat both the high cholesterol and high blood pressure. She asked me how many people I had treated for high blood pressure—the answer was literally thousands. So the “hypertension is not exactly my field” excuse didn’t work. Next I asked Susan if she knew that Tom and I were in the process of adopting a baby from Korea. Surely this would stop her from pressing me to do the book. She told me how happy she was for me, but didn’t let up. I guess she was thinking I would have time to write on the maternity leave I wasn’t anticipating taking. I tried my last card. “You know I always collaborate with my sister [Jo McGowan Chopra] on any writing project.” Jo, a professional writer who lives in India with her husband and three children, had started a school for handicapped children.The school had become a more than full-time job and passion. And on top of the school she had her own writing deadlines. I didn’t commit. I told Susan I would talk to Jo and get back to her in a week. That night I called Jo. She said she would leave the decision up to me, but that she was willing. She even said she thought the project would be fun. I was wavering. Maybe it would be fun, but I also knew if I were going to do it properly, it would require a lot of time. I spoke to the boys, who thought it would be great if Mommy wrote another book with Aunt Jo. Our last book (Heart Fitness for Life) meant Jo had made a few extra trips to the United States. Since “Every day is a good day when Aunt Jo is here,” the boys were excited at the prospect. I reminded them that it might

PREFACE• xvii

mean I would have to work a little harder over the next year. “We can do our homework, and you can write your book,” was Patrick’s suggestion. When Tom finally got home and the boys were in bed, I mentioned that Susan Cohen had called and asked me if I might be interested in writing a book on hypertension. Tom’s response told me I was committed.“Mary, Mrs. G. really could have used a readerfriendly book. If you and Jo can write a book that gets even one person to get her blood pressure under control, then all the work involved will be worth it.” So here it is, The Hypertension Sourcebook—written during homework hour for a full year, reworked and improved in India during Jo’s children’s homework hour. I hope you will find this book a valuable resource. High blood pressure can cause premature heart disease, stroke, kidney failure, and death. But it does not have to.The program outlined in this book will introduce you to lifestyle changes that will dramatically lower your blood pressure. If lifestyle changes alone fail to fully normalize your blood pressure, there are many different medications that lower blood pressure. One will be right for you. For people with high blood pressure, the future has never looked so good. But it’s in your hands. Read this book and decide today to live a long and healthy life.

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Acknowledgments

ö

This book would never have come to be had it not been for the extraordinary patience of my husband Tom and children Patrick, Liam, and Sheila. Sheila arrived about halfway through the book and just happened to nap regularly and go to bed early (otherwise the book might never have been completed). For many people medical school and residency are recalled as a grueling time, with too little sleep and too much intimidation. My experience in medical school and residency was quite the opposite.When I entered medical school at the University of Massachusetts I encountered a group of physicians and teachers whose passion was teaching and whose goal was to make me and my fellow classmates good and caring doctors. The seven years I spent at the University of Massachusetts Medical Center, first as a medical student and later as a resident physician, were challenging, exciting, and yes, exhausting. There was so much to learn and so many people excited to teach. I am especially grateful to Drs. Joseph Alpert, Jim Dalen, Richard Irwin, Lou Braverman, Sarah Cheeseman, David Clive, Mel Pratter, Bruce Weinstein, Nelson Gantz, Abby Adams, Linda Pape, Joel Gore, Ira Ockene, Fran Renzi, and Donna Grogan who taught me not only about illness but about health and motivation. One physician and friend who was an enormous inspiration to me is Sarah Stone. Sarah is one of the most wonderful and caring physicians I have ever met. She was the person who taught me the importance of always remaining a student. She told me that a

