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Blood Pressure

Our guest expert in October 2010, was Dr. Paula Harvey, director of the cardiac research program at Women’s College Hospital, a scientist at Women’s College Research Institute and an assistant professor in the division of cardiology at the University of Toronto.

Dr. Harvey’s research explores how blood pressure and the health of blood vessels are regulated by the body – and how this system of regulation may differ between women and men. She works to apply this knowledge to test new treatments such as exercise and medication in hopes of finding ways to improve the function of blood vessels, lower blood pressure and reduce the risk of heart attacks, heart rhythm disturbances and strokes in women.

Here are the responses to your questions on Blood Pressure.

Q: Do all the popular medications prescribed for high blood pressure cause a cough? Are you aware of any that do not?

A: Cough is a recognised side-effect of one class of medications commonly used to treat high blood pressure called angiotensin-converting enzyme inhibitors (ACE inhibitors). Cough may occur in approximately 10 per cent of people who are prescribed these medications with women affected more commonly than men. The cough is reversible on stopping the medication, with resolution usually within one to four weeks. This side-effect is not associated with other classes of blood pressure lowering medications. If you are on an ACE inhibitor and are experiencing a dry cough which is problematic, you should discuss this side-effect with your doctor who may decide to change you to an alternative class of blood pressure lowering medications.


Q: What causes low blood pressure, and are there any health risks associated with it? What systolic/diastolic measurements qualify as low? Are there symptoms of low blood pressure? How is it treated?

A: The level of blood pressure that is defined as ‘low blood pressure’ (also known as hypotension – the opposite to high blood pressure or hypertension) varies depending on a number of factors including sex and age of the person. While low blood pressure is generally in the range of <90/60 mmHg this measurement would in fact be a normal healthy blood pressure in a young person, particularly in a young woman. Young females will often say they have ‘low blood pressure’ when in fact their blood pressure is appropriate for age and sex, and indeed very healthy.

Low blood pressure is really only problematic when it causes symptoms because as a general principle, low blood pressure in healthy and asymptomatic people protects against cardiovascular disease. Symptoms of abnormally low blood pressure occur when there is inadequate blood flow to the brain and other vital organs. This can lead to tiredness, weakness, blurred vision, confusion, nausea, light-headedness, dizziness and even fainting. A common type of symptomatic low blood pressure is known as ‘postural’ or ‘orthostatic’ hypotension, a condition where blood pressure falls too low and causes symptoms when standing.

Causes of low blood pressure are many and varied and include certain types of drug therapy, excessive fluid loss (dehydration), blood loss, hormonal abnormalities, complications of diabetes and diseases of the nervous system. Also, aging is associated with increased tendency to postural hypotension and therefore blood pressure should be measured both seated and standing in the elderly whenever possible.

Whether or not low blood pressure should be investigated and treated depends on the symptoms and circumstances. It is very important to be aware of the risk of injury from falls and faints if the blood pressure is very low, particularly in the elderly. Attention to hydration and drug therapy is important. Some people with persistent, symptomatic hypotension may need to be referred to a specialist for further investigation and consideration of specific treatments (e.g. hormone therapy, salt therapy, special elastic stockings).


Q: How do mental illness and stress affect blood pressure?

A: Acute stress can cause blood pressure to spike for short periods of time. When faced with a stressful situation, our bodies react by releasing stress hormones into the blood to prepare for the ‘fight or flight’ response. This stress response increases the blood pressure by causing the heart to beat faster and the blood vessels to narrow. However, when the acute stress goes away the blood pressure usually returns to the pre-stress level.

This leads one to question the longer-term effects of stress on blood pressure. Could all those short-term spikes in blood pressure cause high blood pressure in the long term? What about more prolonged or ‘chronic’ stress that causes our bodies to be in the state of ‘flight or flight’ for perhaps days, weeks or longer at one time? The link between repeated episodes of acute stress and/or chronic stress and sustained high blood pressure is unclear, but research into this possible association is ongoing.

What we do know with certainty however is that behaviours linked to stress such as overeating, drinking too much alcohol, smoking and poor sleep are known to contribute directly to sustained high blood pressure and related complications. Activities that can help you manage your stress in a positive way will improve your health and help to lower your blood pressure. These activities might include exercise, healthy eating, yoga, meditation, controlled breathing exercises and improved sleep habits.

