FAMILY MEDICINE® COLUMN
By John C. Wolf, D.O.
Associate Professor of Family Medicine®
Ohio University College of Osteopathic Medicine

[VISIT DOC AGAIN, TALK ABOUT STRANGE HIGH BLOOD PRESSURE DIAGNOSIS]

Question: My brother-in-law has recently joined an HMO. He went to see his new doctor for a physical and was found to be in good shape except for his blood pressure. It was 138 over 90, which I thought was in the normal range. The doctor seemed quite concerned and started him on medicine that day. Before this, he was healthy and vigorous. Now, he is constantly tired and doesn't feel well. He explained this to the doctor, but he insisted that he continue the medicine. Should he really continue with this medicine?

Answer: An estimated 50 million Americans have this very common condition, which doctors call hypertension. It is more prevalent in men, until age 65; after this point women assume the lead in this deadly race.

The reason we are concerned about elevated blood pressure is that it increases the risk of stroke and heart attack - the leading killer of adult Americans. High blood pressure is generally defined as a sustained blood pressure, taken while the person is at rest, greater than 140 over 90 (140/90). Research shows us that those with readings between 140/90 and 150/95 have increased risk, but using medicine to reduce blood pressure is of questionable value. Though there is some disagreement among experts, I feel that it is prudent for anyone with an upper number greater than 150 or a lower number greater than 95 to take steps to reduce their blood pressure. There is no doubt that this will decrease their risk of heart attack and stroke.

There are many treatments for high blood pressure. The most important are often the most difficult - reduce weight to the ideal level, reduce salt (actually it is the sodium in salt we're concerned about) to 2000 milligrams per day, and use beverages containing caffeine and alcohol only in great moderation. These life-style changes are very difficult to make and, therefore, don't always happen.

Less than 10 percent of individuals with high blood pressure have a specific cause that requires specific medication. Most have essential hypertension, which is a fancy way for doctors to describe the condition without telling you that we don't have a clue as to why your pressure is up. The good news is that we can almost always find a combination of medication and life-style changes that will lower blood pressure to within safe limits. This will significantly decrease your risk of premature death from heart attack and stroke.

Now, I will address the specific points of your question. Your brother-in-law reportedly only had one blood pressure measurement before starting medicine for the condition, and that reading was within the normal range. Strange! Normally it requires at least three readings, taken on different days, to determine if the pressure is elevated sufficiently to benefit from drug therapy. Of course, a physician might institute treatment immediately if values of a first reading are dangerously high but that isn't the situation you've reported.

High blood pressure is a symptomless condition. That makes it difficult to convince people to take a drug that may cause some side effects. I can't tell whether your brother-in-law is actually having side effects from his medicine or if he is feeling tired because his blood pressure is now lower than it should be. Frequent blood pressure measurements can clarify that. I often have my patients take their own pressure to gather this important information. Morning and evening readings, for about one week, are usually sufficient to show if the pressure is staying in the normal range. If the pressure is normal, then the problem is caused by side effects from the medication. In this situation, there are often other drugs that can control the pressure without causing these annoying symptoms.

It sounds like your brother-in-law needs to go see his doctor again. I suggest that he take a log of his blood pressure reading along with a list of his undesirable symptoms. Then he and his doctor can figure out what to do.

Family Medicine® is a weekly column. To submit questions, write to John C. Wolf, D.O., Ohio University College of Osteopathic Medicine, Grosvenor Hall, Athens, Ohio 45701.