xix

xx • ACKNOWLEDGMENTS

doctor who has nothing left to learn is a doctor who should retire. That belief stayed with me and made me realize how important it is to continue to ask questions and to question dogma. Sarah helped me realize that the more I know, the more I will be able to teach my patients and that the more I teach the more I learn. Many people remember the competition and the cutthroat aspects of medical school. At the University of Massachusetts it just did not occur, or at least I did not experience it. I know I learned as much from my classmates as from our teachers.They in turn have become great physicians, teachers, and thinkers. I would like to thank my medical school classmates Drs. John Miller, Anne Cushing-Brescia, Beth Coates, Steven Rapaport, Jim Pellegrini, Seth Bilazarian, Elenie Chadbourne, Andy Coco, Michael Connolly, Elisabeth Haeger, Rawden Evans, Debbie Ehrenthal, Susan Lynch, Caroline Marten-Ellis, Bob Quirbach, Ina Ratner, Mary Ellen Taplin, Dan Sullivan, Kenny Colmer, Dan Carlucci, Kathy Fitzgerald, Ross Carol, Dennis Tighe, Mike Cohen, and Aaron Zuckerberg for their friendship and insights. I would also like to thank my residency colleagues Wayne Hoover, Patty Soscia, Dan Carlucci, Joe Antaki, Denis Dupuis, Grace and Jim Desemone, Renee and Jim Doull, Doug Heller, Bernie Clifford, Martin Boucher, Steve Beaudette, Kristie Silver, Mary Ellen Taplin, Bob McGowen, Adrienne WithersBradley, Bob Clinton, David Rind, Sheila Kennedy, Karil Bellah, Michael Thompson, Paul Boffetti, Ron Caputo, Harvey and Allison Goldfine, Larry Greenwald, and Steve Beaudoin for their insights and late-night discussions in the halls of UMass. As I moved from the University of Massachusetts to Johns Hopkins Hospital, I continued to encounter wonderful teachers and mentors including Drs. Peter Kwiterovich, Stephanie Kafonek, Michele Wilson, and Alain Joffe. When I left Johns Hopkins I was lucky to take a job at the New England Heart Institute, where our goal is to provide the best possible care to all patients. I would like to thank my partners:

ACKNOWLEDGMENTS • xxi

Beatty Hunter, Bob Dewey, Bill Bradley, Pat Lawrence, Connor Haugh, Bruce Hook, Brian Shea, Lou Fink, Michael Hearne, Gary Minkiewicz, Gerry Angoff, Steve Beaudette, Craig Berry, Peter Klemintowicz, Bill Graff, and Mark Liebling for recognizing that preventing a heart attack is as important as performing an angioplasty. The outstanding nurse practitioners and physician’s assistants of the New England Heart Institute include: Jeanne Finn, Susan Horton, Judy Tsiorbas, David Allen, Jo-Anne Manson, and Jacqueline Gannuscio. My colleagues at the Cholesterol Management Center make work a joy. Mary Card, the best dietitian I have ever known, inspires everyone she meets—especially her patients—with her creativity and passion for nutrition and good food; Carolyn Finocchiaro, a gifted and wonderful nurse practitioner, has the perfect combination of gentleness, humor, and authority; Zena Ligon’s talent for helping my patients relax makes their blood drawing painless; and Diane Hebert manages my schedule and my life with such dexterity that I move from one thing to another with never a hitch. Thanks also to Elizabeth Schwendler who keeps our hypertension clinical trials on track and to Hope Snazelle, Gail Mullen, and Lisa Klein who make it all happen. I love you all. Finally I must thank Susan Cohen, my literary agent who suggested I do this project, and Hudson Perigo, an excellent editor who always found a nice way of pushing me along when I was slow in meeting my deadlines.

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PART I

HIGH BLOOD PRESSURE _WHAT IS IT?

1 McGraw-Hill's Terms of Use

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CHAPTER 1

ö

DO I HAVE IT?

