Contents
Hypertension Diabetes and Hypertension –A Special Problem What Is Hypertension? What Is Normal Blood Pressure? What Causes Hypertension? How Do You Find Out if You Need Treatment for High Blood Pressure? What Can You Do to Reduce the Risk of a Heart Attack or Stroke? Hypertension and Other Risk Factors for Heart Disease Diabetes: A Major Risk Factor for Heart Disease Summary Facts to Remember About High Blood Pressure and Diabetes Final Advice for People With High Blood Pressure and Diabetes Glossary 1 1 2 7 8 9 13 17 27 34 35 37 38
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High Blood Pressure and Diabetes–Control Them and Live Longer
Hypertension
Hypertension, or high blood pressure, affects about 50 million Americans and more than 600 million people worldwide It is the most common reason that adult Americans visit doctors More than 50 of all people over the age of 60 have it Unlike many conditions, such as bursitis, other painful conditions, or an infection with a high fever, high blood pressure causes few symptoms This fact may explain why many people with high blood pressure are unaware of it or, if they
have it, are not actively seeking medical care
Diabetes and Hypertension– A Special Problem
Many people with high blood pressure also have diabetes Approximately 1520 million Americans and about 200 million people worldwide have diabetes They have lost their ability to burn up sugar that is taken in the diet and turned into fuel for energy Blood sugar glucose builds up in the blood stream rather than being used or stored in the muscles and liver Some of this spills
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High Blood Pressure and Diabetes–Control Them and Live Longer
over into the urine and is wasted and not converted to energy When glucose levels are high in the blood stream or sugar is washed out in the urine, the patient is considered to have diabetes Diabetes increases the risk of heart, kidney, and brain disease If someone has hypertension and diabetes, his/her risk is greatly increased Hypertension is just a medical term for elevated or high blood pressure Hypertension does not mean that a person is overly tense or nervous An elevated blood pressure increases the risk of strokes, heart failure, kidney failure, and heart attacks; if it is treated and controlled, complications that used to occur frequently can
be prevented in a majority of cases Unfortunately, in the United States only about one third of all people with elevated blood pressure are treated effectively In many parts of the world fewer than 1015 are under treatment This is a major reason why people should become educated about this disease, what it can do, and how it can be treated What Used to Happen to People With High Blood Pressure? At the age of 57, Franklin Delano Roosevelt FDR, the 32nd President of the United States, was found to have an elevated blood pressure of 170/90 mm Hg A normal pressure varies between 120130/75 80 mm Hg He had no symptoms of heart disease or blood vessel damage Over the next few years, a slow rise in blood pressure occurred with levels in 1941 and 1942 of 180190/105 mm Hg In 1943 and 1944, his blood pressure rose to levels above 200/110 mm Hg He felt short of breath and had other symptoms of heart failure His heart
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What Is Hypertension?
High Blood Pressure and Diabetes–Control Them and Live Longer
had enlarged, there was evidence that his kidneys were no longer working properly and he possibly had had small strokes The President died of a massive brain hemorrhage stroke on April 12,
1945, at the young age of 63 years Other US presidents, Woodrow Wilson and Warren Harding, and numerous world leaders also have had severe hypertension and its complications FDRs treatment was to rest as much as possible, a low-fat, low-salt diet, and mild sedatives In the 1930s and 1940s, there were no effective and safe treatments available Since that time, many medications have been introduced and have been used successfully to prevent problems Had the President lived 1520 years later, he most certainly would have lived longer His story would have ended differently What Is Blood Pressure and What Is a Normal Blood Pressure? Blood pressure is the force exerted by the blood stream against the walls of arteries that carry blood to various parts of the body Everyone has to have some pressure in their blood vessels to get blood to vital organs and muscles Normally, each time our heart beats about 6080 times a minute at rest it pushes blood out into the larger arteries, which carry blood from the heart Blood then flows into smaller arteries or arterioles to various parts of the body, such as the liver, kidney, or brain These can open wide dilate or close constrict If they are open,
blood pressure remains low; if they constrict, it gets high Blood then returns to the heart through the veins see diagram The beating action of the heart may be compared to a faucet that is intermittently opened
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High Blood Pressure and Diabetes–Control Them and Live Longer
and closed The arteries may be compared to the tubing of a hose The small blood vessels or the arterioles act like a nozzle If the nozzle is kept open, water flows freely through the hose, and not too much pressure is built up on the walls of the hose If, however, the nozzle is almost closed and the faucet remains open, increased pressure is built up on the sides of the hose In the same way, if the arterioles or small blood vessels remain open as the heart beats, blood pressure in the arteries remains fairly low or normal If they narrow or constrict, higher blood pressure results Of course, the circulation in our bodies is a closed system,
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High Blood Pressure and Diabetes–Control Them and Live Longer
and blood is not leaking out anywhere but is being pushed through in surges every time the heart muscle contracts or pumps Blood pressure varies widely When you exercise or are excited or nervous, it can
rise; during sleep, it is lower It may vary during the course of the day by as many as 2030 points How Is It Measured? The amount of pressure in the arteries is measured by the level of air or mercury in a tube This is a part of a blood pressure instrument called a sphygmomanometer sfig-mo-mah-nom-eter Blood pressure should be taken when you are relaxed with your arm at the level of your mid chest area A cuff is placed around the upper arm and inflated with air until the circulation in the artery is temporarily cut off A valve in this instrument is opened and air is gradually released from the cuff The person who is measuring the blood pressure places a stethoscope over the artery on the inner side of the elbow to listen for the first sound of blood rushing through the artery as the pressure in the cuff is lowered The number on the gauge at the moment that this occurs represents the pumping or systolic sis-tal-ik pressure This is the pressure produced in the artery when the blood is pumped from the heart into the large blood vessels Additional air is gradually released from the cuff When all beating sounds stop, the number on the pressure gauge represents the resting or diastolic
di-ah-stal-ik pressure This is the pressure that remains in the arteries when the heart is relaxing between beats Thus, blood pressure is recorded in two numbers as millimeters of mercury mm Hg For example:
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High Blood Pressure and Diabetes–Control Them and Live Longer
120 mm Hg systolic pumping pressure 80 mm Hg diastolic resting pressure
The measurement above would be spoken of as 120 over 80, with the systolic higher number always given first, followed by the diastolic number Many blood pressure cuffs that employ electronic devices or digitalreadout technology do not require the use of a stethoscope to listen for sounds Blood pressure is taken automatically and displayed on a small screen or signaled by a beeping sound These machines are easy to use and are generally accurate
Blood Pressure Levels for Adults
Hypertension
140 90
High Normal or Prehypertension
120140 8090
Ideal or Normal Blood Pressure
110120 7580
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What Is Normal Blood Pressure?
