Under Pressure

Everything you need to know about Hypertension.

Aside from having occasional nosebleeds, Charles Slater felt fine. “But my wife convinced me to go to the doctor,” the Mount Kisco resident says. Good thing: Slater, then 30, learned he had hypertension (also known as high blood pressure), a potentially deadly and often symptomless—but treatable—condition.

Slater followed doctor’s orders to try to lose some weight and to reduce salt in his diet. When that didn’t work, he was prescribed medication. Four decades later, the 70-year-old grandfather still faithfully takes his meds (since updated) and regularly sees both his current internist, Dr. Steven Margulis of Mount Kisco Medical Group, and his cardiologist, Dr. Peter Mercurio of Westchester Health Associates in Katonah. His hypertension, Slater’s happy to say, is in check.

Slater is lucky. About one in four American adults has high blood pressure, and a quarter of them don’t know it. But the stealthy killer is there, overtaxing their cardiovascular systems and wreaking havoc on their bodies. Hypertension is a major reason people have heart attacks and strokes. In 2007, high blood pressure caused at least 200 deaths in our county. Of more than 3,000 local deaths attributed more generally to cardiovascular disease, “many were probably due to hypertension as well,” says County Health Commissioner Dr. Joshua Lipsman.

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The good news is that about 90 percent of high blood-pressure patients can be treated with the right combination of drugs, reports Dr. Marvin Moser of Scarsdale, a clinical professor of medicine at Yale University School of Medicine and former chief of cardiology at White Plains Hospital. Here’s what to know.

Pressure Primer

Blood pressure is, simply, the force your bloodstream puts on the walls of your arteries, the tubes and vessels that carry blood from your heart to your body. Your physician measures your pressure at checkups by inflating a cuff around your upper arm until the circulation in your arm’s artery stops. Then he or she gradually deflates the cuff and puts a stethoscope to your inner elbow, listening for when blood resumes rushing through the artery.

As it does, the doctor records the number on a gauge attached to the cuff. That’s your systolic pressure—the blood pressure in your artery when your heart is pumping. When the beating sounds briefly cease, the gauge’s number drops lower, indicating your diastolic pressure, the force of blood in your artery when your heart rests.

Blood pressure is expressed as those two numbers, with systolic coming first. For example, if your systolic pressure was 120 mm Hg and your diastolic was 80 mm Hg (“mm Hg” signifies the number of millimeters that the mercury in the gauge rose), your doctor would describe it as “120 over 80,” a familiar term to House fans. Those numbers, by the way, are ideal, though up to 130 over 80 is normal for adults.

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High Anxiety

What if the numbers are higher? “Think of your body as being like a car, says Dr. Franklin Zimmerman, senior attending cardiologist and director of critical care at Phelps Memorial Hospital in Sleepy Hollow. Having hypertension is like driving on an incline. The engine, in this case the heart, works overtime,” explains One effect: your overworked heart becomes enlarged. Sooner or later, its muscle gets over-stretched or becomes too thick, and can’t properly pump. Some blood backs up into the lungs, and the heart fails.

Hypertension also strains the walls of small blood vessels. In the brain, this can cause vessels to narrow or develop blisters called aneurysms, which can break loose and cause a brain hemorrhage. The result: a stroke.

Sadly, that’s how Diana Johnstone of Yorktown Heights learned of her hypertension eight years ago. A numb leg sent her to the ER, where her pressure was measured at 200/110. Soon, her left side was paralyzed. Now a patient of Dr. Mercurio’s, Johnstone’s on blood-pressure medication, and though she’s largely recovered from the stroke, walking for long periods can be difficult. “Better to have been taking medicine all along and to have avoided this,” she says.

Scary? There’s more. High blood pressure also can land you in a dialysis center or on a kidney-transplant list. That’s because it narrows and thickens arteries, so your kidney filters less fluid. The arteries can also harden—a condition called atherosclerosis—because if blood pressure is high, fat that normally circulates freely through the bloodstream gets pushed into your artery walls. “It builds up like rust in a pipe,” says Dr. Moser, referring to plaque, the fat cells that clog your arteries, which can cause a heart attack. While high blood pressure doesn’t lead to heart disease and other complications in every person, it remains a huge risk factor for their eventual development.

