May 4, 2013

Treatment Of Systolic And Diastolic High Blood Pressure

Is there a difference in the treatment of systolic hypertension and diastolic hypertension? My systolic pressure is typically in the 120s but my diastolic is in the 90s and 100s. I have had this problem for over 15 years. I exercise regularly and I am not overweight. I’m otherwise in good health and currently taking Verapamil and Cozaar.

Hypertension or high blood pressure is one of the most common diseases that a general doctor like myself sees, but it often remains undiagnosed or undertreated. This is very unfortunate since we now have many drugs that are effective in bringing the blood pressure down to normal, and there is very good evidence that treating hypertension literally saves lives. The treatment of hypertension is one of the reasons that the death rates due to heart attacks, heart failure and stroke have fallen substantially over the past 30 years.

You refer to the systolic and the diastolic pressures. The systolic pressure is the pressure in the large arteries when the heart is actually contracting, and forcing blood out into the arterial system. The diastolic pressure is the pressure in the system between heartbeats, when the heart is not actually contracting. The systolic pressure is always higher than the diastolic. There is no clear-cut dividing line between normal and elevated pressure. We have arbitrarily taken the figures of 140/90 as the line separating normal pressure from hypertension, but in fact the lower the pressure, the better off one is, and doctors are increasingly treating patients to achieve pressure levels under 130/85, and in diabetics, even under 130/80.

For many years it was believed that the diastolic pressure was the more important one, probably because that is the pressure that the arterial system is exposed to most of the time, since diastole, when the heart is not beating, lasts much longer than systole, the time of the contraction. When I was in medical school, at a time when there were few effective treatments for hypertension, we wouldn’t worry about a 65-year-old woman with a pressure of 165/95. Now it is clear that treating a person with such blood pressure is important and will greatly reduce her likelihood of stroke (Harrison Principles of Internal Medicine). Diabetics represent a special case, since the combination of the two diseases produces much more damage to the arterial system and the kidneys. For this reason, the current recommendation for treating hypertension in diabetics is to bring the pressure down even lower than one would in a non-diabetic, to below the level of 130/80.

The combination of hypertension and diabetes is unfortunately all too common, and will become even more common with the increasing incidence of obesity in our population. Obesity is a risk factor for both of these diseases, and makes their treatment more difficult. Trying to lose weight if one has this combination is very important, and even a relatively small amount of weight-loss, like 10 to 15 pounds, may bring the blood pressure down to normal.

The treatment of the systolic and diastolic pressures usually does not differ. That is, drugs or combinations which are effective in reducing the diastolic pressure will usually reduce the systolic as well. One exception to this is people of African American descent, whose systolic pressure may be difficult to control unless a diuretic is used.

You are taking Verapamil, which belongs to the class of calcium channel blockers, and Cozaar, belonging to the class of angiotensin receptor antagonists. This class of drugs has only recently been marketed, and they are only available as brand name drugs. Therefore, they tend to be expensive; and since they are new, there are few studies on long-term effectiveness, particularly studies demonstrating a reduction in mortality. Only beta blockers (Inderal, Tenormin, Lopressor) and diuretics have been around long enough to have been shown to reduce mortality in such long-term studies. Because of this, many experts advise starting treatment with members of those classes, and moving on to other drugs only if there are side effects, or control cannot be achieved with those drugs alone.

Since you appear to have a diastolic pressure persistently in the 90s to the 100s, you are not being treated aggressively enough, in my opinion. You and your doctor should be shooting for a pressure equal to or below 135/85. This may be achieved by either increasing the doses of Verapamil and Cozaar, or adding a third drug. Many doctors will add additional drugs in low doses in the hope of avoiding side effects rather than pushing the dosage of one or two drugs, but either technique is acceptable if the pressure is brought down, and troublesome side effects do not appear.


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