Normal blood pressure may be as low as 70/50 mm Hg in infants or as high as about 130/80 mm Hg in adults Normal pressure for people under 18 is usually below
120/80 mm Hg Over the age of 18 a reading of up to about 130/80 mm Hg is considered within the normal range A diastolic lower number reading between 8590 mm Hg and a systolic upper number reading of 135139 mm Hg is considered high-normal or prehypertension If an adults blood pressure is consistently 140/90 mm Hg or higher, he or she has high blood pressure or hypertension As blood pressure rises above 135140/8590 mm Hg, the risk of heart, kidney, and blood vessel disease increases regardless of age Some physicians used to believe that a normal systolic blood pressure was 100 mm Hg plus age, ie, a 70-year-old person was once considered normal with a systolic blood pressure of 170 mm Hg However, abundant data now show that blood pressures above 140 mm Hg at any age should not be ignored and should be treated Which Reading Is More Important, the Upper Reading Systolic or the Lower Reading Diastolic? Recent studies have shown that the upper reading systolic is more accurate in determining the risk of high blood pressure than the lower reading diastolic It is, therefore, most important to keep the systolic pressure below 140 mm Hg Many older people just have an elevation of the upper
reading 170/80 for example This is called isolated systolic hypertension Lowering these levels has been shown to reduce cardiovascular events, such as strokes and heart failure, even in people over the age of 80
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White Coat Hypertension–Im Just Nervous There are many people whose blood pressure is elevated in a doctors office and normal when taken at home–so-called white coat hypertension Some physicians believe that whitecoat hypertension is nothing to be concerned about Yet, studies have shown that individuals with these kinds of blood pressures already have some changes in their blood vessels They should not be ignored It does not mean that they should immediately be put on medication but it does mean they should be followed and treated with medication if non-drug treatment does not lower blood pressure to normal levels in and out of a doctors office In more than 90 of cases a specific cause is not found However, despite the fact that we cannot pinpoint the exact cause of high blood pressure in most people, we can treat it effectively and prevent progression to more severe disease, heart attacks, strokes, and
heart and kidney failure We do know some of the causes A few patients have abnormalities of the adrenal glands, the glands that sit on top of the kidneys; others have a narrowing of the arteries to the kidneys; there are a very few women whose blood pressure is elevated by birth control pills Role of Heredity and Environment Heredity Plays a Role in Hypertension Persons with one parent with high blood pressure have an increased risk of having hypertension; persons with two parents with hypertension stand a greater chance of having it This does not mean, however, that all children with parents who are hypertensive will develop an elevated blood pressure It suggests that they are more likely to become hypertensive
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What Causes Hypertension?
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and that certain measures should be taken at an early age to prevent this if possible Most importantly, weight should be kept as close to normal as possible and a low-salt diet and exercise should be encouraged Environmental Factors Play a Role Although many people can eat lots of salt without worrying about changes in blood pressure, there are salt-sensitive people whose blood
pressures go up with an increase in salt intake The average intake of salt in the United States is about two teaspoonfuls 1012 g/day although in some parts of the United States, the Caribbean, and Europe it is considerably higher Sodium, which makes up about 40 of salt, is the part of salt that is important We only need less than one half a teaspoonful/day of salt 2 g and less than 1 g or 1000 mg/day of sodium regardless of our occupation or daily activities Nothing is to be lost by getting used to a low-salt diet whether or not you have a family history of hypertension Salt is an acquired taste–if you dont get used to salty foods, you can get along without them, and if you have hypertension, being on a low-salt diet may help to lower your blood pressure A list of foods to be avoided or eaten sparingly is noted in Table I Once you have high blood pressure reducing the amount of salt or sodium that you take in may be helpful but it may not be effective in lowering your blood pressure to acceptable goal levels of below 140/90 mm Hg
How Do You Find Out if You Need Treatment for High Blood Pressure?