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Driving Down Your Numbers

What causes hypertension? “About ninety-five percent of the time, there’s no identifiable cause,” says Dr. Sanford Zevon, a retired cardiologist and former head of cardiology at White Plains Hospital. (The remaining cases stem from problems like hormone imbalances, kidney infections, or, in women, side effects of birth-control pills.) Hypertension sometimes runs in families, so know your history—and get regular checkups. “If only hypertension hurt a little, more patients would see their doctors,” says Dr. Moser. “But usually people can’t feel it.” While some get headaches, dizzy spells, or, like Slater, nosebleeds, it’s rare.

If your blood pressure is high, don’t panic; there’s help. “Scary as hypertension’s effects can be, many are avoidable or reversible if high blood pressure is treated early,” says Dr. Moser. Your physician will determine a course of action. “When a patient has less severe hypertension, my first line of treatment is often TLC—therapeutic lifestyle changes,” says Dr. Zimmerman. “Then I’ll check them again in several weeks.”

Among the key lifestyle changes recommended:
Quit smoking. “When you inhale smoke, it causes the release of chemicals that make your arteries contract, which narrows the opening that lets blood flow through them and raises your blood pressure,” explains Dr. Mercurio, past board member of Northern Westchester Hospital. “The nicotine and other products in cigarette smoke also change your arteries on a cellular level, making them less able to relax. Over time, smoking also can cause changes in your white blood cells and platelets that make them cling together more easily, and adhere to the plaque in your arteries, clogging them.”

Cut down on salt. “Salt causes fluid retention,” Dr. Mercurio explains, “which adds to vessels’ burden. Some people are more sensitive to salt than others, but it’s helpful, generally, to modify your intake.” He adds, “Most of us consume two teaspoons of salt daily, but we only need less than a half-teaspoon a day.”

Watch your fat intake, and lose weight if you’re overweight. “It’s not entirely clear why, but high blood pressure is extremely common in people who are obese and overweight,” says Dr. Zimmerman.

Exercise. “It can make your heart muscle more efficient, so it works less hard to pump your blood and generates less blood pressure,” explains Dr. Mercurio. While you have to exercise regularly for at least one to three months to see the effects, Dr. Mercurio says it can ultimately lower your blood pressure by as much as 10 points.

Lower your stress levels. Read, pursue a hobby, even meditate. Relaxation can temporarily lower blood pressure by reducing your production of adrenaline, a hormone that constricts blood vessels.

When Meds Are a Must

Occasionally, lifestyle changes create happy endings. “One patient of mine, a young woman, was about thirty pounds overweight and had hypertension and high cholesterol,” says Dr. David Cziner, chief of cardiology at White Plains Hospital. “I put her on three medications, saying we’d reassess if she lost weight.” In 18 months, the woman shed the pounds. “We were able to gradually stop her medications,” he says. “Unfortunately, I can’t tell you how many patients I give this advice to, and the next time they come in, they’re the same—or worse.”

More often, healthy living alone doesn’t lower blood pressure enough. People often need two or more of the following classes of hypertension drugs, depending on factors including their age, ethnicity, and other health conditions:

Diuretics, like hydrocholorothiazide and chlorthalidone, reduce blood pressure by flushing extra salt from the body and blood-vessel walls so the vessels can dilate.

ACE inhibitors block production of angiotensin converting enzyme (ACE), a chemical that constricts blood vessels. Some popular ACE inhibitors: Aceon, Altace, and Capoten.
ARBs, or angiotensin II receptor blockers, also interfere with angiotensin production, but target different spots in the body. Some people tolerate them more easily than ACEs. Among them are Avapro, Cozaar, and Micardis.

Combination drugs. Some pills combine a diuretic plus an ACE or ARB. Capozide, Lotensin HCT, and Zestoretic, for example, are diuretic/ACE inhibitor combos; Hyzaar, Avalid, and Diovan HCT contain both a diuretic and an ARB.

Calcium channel blockers prevent calcium, a constrictor, from entering the heart muscle or blood-vessel walls. Some (DynacCirc DR, Norvasc, and Plendil, among them) target blood vessels, while others (like Cardizem CD or Isoptin SR) work on the heart, too. There are also calcium channel blockers combined with ACE inhibitors.

