WHAT CAN BE DONE TO RELIEVE HYPERTENSION?

What kinds of medicines lower high blood pressure?

Many medications known as antihypertensives are available to lower high blood pressure. Some, called diuretics, rid the body of excess fluids and salt (sodium). Others, called beta blockers, reduce the heart rate and the heart's output of blood.

Another class of antihypertensives is called sympathetic nerve inhibitors. Sympathetic nerves go from the brain to all parts of the body, including the arteries. They can cause the arteries to constrict or narrow, thereby raising blood pressure. This class of drugs reduces blood pressure by inhibiting these nerves from constricting blood vessels.

Yet another group of drugs is the vasodilators. These can cause the muscle in the walls of the blood vessels (especially the arteries) to relax, allowing the artery to dilate (widen).

Two other classes of drugs used to treat high blood pressure are the A.C.E. or angiotensin converting enzyme inhibitors and the calcium antagonists (calcium channel blockers). The A.C.E. inhibitors interfere with the body's production of angiotensin, a chemical that causes the arteries to constrict. The calcium antagonists can reduce the heart rate and relax blood vessels.

In most cases these drugs lower blood pressure, but quite often people respond very differently to these medications. Thus most patients must go through a trial period to find out which medications are most effective while causing the fewest side effects.

The most important points for people with high blood pressure to remember are:

Follow your doctor's instructions. Stay on your medication. Dietary and lifestyle changes also may help control high blood pressure. Some people with mild hypertension can lower their blood pressure by reducing sodium in their diet. Excessive alcohol intake (more than two ounces daily) raises blood pressure in some people and should be restricted. Blood pressure also returns to normal in many obese people when they lose weight. Increasing physical activity can reduce blood pressure in some people, too. Before drugs are prescribed, these methods to control blood pressure are often recommended for people with only mildly elevated blood pressure.

(Sources: American Heart Association)

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MEASURING BLOOD PRESSURE

The only way to find out if you have high blood pressure is to have your blood pressure checked. It is measured by a quick, painless test using a medical instrument called a sphygmomanometer.

The test measures systolic pressure (when the heart beats) and diastolic pressure (when the heart rests between beats). Blood pressure is measured in millimeters of mercury (mm Hg). A doctor or another qualified health professional should check a patient's blood pressure at least once every two years.

A rubber cuff is wrapped around a person's upper arm and inflated. When the cuff is inflated, it compresses a large artery in the arm, momentarily stopping the flow of blood.

Next, air in the cuff is released, and the person measuring the blood pressure listens with a stethoscope. When the blood starts to pulse through the artery, it makes a sound; sounds continue to be heard until pressure in the artery exceeds the pressure in the cuff. While the person listens and watches the sphygmomanometer gauge, he or she records two measurements. The systolic pressure is the pressure of the blood flow when the heart beats (the pressure when the first sound is heard). The diastolic pressure is the pressure between heartbeats (the pressure when the last sound is heard). Blood pressure is measured in millimeters of mercury, which is abbreviated mm Hg.

DISTINGUISHING BLOOD PRESSURE LEVELS

Blood pressure is measured in millimeters of mercury (mm Hg). The classifications in the following table are for persons who are not taking antihypertensive drugs and are not acutely ill. When systolic and diastolic pressures fall into different categories, the physician will select the higher category to classify the person’s blood pressure status. Diagnosis of high blood pressure is based on the average of two or more readings taken at each of two or more visits after an initial screening.

Classification of blood pressure for adults age 18 years and older, with recommended follow-up

Category	Systolic (mm Hg)		Diastolic (mm Hg)	Follow-up recommended
Optimal*	<120	and	<80	Recheck in 2 years
Normal	<>	and	<>	Recheck in 2 years
High normal	130 - 139	or	85-89	Recheck in 1 year
Hypertension STAGE 1(Mild)	140 - 159	or	90 - 99	Confirm within 2 months
STAGE 2 (Moderate)	160 - 179	or	100 - 109	Evaluate within 1 month
STAGE 3 (Severe)	>179	or	>109	Evaluate immediately or within 1 week depending on clinical situation

*Optimal blood pressure with respect to cardiovascular risk is <120/80>

(From the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure, NIH publication, 1997)

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FACTORS THAT CONTRIBUTE TO HIGH BLOOD PRESSURE

What factors increase the chance that a person will develop high blood pressure?

Heredity

Male sex

Age

Sodium (salt) sensitivity

Obesity

What other related factors contribute to high blood pressure?