Measuring blood pressure involves a simple test Blood pressure should be taken
when
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High Blood Pressure and Diabetes–Control Them and Live Longer
TABLE I
Some Foods With a High Salt or Sodium Content These should be limited or avoided if you have high blood pressure
Fast Foods Potato chips Pretzels Salted crackers Biscuits Pancakes Most commercial pastries cakes Pickles Sauerkraut Soy sauce Ketchup Olives Commercially prepared soups Bouillon Ham Sausages Frankfurters Smoked meats or fish Sardines Tomato juice Many canned vegetables Many kinds of cheese
NOTE: LOOK AT LABELS
Avoid or limit foods with more than 150 mg sodium in each serving
you are sitting quietly with your arm at mid chest level It should be taken several times at each sitting A careful medical history is taken to determine whether or not there are any clues to a specific cause of the disease A urine or blood test will rule out the presence of significant kidney disease as a cause of high blood pressure A blood test for a mineral called potassium may help to rule out the presence of too much of a certain hormone
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from the adrenal gland Expensive, complicated, or painful tests are not necessary and one or two visits to a
doctors office or clinic will complete the work-up It is rarely necessary to be hospitalized for studies for high blood pressure What Does High Blood Pressure Do If Left Untreated? The Heart Just as a persons biceps or arm muscles get bigger after weight lifting over a period of time, the heart muscle enlarges if it has to work harder than usual to push blood into vital organs of the body This does not happen overnight The heart may become enlarged over time but function normally for many years However, if high blood pressure remains untreated, the heart muscle eventually may not be powerful enough to push blood forward into the body Blood is backed up into the lungs Heart failure occurs Just as pressure in a hose can be reduced by opening up the nozzle and letting water flow freely through it, a persons blood pressure can be lowered by dilating or opening up the small blood vessels between the arteries and veins If this is done, the heart doesnt have to pump as hard each time it beats After treatment has lowered blood pressure and it has remained controlled for several months to a year, there is a good possibility the heart will return to its normal size Heart failure is rare in
people whose blood pressure is controlled The Brain Uncontrolled elevated blood pressure can cause a stroke If blood pressure remains high, damage occurs to the lining of blood vessels in the brain and little blisters may form These may rupture with hemorrhaging or bleeding into the brain causing weakness on one side of the body or loss of speech Strokes can also be caused by narrowing or closure of
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some of the vessels in the brain Hypertension and diabetes speed up this process Lowering elevated blood pressure and controlling blood sugar levels prevent strokes The Kidney The kidney may fail to function if high blood pressure is left untreated This is especially true if diabetes is also present Over time, damage occurs to the small arteries in the kidney The kidney is then unable to wash out waste products; these build up in the body Certain chemical changes, which become life threatening, may occur Dialysis or transplantation of the kidney may become necessary Early treatment of hypertension and effective management of diabetes may prevent this serious complication Hardening of the Arteries More rapid progression
of hardening of the arteries or atherosclerosis like rust on the inside of a pipe is definitely noted in patients with elevated blood pressure–and even more commonly
Summary
High Blood Pressure may cause: The heart to enlarge Little blisters aneurysms in the blood vessels in the brain Progressive narrowing of kidney blood vessels Increased rate of hardening of the arteries all over the body especially in the heart, brain, and kidneys Many of these effects can be prevented by treatment
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in people with diabetes and hypertension If one of the coronary arteries that supply blood to the heart muscle develops a plaque and becomes plugged with fatty material, the blood supply to a portion of the heart is cut off A heart attack occurs Many heart attacks can be prevented by treatment of hypertension
Lower Blood Pressure–Keep Your Weight Down Lose weight if you are heavy and maintain normal weight as long as you can The heavier you are the greater your chance of developing diabetes, having an elevated fat cholesterol level in your blood stream, and developing high blood pressure These all contribute to increasing
your risk for heart attacks or strokes Losing weight, if appropriate, is probably the single most important non-drug treatment for high blood pressure There is no easy way to lose weight Recent publicity regarding the benefits of a high fat, high protein, or low carbohydrate diets have served to confuse; weight reduction results from taking in fewer calories than you burn up A balanced diet still is the healthiest diet Increasing activity or reducing caloric intake are the two ways to lose weight There is nothing magic about this Most people are unaware of what their ideal weight should be, how many calories they require to maintain weight and how many calories are necessary to lose weight Simple formulas help to determine this see pages 14, 15 Reducing your salt or sodium intake is also important Here are some clues to help you reduce your salt intake
What Can You Do to Reduce the Risk of a Heart Attack or Stroke?
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Cut down on the amount of salt used at the table Reduce salt used in cooking a little bit each day until you no longer use any Read food labels to find the amount of sodium in foods Avoid or limit
foods with more than 150 mg in each serving Choose foods that do not list salt as one of the first three ingredients Look for foods with the words sodium free, low sodium, very low sodium, or unsalted on the label Use fresh or frozen fruits and vegetables whenever possible Many contain large amounts of potassium, a mineral that may
How to Measure Ideal or Desirable Weight in Adults
106 lb for the 1st 5 feet 6 lb for each additional inch 100 lb for the 1st 5 feet 5 lb for each additional inch A 5 foot 10 inch man should ideally weigh 166 lb 106 10 6 60 A woman who is 5 feet 5 inches should ideally weigh 125 lb 100 5 5 25 These weights are approximate A variation of 510 lb is acceptable
Men
Women
Example:
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be beneficial to some people with high blood pressure Limit intake of smoked, cured, or processed meats Use fewer sauces, mixes, and instant products Use mostly low-salt ingredients in recipes Rinse canned foods to remove some of the salt If you crave the taste of salt, try one of the
How to Estimate the Number of Daily Calories You Need to Maintain Your Weight
If you are sedentary
Ideal weight
13 Ideal weight 15 Ideal weight 17
If you are moderately active If you are very active Example:
Wt 166 510 man 15 moderately active 2490 calories/day Wt 125 55 woman 13 sedentary 1625 calories/day
These are approximate numbers