H

igh blood pressure (also called hypertension) is extraordinarily common. The most recent national surveys suggest that fifty million Americans (20 percent of the adult population) have hypertension. By the time Americans reach the age of sixty, six out of ten people have high blood pressure, and it is the second most common reason for a visit to the doctor. The precise cause of most cases of high blood pressure cannot be determined. In fact, high blood pressure is less likely to be due to one single cause and is typically the result of a complex interaction between an individual’s genes and his environment. There is, however, no doubt that certain people are more likely to develop high blood pressure than others. For example, being overweight, having diabetes, and drinking more than two alcoholic beverages per day increase one’s risk, especially in those genetically predisposed to hypertension. Certain medications increase the risk. A family history of high blood pressure (especially in your father) means you will be more susceptible yourself. African Americans are at higher risk than are white or Hispanic Americans. And after the age of forty-five, women are at higher risk than men.

3 McGraw-Hill's Terms of Use

4 • HIGH BLOOD PRESSURE—WHAT IS IT?

Over the past twenty years the National Health and Nutrition Examination Surveys (NHANES) have been conducted three times with the results compiled in reports titled NHANES I, NHANES II, and NHANES III. These surveys are designed to assess the overall health status and dietary habits of the American people. They have evaluated the percentage of people with high blood pressure who are aware of the problem, who have been treated, and whose blood pressure has been reduced to an acceptable level. NHANES III was conducted in two phases, and the results revealed a surprising and disturbing trend (illustrated in Table 1.1). Table 1.1 High Blood Pressure Awareness, Treatment, and Control in U.S. Adults: 1976-1994 NHANES II (1976-1980)

NHANES III PHASE 1 (1988-1991)

NHANES III PHASE 2 (1991-1994)

Aware of high blood pressure: 51% 73%

68%

Treated for high blood pressure: 31% 55%

54%

Controlled to a level below 140/90 mmHg: 10%

29%

27%

Although it is obvious that great strides have been made during the last twenty years, the trend seen between the first and second phases of the NHANES III survey indicates that among Americans there has been a reduction in awareness, treatment, and control of hypertension. It is frightening to think that only 27 percent of people with high blood pressure are being treated to an acceptable level. The consequences of undertreatment may be deadly. Since high blood pressure predisposes those who have it to heart disease

DO I HAVE IT? • 5

and stroke (our number one and number three causes of death in the United States), failure to treat significantly increases the risk of developing these serious medical conditions. Hypertension is also strongly associated with kidney disease, which frequently progresses so far that dialysis is required. I hope that by the time you have finished this book, you will have the tools you need to achieve perfect control of your blood pressure, either with lifestyle changes alone (diet, exercise, and supplements) or with lifestyle changes in combination with medications. Although I hope you will find this book valuable and informative, it is not a substitute for working closely with your own personal physician. For example, while exercise is an extremely powerful tool for lowering blood pressure, you should not begin an exercise routine without consulting your doctor. If you have many risk factors for the development of heart disease, suddenly plunging into a demanding new physical routine might do you more harm than good. Your doctor might recommend a stress test to determine if your heart would be compromised by vigorous exercise, and such a test would also help her provide you with guidelines for the duration and intensity of exercise. Now that we have talked a little about hypertension and how common it is, let’s review how blood pressure is measured and help you determine if yours is elevated. And if so, how seriously? A person’s blood pressure is measured using a device called a sphygmomanometer (sfig’-mo-ma-nom-e-ter). A cuff is wrapped around your upper arm and held in place with a Velcro closure. The cuff is then inflated to the point at which your pulse no longer flows in your artery. A stethoscope is placed over the artery at the bend in your arm and the tester listens as the air is gradually released from the cuff and blood forces its way through the artery.A gauge attached to the cuff provides a reading of this maximum amount of pressure, known as the systolic blood pressure. This is the pressure in your arteries when your heart is pumping blood out to your body.

6 • HIGH BLOOD PRESSURE—WHAT IS IT?