Heavy alcohol consumption

Use of oral contraceptives and some other medications

Sedentary or inactive lifestyle

Because medical science doesn't understand the causes of most cases of high blood pressure, it's hard to say how to prevent it. Still, several factors may contribute to it. Being overweight or using excessive salt are two avoidable factors.

Age is one risk factor that can't be changed. Generally speaking, the older people get, the more likely they are to develop high blood pressure.

Heredity is another factor. People whose parents have high blood pressure are more likely to develop it than those whose parents don't.

The incidence of high blood pressure isn't directly related to a person's sex. However, doctors usually keep a close watch on a woman's blood pressure during pregnancy or if she's taking oral contraceptives. Some women who have never had high blood pressure develop it during pregnancy. Similarly, a woman taking oral contraceptives is more likely to develop high blood pressure if she's overweight, has had high blood pressure during pregnancy, has a family history of high blood pressure or has mild kidney disease.

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High Blood Pressure / Hypertension

(Source: American Heart Association)

* High blood pressure / hypertension was listed on death certificates as the cause of death of 38,130 Americans in 1994 and was listed as a contributing cause on more than 180,000 other death certificates of stroke, heart attack and heart failure victims.
* About 50 million Americans age 6 and older have high blood pressure.
* One in four American adults has high blood pressure.
* The cause of 90 -- 95 percent of cases of high blood pressure isn't known; however, high blood pressure is easily detected and usually controllable.
* People with lower educational and income levels tend to have higher levels of blood pressure.
* From 1984 to 1994, the death rate from high blood pressure declined 3.9 percent, but the actual number of deaths rose 21.7 percent.

Age, Sex

* Men are at greater risk for high blood pressure than women until age 55. From age 55 to 74 the risks for men and women are about equal; after that, women are at greater risk than men.
* High blood pressure is two to three times more common in women taking oral contraceptive pills for five years or longer than in women not taking oral contraceptives.
* 73 percent of Japanese-American men ages 71 -- 93 have high blood pressure according to the Honolulu Heart Study.

Disability/Discharge

* Surveys conducted in 1991 -- 92 showed an estimated 2.2 million Americans age 15 and older had disabilities resulting from high blood pressure.
* 151,000 males and 221,000 females diagnosed with high blood pressure were discharged from hospitals in 1994.

** Preliminary estimate from Phase I of the National Health and Nutrition Examination Survey III (NHANES III), 1988 -- 91.

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Coronary Disease Risk Factors

Cigarette/Tobacco Smoke

• In 1990 about 417,000 Americans died of smoking-related illnesses.
• Nearly one-fifth of deaths from cardiovascular diseases are attributable to smoking. It's also estimated that about 37,000 -- 40,000 nonsmokers die each year from cardiovascular diseases as a result of exposure to environmental tobacco smoke.
• Smoking-related illnesses cost about $50 billion annually in medical care.
• Studies show that among people age 18 and older in the United States, smoking has declined by about 40 percent since 1965, although recent data indicate that this downward trend may have leveled off.

Age, Sex

• Every day 3,000 American young people become smokers, according to estimates by the Centers for Disease Control and Prevention.
• 75 percent of adult smokers started before age 18 and 90 percent began before they were 21, according to Centers for Disease Control and Prevention estimates.
• 43 percent of American children ages two months to 11 years are exposed to environmental tobacco smoke in the home.
• Current estimates are that 26.0 million men (28.2 percent) and 23.1 million women (23.1 percent) in the U.S. are smokers, putting them at increased risk of heart attack. In addition, an estimated 2.2 million adolescents ages 12 -- 17 are smokers.
• The World Health Organization reports that 20 -- 35 percent of women in developed nations smoke compared with 2 -- 10 percent of those in the developing nations.
• Studies show that women smokers who use oral contraceptives are much more likely to have a heart attack and much more likely to have a stroke than women who neither smoke nor use birth control pills.
• Studies show that smoking prevalence is several times higher among those with less than 12 years of education compared to those with more than 16 years of education.
• 47.7 percent of working adults who are 17 years old or older and do not use tobacco reported exposure to environmental tobacco smoke at home or at work.
• Of adults who don't use tobacco, 37.4 percent reported exposure to environmental tobacco smoke at home or at work.
• The risk of death from coronary heart disease increases by up to 30 percent among those exposed to environmental tobacco smoke at home or at work.