Remember, if you take in 500 calories/day less than you need, or take in 300 fewer calories and burn up 200 calories with exercise you will lose 1 lb/wk People over 60 years of age require fewer calories to maintain body weight
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High Blood Pressure and Diabetes–Control Them and Live Longer
lower salt substitutes, especially ones with added potassium Unfortunately, more than 50 of the salt we eat comes from processed food It is difficult to limit sodium intake if eating in a restaurant or eating a lot of processed foods is part of your lifestyle Remember, if you are being treated for heart failure, try to keep your sodium intake considerably below 2000 mg 2 g per day Blood pressure responses to limiting sodium intake vary In some salt-sensitive people, pressures will decrease; in those who are not salt sensitive they may not change There is no certain way to prove whether or not you are salt sensitive But, in general there is no down side or
harm in limiting salt intake Smoking Is a Major Risk Factor for Heart Disease Obviously if you smoke, you should stop and if you do not smoke, dont start It is interesting to note that the risk of a heart attack in a person who once smoked but has stopped is almost the same as a person who has never smoked Exercise Exercise is one of the more important things that you can do to maintain your weight, keep your blood fat or cholesterol level as close to normal as possible, and perhaps lower your blood pressure Exercise need not include jogging or running or going to a health club and doing high impact aerobics It has been shown that moderate exercise, for example, walking briskly 3040 minutes 34 times a week, is adequate to reduce your cardiovascular risk Tension and Anxiety Although reducing tension or anxiety may make you feel better,
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there is little evidence that depending on relaxation techniques, vacations, or getting away from it all will lower your blood pressure over time Alcohol Numerous studies have shown that having one or two drinks a day will not only not increase your risk of heart attack or stroke, but
may actually decrease it However, people who drink more than four or five drinks a day are at increased risk for cardiovascular disease You should set a limit of one to two glasses of beer, two glasses of wine or about one or one and a half drinks of 80 proof whiskey or scotch, etc per day Remember, if you have a family history of alcoholism or sensitivity to alcohol, you should not drink at all All of these lifestyle modifications may help but medication is necessary if blood pressure remains higher than 140/90 mm Hg Cutting out smoking, losing weight, exercising, relaxing more, and most especially reducing salt and fatty intake are all good for you but they dont work in a majority of patients
People with high blood pressure often are overweight and have other risk factors for heart disease, such as elevated cholesterol levels in the blood or a high blood sugar level that may indicate diabetes It is important to also correct these factors in addition to treating the blood pressure Regulating fat intake and cholesterol levels should, therefore, be an important part of a treatment program in people with hypertension A great deal of meat and dairy products are still consumed in the
United States although the amount is considerably less than
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Hypertension and Other Risk Factors for Heart Disease
High Blood Pressure and Diabetes–Control Them and Live Longer
1015 years ago People in Eastern Europe, where heart disease risk is even greater than in the United States, eat a great deal of fatty foods Animal fats tend to raise blood cholesterol levels and, as noted, together with high blood pressure, greatly increase the chance for a heart attack Keeping cholesterol at desired levels may not be possible with a diet alone, but certain dietary adjustments may be helpful Avoiding fatty foods, such as processed pork and bacon, using 1 or skim milk instead of whole milk, and reducing the amount of cheese, butter and eggs, will help but may not be successful in keeping cholesterol levels within a normal range in a majority of patients Most people with elevated cholesterol levels will need medication to reduce these and the harmful low-density lipoproteins LDLs to desirable levels There are many medications available to do this but the most effective and best tolerated are medications called statins Examples of these are Crestor, Lipitor, Pravachol, and Zocor Studies
have demonstrated that correcting high levels of cholesterol and LDL will reduce cardiovascular events, especially in patients at high risk, ie, those with heart disease Other medications, such as nicotinic acid, are effective but may not be as well tolerated The fibric acid derivatives Lopid or Tricor are also effective in raising the good cholesterol highdensity lipoprotein [HDL] Controlling blood fat levels is especially important in people with high blood pressure and diabetes Many hypertensive patients, especially diabetics, will need both antihypertensive and
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lipid-lowering treatment In addition, once blood pressure is controlled, a baby aspirin 81 mg should be taken once daily to possibly prevent a heart attack
Facts About Cholesterol
Cholesterol–a fatty substance necessary for production of hormones, healthy cell growth, etc Elevated levels in the blood increase risk of heart disease High blood pressure plus elevated cholesterol greater risk
In people without heart disease: Normal up to about 240 mg/dL Elevated above 240 mg/dL In people with heart disease or diabetes a desirable level is below 200
mg/dL
Components of total cholesterol
LDL low-density lipoproteins– so-called bad cholesterol
In healthy people–should be below 160 In people with high blood pressure–should be below 130 In people with heart disease or diabetes–should be below 100
HDL high-density lipoproteins– the good cholesterol Normal range–above 4550 If this level is higher than 60 as it is in many younger women, risk of a heart attack is actually reduced
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How Long Do You Try Non-Drug Treatment For Your High Blood Pressure? This depends on how many other risk factors are present If you are a 45-year-old woman, for example, with blood pressures of 145/9095 mm Hg, you need treatment; but if you have no other risk factors, ie, your cholesterol is below 240, you are a nonsmoker, you are thin, exercise regularly, and dont have diabetes, you might be tried on non-drug treatment for as long as 36 months On the other hand, if you are a 45-year-old man with the same blood pressure, but also have diabetes, you should be started with medication as well as non-drug treatment at the same time One of the mistakes in treatment is to depend
totally and for too long a period of time on lifestyle changes to control blood pressure If, after a reasonable period of time that depends on how many other risk factors you have, your pressure is not below 140/90 mm Hg, your physician will probably decide to give you medication Dont feel that you have failed if you end up taking medication Remember, studies have demonstrated that the reduction of blood pressure will prevent progression from less severe to more severe high blood pressure, will prevent enlargement of the heart and heart failure, and will dramatically reduce strokes, stroke deaths, heart attack deaths, and kidney failure Benefit has been noted in both young and old persons, even those over 80 years of age Getting blood pressure down to below 140/90 mm Hg if at all possible is a good idea for all ages–and worth the effort Medications For High Blood Pressure There are many types of blood pressure-lowering