Mental illness, in particular depression, has been linked to increased risk of heart disease as well as poorer outcomes. However, mental illness has not been directly linked to sustained high blood pressure. Certain factors linked with mental illness and the related emotional stress, for example social isolation from family and friends, may contribute to behaviours that lead to high blood pressure such as unhealthy lifestyle and perhaps also problems such as neglecting to take prescribed heart and blood pressure medications.


Q: What can family members do to help relatives living with high blood pressure?

A: Successful management of hypertension (high blood pressure) requires lifelong adherence to a healthy lifestyle and compliance with prescribed medication. A person with hypertension needs to develop and maintain motivation to leave behind the ‘bad’ old habits that not only contribute to the development of hypertension but also determine the degree of success of treatment of high blood pressure. A blood pressure healthy lifestyle requires:

  • replacing a diet high in processed foods with a ‘dietary approach to stop hypertension’ (also known as DASH) diet
  • regular physical activity (accumulation of 30 to 60 minutes of moderate intensity exercise four to seven times per week)
  • ‘low risk’ alcohol consumption
  • attaining and maintaining a health body weight
  • smoke-free environment
  • positive stress management

Not surprisingly, family support can be invaluable in helping a person make these important lifelong changes. Family members can help not only by motivating and encouraging their relative to stick to this healthy lifestyle, but by making a commitment for all family members to make the healthy change. It is so much easier for a person to remain motivated if they are not making these changes on their own. What is more, every member of the family will benefit from a commitment to a healthy lifestyle.


Q: Can you comment on white coat syndrome? I get horribly nervous at medical appointments. How do I keep my blood pressure down when I’m dealing with nurses/doctors who can be so nerve-wracking?

A: Some people have higher blood pressure when they visit a doctor’s office than when they go about their usual daily activities. This is referred to as white coat syndrome or white coat hypertension. The ‘white coat’ refers to the white coat worn by the doctor and therefore a clinical or medical environment. The white coat syndrome is thought to be caused by anxiety. White coat syndrome occurs in up to 20 per cent of people and tends to be most common in children and the elderly. White coat syndrome can occur in people with otherwise normal blood pressure but can also occur in people with background high blood pressure.

There are no symptoms of white coat syndrome. While some people are aware of being nervous when having their blood pressure measured in a medical environment others may think they are relaxed, unaware of the underlying anxiety. While having your blood pressure measured in the clinic on multiple visits (preferably by someone other than the doctor such as a nurse or medical assistant) may reduce the white coat effect, the best way to find out if you have white coat syndrome is to have your blood pressure measured away from the medical environment. This can be done one of two ways: either you take a series of readings yourself at home with a semi-automated machine, or alternatively, the doctor arranges for you to wear a fully automated blood pressure monitor for a period of 24 hours. This is called ‘ambulatory blood pressure’ or ‘24-hour blood pressure’ monitoring. Using this method, your blood pressure is measured automatically at regular intervals over the 24-hour period providing detailed information on your blood pressure during day-time activities and during night-time sleep.

Remember, if you do have white coat syndrome you are probably at increased risk for future development of high blood pressure in the longer term. Therefore, you should have your blood pressure measured (using one of the above described methods) on a regular basis – at least once a year. Maintaining a healthy lifestyle will help protect against the future development of sustained high blood pressure.


Q: What would be the target blood pressure for a 60-year old male with dilated cardiomyopathy and 70 percent blockage in the left anterior descending artery?

A: The person described has evidence of coronary artery disease and also poor heart function suggestive of congestive heart failure. Current guidelines recommend that blood pressure in the setting of cardiovascular disease be treated to <140/90 mmHg (based on readings in the medical clinic by the doctor). Some doctors may prefer to treat to a target of <130/80 mmHg to be sure of maximal protection against further progression of cardiovascular disease but this target has not yet been proven in big clinical trials. However, if this person also has diabetes or kidney disease the blood pressure target would definitely be <130/80 mmHg.


Q: I have always wondered why sometimes people can hear the sound of blood rushing through their veins. Does that have any connection to blood pressure?