Cholesterol

An estimated 97.2 million American adults (52.1 percent) have blood cholesterol levels of 200 milligrams per deciliter (mg/dL) and higher, and about 38.3 million American adults (20.5 percent) have levels of 240 mg/dL or above.*

• About 36.5 percent of American youth age 19 and under (27.4 million young people) have blood cholesterol levels of 170 mg/dL or higher. (This is comparable to a level of 200 mg/dL in adults.)
• 13.0 million boys and 14.4 million girls age 19 and under have blood cholesterol levels of 170 mg/dL or higher.
• Studies done on people age 20 and older show that women's cholesterol is higher than men's beginning at age 55.
• Before age 45, the range of means for total blood cholesterol of women is from 185 -- 207 mg/dL, but between ages 45 and 64, the range rises to between 217 and 237 mg/dL.
• Among elderly Japanese-American men in the Honolulu Heart Program Fourth Examination (1991 -- 93), 42 percent had cholesterol levels greater than or equal to 200 mg/dL or were taking cholesterol-lowering medication.

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*Centers for Disease Control and National Center for Health Statistics: Unpublished and published data from Phase I, National Health and Nutrition Examination Survey III (NHANES III), 1988 -- 91 and the American Heart Association.

Physical Inactivity

• About 22 percent of American adults report regular sustained physical activity of any intensity lasting 30 minutes or more five times a week.
• About 15 percent of U.S. adults engage in regular vigorous physical activity three times a week for at least 20 minutes.
• About 25 percent of Americans age 18 or older report no leisure-time physical activity.
• 1994 Behavioral Risk Factor Surveillance Survey (BRFSS) state data show that 60 percent or more of adults did not achieve the recommended amount of physical activity, and in half of the states 73 percent or more of adults were not active enough.
• People with lower incomes and less than a 12th grade education are more likely to be sedentary.
• The relative risk of coronary heart disease (heart attack) associated with physical inactivity ranges from 1.5 to 2.4, an increase in risk comparable with that observed for high cholesterol, high blood pressure or cigarette smoking.
• Less active, less fit persons have a 30 -- 50 percent greater risk of developing high blood pressure.
• As many as 250,000 deaths per year in the United States -- about 12 percent of total deaths -- are attributed to a lack of regular physical activity.

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Age, Sex

• Nearly half of American youth ages 12 -- 21 are not vigorously active on a regular basis. Physical activity declines dramatically during adolescence.
• Daily enrollment in Physical Education classes has declined among high school students from 42 percent in 1991 to 25 percent in 1995.
• Only 19 percent of all high school students are physically active for 20 minutes or more in physical education classes every day during the school week.
• A 1996 report of physical Activity showed the number of Americans age 18 and older who reported no physical activity was 15.8 percent of men and 27.1 percent of women.
• The percentage of adults ages 65 -- 74 and 75 and older who reported no leisure time physical activity in 1992 was 33.2 percent and 38.2 percent for men and 36.6 percent and 50.5 percent for women, respectively. In 1988 -- 91, it was 17.5 percent and 34.5 percent for men and 32.5 and 54.3 percent for women, respectively.

Overweight

Based upon 1988 -- 91 data, nearly 62 million American adults (28.1 million men and 33.9 million women) are 20 percent or more above their desirable weight, an increase of 36 percent over 1960 -- 62 examination data.

• 33 percent of overweight men and 41 percent of overweight women are not physically active during their leisure time.
• Data show the prevalence of overweight among American adolescents age 12 to 19 to be 21 percent (20 percent for males and 22 percent for females).
• Among native Hawaiians, 65.5 percent of males and 62.6 percent of females are overweight.

Diabetes Mellitus

Diabetes killed 55,390 Americans in 1994. 1993 final mortality: males -- 23,430 deaths (43.5 percent of total deaths from diabetes); females -- 30,464 (56.5 percent of total deaths from diabetes).

• 7,800,000 Americans have diabetes (3.6 million males and 4.2 million females).
• 625,000 new cases of diabetes are diagnosed every year.
• 502,000 Americans diagnosed with diabetes mellitus were discharged from hospitals in 1994. Of these, 223,000 were males and 279,000 were females.
• More than 80 percent of people with diabetes mellitus die of some form of heart or blood vessel disease.
• In the 1991 -- 93 phase of the Honolulu Heart Program, 17 percent of Japanese-American men ages 71 -- 93 had diabetes. In addition, 19 percent had unrecognized diabetes and 32 percent had impaired glucose tolerance.