Beta blockers slow the heart and make it contract less forcefully. Two well-known ones: Lopressor and Tenormin.

Other, lesser-used drugs exist, including some that simultaneously address other health problems.

It’s crucial to take your medications. People sometimes skip them to save money (a regimen can cost several hundred dollars monthly). “I don’t see many Westchester patients who can’t afford their medication, but some people stretch prescriptions by cutting pills in half,” says Dr. Mercurio.

Others are stubborn. “One patient stopped his medications because he didn’t like something he’d read about them on the Internet,” says Dr. Zimmerman. “His blood pressure shot up. If you suddenly halt your medication, it can rebound higher.”

Another cautionary tale is Cindy McCain’s. Senator John McCain’s wife was prescribed hypertension drugs but didn’t take them, feeling she was too young. One morning in 2004, McCain, then 49, had a stroke. “It was a hell of a lesson to learn,” she has said about the incident.

But there are positive lessons too, like Charles Slater’s. “I’m grateful for my doctors and my medications,” says Slater, who hasn’t had a nosebleed in years.

Could Race Raise Risk?

No one knows precisely why, but certain ethnic groups are more prone to hypertension than are others. The Centers for Disease Control analyzed data collected from thousands of Americans between 1999 and 2002, and found that while approximately 27 percent of whites had high blood pressure, its prevalence among non-Hispanic blacks was far higher—about 40 percent. (Hypertension tends to develop earlier among blacks as well, and can be more severe.) Mexican Americans, meanwhile, had slightly lower rates than either of those ethnicities, roughly 25 percent. Though Asian Americans were not specifically mentioned in the study, Asian and Pacific Islander adults have lower hypertension rates than white adults have, according to the U.S. Department of Health and Human Service’s Office of Minority Affairs.

“Precious” Minerals

Your mom always told you to eat your vegetables—but when it comes to your blood pressure, eating your minerals comes in handy, too. According to an article recently published in a supplement to the Journal of Clinical Hypertension, a diet that includes foods rich in potassium, magnesium, and calcium may help reduce a person’s risk for hypertension, or at least lessen its severity. Better yet, it also may lower the chances for a stroke or coronary heart disease. Low-fat dairy foods are among the many good sources of all three minerals; others include bananas, white-fleshed fish, and potatoes.

No one’s sure why these minerals have such pronounced effects, though it’s speculated that potassium in particular may prevent blood vessels from constricting, or may actually make them relax. But check with your doctor before making dietary changes (and certainly before taking supplements of any kind). People with certain health conditions, such as kidney problems, may have difficulty tolerating an increased mineral intake.

Resident Expert

For more than 50 years, Dr. Marvin Moser, a Scarsdale resident, has been one of America’s leading authorities on high blood pressure. Honored twice by the National Institutes of Health—for his research and treatment breakthroughs and for his role in developing innovative blood-pressure management programs—he’s universally revered by his peers. “Hypertension education is so important, and Dr. Moser has been great in spreading the word,” says Sleepy Hollow cardiologist Dr. Franklin Zimmerman.

Dr. Moser began his work in the late 1940s, when treatments were primitive. “We treated high blood pressure with rigid salt restrictions no one could follow, or extensive surgery to slow part of the nervous system,” he recalls. “Some people with severe hypertension would live just six months to a year without treatment, so drastic measures were justified.” In the ’50s, he helped research the first blood-pressure drugs, and has been involved in developing almost every new one since. He was also among the first doctors to realize that heart enlargement, a common consequence of hypertension, could be reversed if properly treated.

Currently he’s a clinical professor of medicine at Yale University School of Medicine and editor-in-chief of the Journal of Clinical Hypertension. He continues his outreach efforts as president of the Hypertension Education Foundation, Inc. (hypertensionfoundation.org), a nonprofit that increases awareness of hypertension and its treatment.

Deborah Swaney is an award-winning health writer and mother of two who resides in Scarsdale. When her four-year-old daughter overheard her interviews for this story, she sadly announced that her teddy bear has hypertension. “Fortunately, the treatment for teddy bears proved to be fairly simple,” Swaney says. “It required a fake shot in the bear’s arm, and a bowl of strawberry ice cream for his owner.”


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