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drugs available and your doctor should be able to find one or a combination of several that will work in your case Alt 
hough blood pressure may not be reduced to below 140 in everyone, about 80 of
people can have their pressure reduced to normal and maintained at those levels Some medications include: Diuretics wash out extra salt or sodium from the body and from blood vessel walls and allow the blood vessels to dilate, thereby reducing blood pressure They are highly effective and well tolerated Most people are able to continue their use for many years When diuretics are used and blood pressure lowered, data show a reduction in heart attacks, strokes, heart failure, etc Some commonly used diuretics include hydrochlorothiazide and chlorthalidone A diuretic should be the first drug of choice in most patients, or if another medicine is used first and blood pressure is not controlled, a diuretic should be added A diuretic is often combined with another medication to prevent the loss of potassium, an important mineral Examples of these combinations include Dyazide or Moduretic Beta-Blockers have also been in use for many years These drugs reduce the effect of adrenalin in various parts of the body, slow down the heart rate, and reduce its force every time it contracts This reduces the work of the heart and lowers blood pressure In addition, these drugs reduce the production of a
substance called renin This enzyme is involved in a series of reactions that result in the production of a chemical angiotensin II that narrows blood vessels and elevates blood pressure Blocking the production of renin is an effective way to lower blood pres21
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sure Commonly used beta-blockers include Tenormin and Toprol XL ACE Inhibitors are a class of drugs that is widely used These medications prevent the production of the chemical angiotensin II that causes blood vessels to constrict Vessels open up and blood pressures are lowered These drugs are especially effective in people with heart failure when used along with a diuretic, and in most cases, digitalis They are also especially effective in patients with diabetes, kidney disease, and hypertension Commonly used ACE inhibitors include Accupril, Altace, Monopril, Vasotec, and Zestril These are most effective when given with a diuretic Angiotensin II Receptor Blockers ARBs, medications related to ACE inhibitors, act on the same chemicals as the ACE inhibitors but at a different location Blood pressure is reduced These agents are also highly effective in patients
with diabetes and kidney disease Commonly used ARBs include Atacand, Avapro, Cozaar, and Diovan There are numerous combinations of medications available that contain a diuretic, ie, beta-blockers and diuretics, ACE inhibitors and diuretics, and ARBs and diuretics In the majority of cases, especially in diabetics or people with kidney disease, more than one medication will be necessary to control blood pressure at goal levels The available combinations are highly effective in approximately 7075 of patients Commonly used combinations that include a diuretic are Tenoretic, Ziac, Vasoretic, Zestoretic, Hyzaar, Avalide, Benicar HCT, Diovan HCT, and Atacand HCT
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Calcium Channel Blockers CCBs have been in use for more than 20 years They act by preventing calcium from entering blood vessel walls or heart muscle There are different types of CCBs Some, like Norvasc and DynaCirc, primarily act to dilate blood vessels Some, like Cardizem CD or Calan SR, may dilate blood vessels but also slow down the heart rate CCBs are available in combination with other medications such as the ACE inhibitors Examples include Lexxel, Lotrel,
and Tarka Alpha-Blockers, which also act as vasodilators, are also available These are generally not used as initial treatment but are effective in patients with prostate disease A patient with hypertension and prostate disease might be put on one of these drugs in addition to other medications Examples of alpha-blockers are Cardura and Hytrin There are many other medications available but the classes of drugs listed in Table II are used in the majority of patients Only about 4050 of people will have their blood pressure decreased to normal levels with any one of the medications when given alone regardless of the drug chosen for initial therapy It may be a nuisance and expensive to be on two or three different pills at one time, but it is well worth it if your blood pressure is brought down to normal and future illnesses and disability are prevented Taking one pill containing two different medications may help to simplify treatment It is important to emphasize that diabetic patients and people with kidney disease most often require multiple medications to reduce their pressures to normal levels
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TABLE II
Some
Commonly Used Antihypertensive Drugs
Diuretics: ACE Inhibitors: Hydrochlorothiazide Accupril Altace Monopril Vasotec Zestril Cardura Hytrin Prazosin Atacand Avapro Benicar Cozaar Diovan Micardis InnoPranTM XL Tenormin Toprol XL Atacand HCT Avalide Diovan HCT Hyzaar Micardis HCT Teveten HCT Vaseretic Ziac Calan SR Cardizem LA DynaCirc CR Procardia-XL Norvasc
Alpha-Blockers:
ARBs:
Beta-Blockers:
Combinations With Diuretics:
Calcium Channel Blockers:
Combinations of ACE inhibitors and calcium channel blockers: Lexxel, Lotrel, Tarka
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Possible Side Effects From Medications That Lower Blood Pressure Side effects may occur when any drug is taken In some instances, even simple aspirin may cause stomach trouble Some people are allergic to drugs like penicillin, and the same is true for medications that lower blood pressure For example, a few people taking diuretics may experience weakness and muscle cramps because, in addition to salt sodium, another important mineral, potassium, may be washed out of the body This is not common when low doses are used Some combination medications, like Dyazide or Maxzide, prevent this
from happening A chronic cough may result from an ACE inhibitor Most people taking medication for high blood pressure do not experience side reactions In fact, recent studies indicate that many people feel better on medication because their blood pressures are lower If you have high blood pressure, are on medication, and experience a symptom that bothers you, do not stop medication; this could lead to trouble Instead, call your doctor to see what can be done about it, or ask if the dosage of the drug should be reduced or the prescription changed to another drug Your physician knows about possible medication effects He or she should be able to correct them in most instances Often, a pharmacist or other health care professional will be able to help you get over the rough spots and stay on therapy In some cases, after blood pressure has been normal for a year or more, it may be possible to reduce medication, or, in rare cases especially if a weight loss of more than 1015 pounds has occurred, to eliminate it