(Sources: American Heart Association)

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Coronary Heart Disease and Angina Pectoris

(Source: American Heart Association)

• Heart attack is the single largest killer of males and females in the developed world.
• This year as many as 1,500,000 Americans will have a new or recurrent heart attack, and about one-third of them will die.
• At least 250,000 people a year die of heart attack within one hour of the onset of symptoms and before they reach a hospital. These are sudden deaths caused by cardiac arrest, usually resulting from ventricular fibrillation.
• 13,670,000 people alive today have a history of heart attack, angina pectoris (chest pain) or both. This breaks down to 6,930,000 males and 6,750,000 females.
• Studies show that the risk of death from heart disease is much greater for the least-educated than for the most-educated people.
• From 1984 to 1994, the death rate from heart attack declined 28.6 percent, but the actual number of deaths declined only 9.9 percent.

Age, Gender

• Based on the Framingham Heart Study, five percent of all heart attacks occur in people under age 40, and 45 percent occur in people under age 65.
• 84.6 percent of people who die of heart attack are age 65 or older.
• About 80 percent of coronary heart disease mortality in people under age 65 occurs during the first attack.
• In 48 percent of men and 63 percent of women who died suddenly of coronary heart disease, there were no previous symptoms of this disease.
• 1993 coronary heart disease final mortality: male deaths -- 250,362 (51.1 percent of deaths from coronary heart disease); female deaths -- 239,701 (48.9 percent of deaths from coronary heart disease).
• The Cardiovascular Health Study showed the prevalence of myocardial infarction in older American men was 18.0 percent for ages 65 -- 69 and 29.6 percent for ages 80 -- 84. The prevalence in older women was 9.7 percent for ages 65 -- 69 and 17.9 percent for age 85 and older.

After an Attack

• At older ages, women who have heart attacks are more likely than men to die from them within a few weeks.
• Sudden death occurs at from four to six times the rate of the general population among people who've had a heart attack.
• 27 percent of men and 44 percent of women will die within one year after having a heart attack.
• 1,219,000 males and 899,000 females diagnosed with coronary heart disease were discharged from hospitals in 1994.

Angina Pectoris

Estimates are that 7,120,000 people in the United States have angina pectoris (chest pain). This breaks down to 2,860,000 males and 4,290,000 females. A small number of deaths are coded as being from angina pectoris. These are included as a portion of total deaths from coronary heart disease.

• Based on the Framingham Heart Study, about 350,000 new cases of angina occur each year.
• The estimated prevalence of angina is greater in women than in men.
• About 68,000 males and 84,000 females diagnosed with angina pectoris were discharged from hospitals in 1994.
• The Cardiovascular Health Study showed the prevalence of angina pectoris in older men was 21.1 percent for ages 65 -- 69 and 27.3 percent for ages 80 -- 84. For older women the prevalence was 13.7 percent for ages 65 -- 69 and 24.7 percent for age 85 and over.

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Three Myths about CVD

THREE MYTHS

Myth #1:
Basically, it's men who need to worry about CVD, since they have more heart attacks than women.

FACT:
WOMEN'S DEATHS FROM CARDIOVASCULAR DISEASES (CVD) ARE INCREASING

Leading Causes of Death for Total Females

United States: 1993

CVD = Cardiovascular Diseases

Cardiovascular Disease Mortality Trends for Males and Females, 1979-93

More than one in five women has some form of cardiovascular disease.

Since 1984 the number of cardiovascular disease deaths for women has exceeded those for men. The difference in deaths currently is more than 43,100.

Final 1993 mortality for cardiovascular disease was 500,387 for women compared with 457,211 for men.

In the United States, all cardiovascular diseases claimed the lives of 500,387 females annually while all forms of cancer killed 250,529 females. (Breast cancer claims the lives of about 43,600 females each year; lung cancer claims another 57,600.)

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Myth #2
Heart disease no longer represents a serious threat.

FACT:
CVD IS A MOST SERIOUS THREAT

Medical scientists have made tremendous progress in fighting cardiovascular diseases. Even so, more than 954,000 deaths annually; nearly 42 percent of all deaths every year. In fact, since 1900 the No. 1 killer in the U.S. has been CVD in every year but one (1918).

Deaths don't tell the whole story, either. Of the current U.S. population of about 258 million, more than 57 million people have some form of these diseases. And as the population ages, these diseases may have an even greater human impact. Heart failure, for example, is becoming much more prevalent.

Cancer, AIDS and other diseases deserve research and attention. But it's important to remember that CVD ranks far ahead of them as a cause of death.