A: Sometimes people can hear a noise that beats in time with their pulse, a condition known as ‘pulsatile’ or ‘vascular’ tinnitus. People are often most aware of this sound when in quiet environments, such as when lying in bed at night before sleep. The sound is thought to be caused by turbulence of blood as it flows through the blood vessels in the neck. A number of conditions may be associated with pulsatile tinnitus ranging from fluid and/or infection in the middle ear to abnormalities of the blood vessels in the neck. Although high blood pressure is not a cause of this condition, it can make the pulsing sound louder due to increased blood flow through the neck blood vessels. For example, the build up of cholesterol plaque in the carotid artery (atherosclerosis) may cause turbulent blood flow that a person can hear and also that the doctor can hear when listening over the artery with a stethoscope. A person with this condition may hear this sound more loudly or clearly if they also have high blood pressure.

Whilst most causes of this condition are benign, it is important to speak to your doctor to determine any need for specific investigation and/or treatment.


Q: I am a 68-year-old woman with poorly controlled blood pressure typically 150/80, pulse 60. I’m 35 pounds overweight, eat properly and exercise frequently (primarily cardio and weight training). I take a diuretic, beta blocker, a calcium channel blocker and an angiotensin II inhibitor. I have trouble doing intense aerobics (a weird feeling of not being able to take a deep breath but not yet out of breath) and a friend said you shouldn’t exercise intensely if you take beta blockers. Is this true?

A: Your friend’s statement is partially true. While we do not specifically advise people against intense exercise whilst taking beta blockers, this class of medication can reduce exercise performance and tolerance by dampening down the heart’s response to the demands of exercise. When we exercise, our cardiovascular system responds to the increase in oxygen required by the exercising muscles through a number of mechanisms. These include increase in heart rate and increase in strength of heart contraction. Beta blockers act on the heart to limit heart rate and reduce heart force of contraction and therefore can lead to reduced exercise tolerance (i.e. you may find you are unable to exercise for as hard or for as long). While this can protect the heart against excessive demands and provide very important heart protection in some people, it can contribute to symptoms of tiredness and fatigue and inability to perform the most strenuous of exercise. Also if a person has underlying breathing problems such as asthma or emphysema, symptoms of these underlying breathing problems can be exacerbated by beta blocker therapy.

I suggest that you discuss this issue with your doctor. Many different factors can contribute to reduced exercise tolerance and breathing difficulties that may be unrelated to the beta blocker therapy. If these effects are thought to be due to the beta blocker, then the dose may need adjustment or an alternative medication may be required. Certainly exercise is important for you to be able to maximise your healthy lifestyle to help with blood pressure (and weight) control.


Q: Are newer medications in existing drug classes (such as beta blocker and calcium channel blockers) better or more effective than older versions of these types of drugs?

A: This is a difficult question as it varies with each medication and drug class! In general, each new medication that is developed within an existing drug class tends to be marketed as having special properties that make it superior to older members of the drug class. This can be very confusing for doctors (prescribers) and patients. Generally, the beneficial and adverse effects of the newer drugs are similar to those of the older drugs of the same class. However, in some cases there may be some important differences in potency (dose of medication required for a desired beneficial effect), type and frequency of adverse (side) effects, the way the drug is broken down and removed from the body (e.g. via the kidneys or liver) or the way that a drug is administered (e.g. oral versus injection versus skin patch). One particular feature that often differs between older and newer drugs of a certain class is the duration of action of the drug after each dose (usually longer duration with newer versions). Longer-acting medications may help provide more prolonged blood pressure lowering effect per dose, allowing for the medication to be administered less frequently (ideally once per day). This might help provide smoother blood pressure control over the 24-hour period, less blood pressure increase if the person is late taking their medication (or misses a dose) and help with drug compliance by reducing the number of times per day the drug needs to be taken. However, many drugs of a class can be used interchangeably as long as the person is prescribed the appropriate drug, at the most effective dose, with the correct dosing schedule (number of doses per day) and with attention to possible side-effects. It is important to discuss the different medication options with the doctor to make sure that the best medication is prescribed for each individual’s circumstances and needs.


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