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completely Careful follow-up is important in these instances Treatment or Cure? Modern drug treatment does not
cure hypertension It keeps blood pressure at normal levels, but usually only as long as medication is continued If treatment is stopped, blood pressure usually goes back to where it was before, although in some instances this may not happen for several to as long as 69 months If doctors do not explain this or patients fail to realize how important it is to continue treatment, complications may occur
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There are two types of diabetes, commonly referred to as type 1 or type 2 Type 1 diabetes occurs mostly in younger people In these cases, the pancreas, an organ near the intestinal tract and liver, which normally secretes a hormone called insulin, isnt working properly Without adequate insulin the carbohydrates and other foods that we take into our body are not processed appropriately Insulin is necessary to help store glucose sugar in the body cells providing them with energy It is also involved in the storage of reserve supplies of glucose in the muscles and liver Type 2 diabetes is common in patients with high blood pressure and usually occurs in adults This accounts for more than 90 of all cases The incidence of
type 2 diabetes is increasing rapidly worldwide with extremely high rates in Southeast Asia and Eastern Europe As more people become obese, diabetes becomes more common In people with type 2 diabetes, the pancreas may have secreted adequate amounts of insulin through the years but for some reason the body is resistant to the usual amounts; more insulin is required to break down carbohydrates that we take in our diet These patients have insulin resistance, a common finding in patients with high
Diabetes: A Major Risk Factor for Heart Disease
Diabetes
Too much sugar in the blood Less sugar stored in muscles and tissues High sugar levels may cause damage to the eyes, kidneys, nerves, or blood vessels
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blood pressure Over the years the pancreas must work harder to produce more insulin to metabolize the sugar taken in Eventually, the pancreas becomes exhausted and blood sugar levels rise When someone has diabetes and hypertension together, they are at greater risk for a heart attack, stroke, and kidney failure than with either disease alone In addition, many people with diabetes and hypertension also have abnormal
amounts of fatty material in their blood stream Many of the changes in lifestyle that are recommended for people with hypertension are also appropriate in diabetics How to Diagnose Diabetes is diagnosed by a test that measures the amount of blood sugar or glucose in the blood If a fasting blood sugar of more than 126 mg/dL is recorded on at least two occasions, the diagnosis is justified The diagnosis is also justified if the level is above 200 mg/dL in a specimen taken after meals Blood sugars are routinely determined when a doctor takes a screening blood chemistry in hypertensive patients What to Do About Diabetes and High Blood Pressure? A person with diabetes can be considered to be at almost as great a risk for vascular disease as a person with a previous coronary event, angina pectoris, or other symptoms of heart disease Anyone with hypertension who also has diabetes must be treated vigorously Medical therapy to lower blood pressure should be started at the same time as lifestyle interventions, without a 23 month trial period, and blood pressure should be lowered if at all possible to levels lower than in the general public In other
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High Blood Pressure and
Diabetes–Control Them and Live Longer
words, elevated blood pressure should be lowered to below 130/8085 mm Hg Treatment of hypertension in diabetics will markedly reduce strokes, heart attacks, heart failure, and kidney failure The drugs of choice in the treatment of diabetic hypertensives probably are the ACE inhibitors or the angiotensin II receptor blockers Almost all of the time these agents should be used with a diuretic to reduce blood pressures to goal levels These combinations have been shown to prevent many of the complications that used to occur in untreated diabetics In diabetic hypertensives there are multiple abnormalities of metabolism The use of these medications, by virtue of their effects on one of the enzyme-hormone systems in the body, may be able to correct many of these Some of the other antihypertensive drugs, such as beta-blockers, have also been shown to reduce complications when used along with diuretics Complications in diabetics are similar to those noted in nondiabetic hypertensives–heart attacks, strokes, and kidney failure However, kidney failure is more common and occurs
Things to Do if You Have Diabetes
Keep weight as close to normal as
possible Exercise regularly Keep the sugar content in the blood as close to normal as possible Monitor blood pressure and cholesterol levels and reduce them if they are high
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High Blood Pressure and Diabetes–Control Them and Live Longer
TABLE III
A Reasonable Diet for a Diabetic Patient
About 5055 as carbohydrates cereals, fresh fruits, vegetables–not refined sugar or sweets
2000 calories would include about 1000 cal/day or 250 g a day of carbohydrates About 1520 as protein 400 cal/day or 100 g/day About 2025 of fat 400500 cal/day or approximately 50g/day ie, low-fat dairy products; limited intake of fatty meats, bacon, etc
Example:
1 g of carbohydrates 4 calories; 1 g of fat 9 calories
Read food labels
The aim of a diabetic diet is to decrease the need for insulin and to allow the available insulin to work better
more readily in diabetic hypertensives than in people with high blood pressure and normal blood glucose levels In addition, diabetics are more susceptible to problems with blood vessels in the legs, and to changes in the eyes, which may lead to blindness These complications can also be reduced by lowering blood pressure and maintaining normal levels of
sugar in the blood What About Controlling Glucose Blood Sugar Levels? It has been shown that controlling levels of glucose in the blood is effective
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High Blood Pressure and Diabetes–Control Them and Live Longer
in improving the tone of the linings of blood vessels and, along with blood pressure control, will help to delay hardening of the arteries Numerous diets are available, which suggest a carbohydrate intake of approximately 50, a protein intake of about 2530, and a fat intake of about 2025 of total calories Table III Diet alone is not going to work in a majority of diabetic patients unless it is accompanied by weight loss Since many diabetics are obese, a weight reduction program may help to regulate blood sugar A majority of patients with diabetes will, in addition to their blood pressure-lowering drugs and medications used to control abnormal fats in the blood stream, require certain medications that will help control their diabetes Most patients with adult onset diabetes will not require insulin since they already have some insulin available but it is not being utilized properly Exercise To re-emphasize: Exercise should be part of any treatment program in diabetes as