Finally, according to the most recent computations, if all forms of major cardiovascular disease were eliminated, life expectancy would rise by almost 10 years. If all forms of cancer were eliminated, the gain would be three years.

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Myth #3:
If a heart attack doesn't kill you, you'll recover and be fine.

FACT:
TWO-THIRDS OF HEART ATTACK PATIENTS DON'T FULLY RECOVER

People who survive the acute stage of a heart attack have a chance of illness and death that's two to nine times higher than the general population. The risk of another heart attack, sudden death, angina pectoris, heart failure and stroke -- for both men and women -- is substantial. Within six years after a heart attack, 23 percent of men and 31 percent of women will have another heart attack, 41 percent of men and 34 percent of women will develop angina, about 20 percent will be disabled with heart failure, nine percent of men and 18 percent of women will have a stroke, 13 percent of men and six percent of women will experience sudden death.

About two-thirds of heart attack patients don't make a complete recovery, but 88 percent of those under age 65 are able to return to their usual work.

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Bias or Biology?

Clearly, there are divergences in the way that men and women are diagnosed and treated for heart disease. But how much of this difference is due to ingrained prejudices in society and medicine, and how much is due to actual dissimilarities in men's and women's physiologies? Are women's coronary arteries different from men's? Do the risk factors that have been proven to
promote heart disease in men-including smoking, a high- fat diet, and lack of exercise-apply equally to women? Can women derive the same heart benefits from a change in lifestyle?

In trying to answer these questions, one almost immediately stumbles into a gaping void of epidemiologic information pertaining to women's heart disease. Whatever differences there may be in the incidence and development of coronary disease in men and women, the discrepancies in the amount it has been studied in each sex are striking.

Until the last few years, nearly every large-scale study of heart health has excluded women as a matter of policy. The Veterans Administration Cooperative Study, one of the first to document the benefits of coronary surgery for angina; the Multiple Risk Factor Intervention Trial (known,
tellingly, as "Mr. Fit"), which showed that heart attacks could be reduced by eliminating certain risk factors; and the U.S. Physicians Study, which demonstrated that aspirin could help prevent heart attacks-none enrolled a single woman.

The reasons for what now seems a glaring omission? There's no way to measure the role that institutional prejudice, inertia, or gender bias may have played. But one factor that did enter the calculation-as it enters every epidemiologic study-was cost.

"Large-scale studies seek to enroll as many participants as their budgets will allow. Because heart disease is far more common in middle-aged men than in middle-aged women, most early studies, working with limited financial resources, focused on men," says Meir Stampfer, Harvard professor of epidemiology and nutrition. "As a result, researchers missed out on some of the unique features of coronary disease in women."

It is an omission that Stampfer and his colleagues have helped redress through the Nurses' Health Study and Nurses' Health Study II, which have enrolled more than 200,000 women over the past 19 years. The studies have assessed women's heart disease in light of a wide array of variables:smoking, nutrition, physical activity, use of oral contraceptives, and more.

"From all the evidence we've gathered to date, it's fair to say that whatever constitutes a risk factor for coronary disease in one sex is a risk factor in the other sex as well," Stampfer says.

There are a few exceptions--diabetes, for instance, increases women's chances of coronary disease slightly more than it does men's-but, in general, if something is bad-or good-for men's coronary arteries, it will have the same effect on women's arteries. This research has convincingly put the lie to the myth-still flickering in some quarters-that women can smoke and
magically avoid heart disease. "The Nurses' Health Study showed that even low levels of cigarette use-one to four cigarettes a day-doubles a woman's risk of heart attack," he says.

The Nurses' Health Studies also have explored whether there is a link between oral contraceptive use and coronary disease in women. The findings,Stampfer says, ought to be reassuring to some women and alarming to others.
"Women who use oral contraceptives and do not smoke are at no extra risk for coronary disease. Women who smoke and do not use oral contraceptives face a risk of coronary disease three to four times above normal. Women who smoke and use oral contraceptives face 20 to 30 times the risk" That increase, he adds, lasts only as long as women continue to smoke. Kicking the habit
rapidly returns their risk to normal.

The studies of oral contraceptives, while encouraging, need to be updated in light of recent changes in the chemical formulation of birth-control pills, Stampfer adds. "Modern contraceptives are often prescribed at lower doses than the contraceptives of just a few years ago. There has been some suggestion that lower doses may actually confer a protective effect against coronary disease, but there's no documented proof."

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