The air continues to be released gradually from the cuff until no sound is heard through the stethoscope. This level represents your diastolic blood pressure or the pressure within your arteries when your heart is relaxed, between heartbeats. Blood pressure is always expressed as the systolic blood pressure over the diastolic blood pressure, with the systolic figure (representing the peak pressure) always being higher than the diastolic. Blood pressure is measured in millimeters of mercury (mmHg) because the first sphygmomanometers used mercury in the pressure gauge. The data in Table 1.2 were recently (1997) developed by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.You can use it to determine where your blood pressure stands. Table 1.2 Healthy versus High Blood Pressure CATEGORY

SYSTOLIC BLOOD PRESSURE mmHG

Healthy Blood Pressure Optimal Normal High Normal

⬍ 120 ⬍ 130 130–139

High Stage Stage Stage

140–159 160–179 ⬎ 180

Blood Pressure 1 2 3

DIASTOLIC BLOOD PRESSURE mmHG

⬍ 80 ⬍ 85 85–89

and/or and/or and/or

90–99 100–109 ⬎ 110

If you have high blood pressure and you fall into one category for systolic and another for diastolic, you are classified as having the higher stage. For example, a woman with a blood pressure of 150/108 is classified as having Stage 2 hypertension because even though her systolic blood pressure is Stage 1, her diastolic is Stage 2.

DO I HAVE IT? • 7

High blood pressure needs to be treated, because without therapy a person’s risk of developing heart disease and stroke increases dramatically. The absolute risk of developing these conditions is influenced not only by a person’s blood pressure but by other risk factors. As you and your doctor make decisions on how best to treat your blood pressure, you will want to take into account your other risk factors. You may want to examine the Coronary Heart Disease (CHD) Score Sheet developed by the investigators from the famous Framingham Heart Study. The Framingham Heart Study examined thousands of men and women in Framingham, Massachusetts, starting more than fifty years ago. The people of Framingham consented to be examined every year or so for decades. Today, many of the offspring of the original Framingham study subjects are study participants themselves. The Framingham study, which did not treat risk factors but rather monitored physical exam findings and blood chemistries, has contributed enormously to our understanding of heart disease. In fact, the study helped prove that smoking, high blood pressure, and high cholesterol were all risk factors for the disease. You can use the Score Sheets in Table 1.3 to figure out your risk of developing heart disease over the next ten years. There are two different Score Sheets, one for women and one for men. These Score Sheets are only for determining heart disease risk. As far as I know there is no such tool for stroke. As you can see in Table 1.3, the Score Sheet takes into account age, sex, smoking status, diabetes, and blood pressure in determining risk. In answering the cholesterol section, if you only know your total cholesterol, use the lower chart in step 2; if you know your low-density lipoprotein cholesterol (LDL-cholesterol or bad cholesterol), use the upper chart. Because knowing the LDLcholesterol is a bit more predictive than just the total cholesterol, go to that column in figuring your points for other risk factors. The only place your point score will differ is under high-density

Table 1.3 CHD Scoresheet for Men CHD score sheet for men using TC or LDL-C categories. Uses age,TC (or LDL-C), HDL-C, blood pressure, diabetes, and smoking. Estimates risk for CHD over a period of 10 years based on Framingham experience in men 30 to 74 years old at baseline.Average risk estimates are based on typical Framingham subjects, and estimates of idealized risk are based on optimal blood pressure, TC 160 to 199 mg/dL (or LDL-C 100 to 129 mg/dL), HDL-C of 45 mg/dL in men, no diabetes, and no smoking. Use of the LDL-C categories is appropriate when fasting LDL-C measurements are available. Pts indicates points. Hard CHID events exclude angina pectoris. Key Risk 1 2 3 4 5

Very low Low Moderate High Very high

STEP 1 Age Years

LDL Pts

Chol Pts

30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74

−1 −0 1 2 3 4 5 6 7

[−1] [0] [1] [2] [3] [4] [5] [6] [7]

STEP 2 LDL-C Risk

(mg/dL)

(mmol/L)

1 2 3 4 5