well as in hypertension This need not be vigorous or involve jogging or running but
In Diabetes
If blood sugar is not maintained at levels below 125 mg/dL or HbA1C below 65, medication may be necessary There are many safe and effective medications available If blood pressure and cholesterol levels are not reduced to normal levels by lifestyle changes there are many safe and effective medications that will help
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High Blood Pressure and Diabetes–Control Them and Live Longer
should include walking, biking, swimming, etc Exercise helps burn up calories, may reduce blood pressure and the fat content in the blood, and may reduce the amount of medicine that has to be taken to control blood sugar
TABLE IV
Examples of Currently Available Oral Medications for Diabetes
Generic Name Trade Name Recommended Starting Dose mg
Chlorpropamide 250 qd Diabinese 100 qd Tolazamide Tolinase 250 bid Tolbutamide Orinase Glipizide extended release 5 qd Glucotrol XL Glyburide 255 qd DiaBeta, Micronase Repaglinide 05 bidqid with meals Prandin Rosiglitazone 4 qd Avandia Metformin 500 qd with dinner Glucophage Glyburide/metformin 125/250 qd with meals Glucovance Acarbose 25 tid with meals Precose
Miglitol 25 tid with meals Glyset
Not all medications are listed
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High Blood Pressure and Diabetes–Control Them and Live Longer
Antidiabetic Medications There are many different types of antidiabetic agents Examples of these are listed in Table IV Some of them, like repaglinide Prandin, tolbutamide Orinase, or chlorpropamide Diabinese increase insulin secretion These drugs may cause a decrease in blood sugar to low levels because of their effect on insulin Glipizide Glucotrol XL lowers glucose by decreasing the production of glucose in the liver and by enhancing insulin secretion Metformin Glucophage suppresses the production of glucose in the liver and increases the burning up of glucose in tissues This medication, as well as the others listed, such as glyburide, are useful in regulating blood sugar levels in obese patients with type 2 diabetes who are unresponsive to diet alone Other agents like Avandia may decrease insulin resistance Some of these medications may cause a weight gain or increase in water retention Finally, there are drugs like Precose which delay the absorption of carbohydrates and thereby limit the increase in blood glucose after meals All of these drugs
have certain side effects and dosage must be adjusted carefully It is occasionally necessary to use two of these medications together in order to control blood sugar levels If oral medication is not effective, insulin injections may have to be given There are several different types of insulin available with different durations of action Careful monitoring of blood sugar levels is necessary if insulin is used Physicians knowledgeable in the management of diabetes should be involved in the care of the diabetic patient, especially if insulin is being given What Does Treatment Accomplish? In the diabetic hypertensive patient, lowering of blood pressure and controlling blood sugar levels
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High Blood Pressure and Diabetes–Control Them and Live Longer
to below 120 mg/dL will decrease many of the complications that might have occurred This includes changes in the eyes and the kidneys It is important that patients with diabetes and high blood pressure be treated vigorously to prevent cardiovascular as well as kidney complications The lifespan of the diabetic patient with hypertension has been dramatically prolonged by these efforts
Summary
Hypertension and diabetes are major health
problems that result in much family tragedy, many thousands of lost workdays, and a great deal of human grief These might be prevented if more people watched their salt intake and their weight Modern treatment can save lives Adequate treatment of high blood pressure has reduced the incidence of strokes and stroke deaths as well as heart attacks It has dramatically decreased the occurrence of heart failure resulting from hypertension and has prevented many cases from progressing from less severe to severe hypertension or kidney failure Studies have established the benefits of treating high blood pressure even in people over 60 years of age even if just the upper reading systolic pressure is elevated, eg, a blood pressure of 160170/80 mm Hg A patient with diabetes is at high risk for a heart attack or stroke to begin with and at higher risk if he or she has hypertension Control of blood sugar, blood cholesterol, and blood pressure will prevent complications and prolong life It is important to keep fasting
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High Blood Pressure and Diabetes–Control Them and Live Longer
blood sugar levels close to or lower than 120 mg/dL and to reduce the HbA1c level, which is a measure of the
blood sugar levels over a several months period of time, to 65 or below HbA1c measures the amount of glucose that has attached itself to the hemoglobin component of red blood cells The level is not useful to make a day-to-day change in treatment since it reflects the average amount of glucose in the blood over a 23 month period of time
High blood pressure may not cause symptoms Usually the only way to find out if you have it is to have your blood pressure measured Tests to evaluate elevated blood pressure and diabetes are usually simple, and hospitalization is rarely necessary The outlook for people with high blood pressure and/or diabetes is excellent In most cases, their habits need not be changed a great deal They can look forward to a long life, free of many of the fears that used to accompany this diagnosis, as long as they continue treatment Being heavy or obese may go along with having high blood pressure and diabetes, but losing weight alone may not control blood pressure in many people Smoking is bad for you, and you should stop it or never start to prevent heart disease as well as lung damage If you are very anxious, relaxing or taking tranquilizers or sedatives
may help to lower blood pressure in some less severe cases, but these treatments will not work in the majority of patients
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Facts to Remember About High Blood Pressure and Diabetes
High Blood Pressure and Diabetes–Control Them and Live Longer
A low-salt diet may help to lower blood pressure in some people with less severe hypertension, but most people cannot stay on a rigid enough salt-restricted diet to lower blood pressure adequately without specific medication If modifying your eating habits and lifestyle do not lower your blood pressure or blood sugar levels, there are excellent medications available to control them in a large majority of patients Although side effects or annoying symptoms may occur with some of the blood pressure lowering drugs, these usually can be controlled or eliminated by changing dosages or switching to another medication Above all, remember that just being on treatment does not mean that your blood pressure or blood sugar levels are controlled If your blood pressure is not below 140/90 mm Hg, or your fasting blood sugar level is not below 120 mg/dL despite lifestyle changes and medication, ask your doctor why Some aspect of your treatment may
have to be changed
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High Blood Pressure and Diabetes–Control Them and Live Longer
Remember that controlling the upper blood pressure reading to below 140 mm Hg may be more important than controlling the lower reading Normal blood pressure cannot be achieved in everyone, but about 8085 of people with high blood pressure can be successfully treated regardless of the severity of their disease If you have diabetes or kidney disease, efforts should be made to get your pressure to about 130/8085 mm Hg
Final Advice for People With High Blood Pressure and Diabetes
1 It is up to you to have your blood pressure and blood sugar checked 2 If your blood pressure is elevated, it is the responsibility of your physician to prescribe the right combination of medications and other treatment to bring your blood pressure back to normal levels 3 If your blood sugar level is high or you have sugar in the urine, you should be following a specific diet, exercising regularly, and taking medication if necessary to reduce your blood sugar level to normal In the final analysis, it is up to both you and your doctor to recognize how important treatment is and to follow a program that keeps your blood
pressure and blood sugar levels under control
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High Blood Pressure and Diabetes–Control Them and Live Longer
Glossary
Aneurysms: Small blister-like expansions of blood vessels They represent weak spots in the artery They may rupture and cause bleeding or a hemorrhage Angiotensin-Converting Enzyme Inhibitors ACE Inhibitors: Medications that block the formation of a substance that constricts blood vessels Antidiabetic Medications: Drugs that help to regulate blood sugar levels Atherosclerosis: Hardening of the arteries Fatty material is deposited in the walls of arteries, which are thereby narrowed Angiotensin or A-II Receptor Blockers ARBs: Medications that block the effects of substances that cause blood vessels to narrow Blood Pressure: Pressure exerted against the walls of the arteries Systolic upper reading: pressure recorded at the time when the heart is pumping Diastolic lower reading: pressure recorded when the heart is resting, in between beats Normal Blood Pressure over age 18: up to 135/85 mm Hg A blood pressure reading of 135139/8589 mm Hg is considered high-normal Isolated Systolic Hypertension ISH: A systolic blood pressure above 140 mm Hg and a diastolic blood
pressure below 90 mm Hg
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High Blood Pressure and Diabetes–Control Them and Live Longer
indicates ISH common in persons 60 years of age or older Calcium Channel Blockers: Medications that interfere with the movement of calcium in and out of the blood vessel walls Dilation of blood vessels and a lowering of blood pressure result from their use Cardiovascular: Refers to heart and blood vessels, eg, diseases of the cardiovascular system Cholesterol: A fatty substance in our bodies that is necessary for producing certain hormones, etc It is found in many foods milk, eggs, and meat, etc Vegetables, grains, and fruits do not contain any cholesterol If too much cholesterol is present in the blood, the process of hardening of the arteries may be hastened Coronary: Refers to the heart, eg, coronary arteries are those arteries that supply blood to the heart muscle Diabetes: A disease in which blood sugar levels are high and where some sugar is spilled in the urine Untreated, it may lead to serious complications Diuretics: Medications that wash out salt sodium from the body and help to reduce elevated levels of blood pressure Hemoglobin A1c: A measure of the amount of glucose that has
attached itself to hemoglobin in red blood cells A good index of average blood sugar levels over the previous 23 months; not to be used for day-to-day regulation of blood sugar Hypertension: High blood pressure A consistent blood pressure recording of more than 140/90 mm Hg
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High Blood Pressure and Diabetes–Control Them and Live Longer
mm Hg: Millimeters of mercury The blood pressure numbers in this booklet refer to the height to which your blood pressure would push a column of mercury Potassium: A mineral in the cells of the body that may be washed out by diuretics, especially in high doses Can be found in foods such as bananas and orange juice Salt substitutes usually contain potassium Salt: Common table salt is sodium chloride Potassium chloride is a salt substitute Sodium: A component of salt about 40 of salt is sodium This is a mineral that may contribute to high blood pressure if taken in large amounts by certain people Sphygmomanometer: A device that measures blood pressure Statins: A class of medications that is highly effective in reducing elevated cholesterol and LDL cholesterol Stroke: Sudden loss of function of a part of the brain due to interference with its blood
supply May be caused by a clot thrombosis or rupture of a blood vessel hemorrhage Sympathetic Nerves: Nerves that, when stimulated, constrict or narrow blood vessels and cause blood pressure to rise Uremia: The result of kidney failure Waste products accumulate in the body when the kidney fails to excrete enough of them in the urine Vascular: Refers to blood vessels
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High Blood Pressure and Diabetes–Control Them and Live Longer
Questions for my Doctor:
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High Blood Pressure and Diabetes–Control Them and Live Longer
Notes:
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High Blood Pressure and Diabetes–Control Them and Live Longer
Notes:
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High Blood Pressure and Diabetes–Control Them and Live Longer
Notes:
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Marvin Moser, MD, is a Clinical Professor of Medicine at the Yale University School of Medicine and was Senior Medical Consultant to the National High Blood Pressure Education Program of the National Heart, Lung, and Blood Institute from 1974 to 2002 He was Chairman of the first Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and a participant in the six subsequent committees He is Emeritus Chief of the Cardiology Section at the White Plains,
NY, Hospital Medical Center, a Fellow of the Council for High Blood Pressure Research of the American Heart Association, and the author of eleven books, including Lower Your Blood Pressure and Live Longer, Week by Week to a Strong Heart, and Heart Healthy Cooking For All Seasons He was a Co-Editor and contributor to the Yale University School of Medicine Heart Book He has published more than 500 scientific papers in the field of hypertension and cardiology He is Editor in Chief of The Journal of Clinical Hypertension, President of the Hypertension Education Foundation, and has received numerous awards for research and treatment of high blood pressure, including the 2004 Clinical Award of the International Society of Hypertension He is an honorary fellow of the Royal College of Physicians and Surgeons
About the Author
45
HEF
Hypertension Education Foundation, Inc
Hypertension Education Foundation PO Box 651 Scarsdale, NY 10583 wwwhypertensionfoundationorg
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Source:ces.ncsu.edu
