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Experts Talk About: Treatment Options

Dr. Roccella: Henry, earlier you said there is solid information about the benefits of treating hypertension, or lowering blood pressure. What kinds of treatments are you talking about?

Dr. Black: Well there are two kinds of treatments: with drugs and without.  I think the platform that we all support is to use lifestyle modification first, but if it doesn't get you to your goal in a reasonably short period of time -- maybe three to six months, or even less -- be prepared to use introduce pharmacologic therapy.

Dr. Roccella: Nancy, what kind of lifestyle modification is Henry talking about?

Ms. Houston Miller: Well, there are behaviors you can change to not only lower blood pressure but also to prevent high blood pressure. It's important to ensure that your weight is normal, meaning you are not overweight or have a body mass index of less than 25. You can also adopt a diet that is high in fruits and vegetables, such as the DASH diet which has been heavily researched to look at its benefit.  Watching your sodium to make sure it is less than a 100 milli-equivalents -- or about a teaspoon of sodium a day -- is also critically important. Get regular physical activity, at least 30-minutes on most days of the week. Also, moderate your alcohol intake.  For women who choose to drink alcohol, we advocate no more than one alcoholic drink per day.

Dr. Roccella: Does this lifestyle modification really work?

Ms. Houston Miller: Lifestyle modifications can significantly lower blood pressure, and certainly prevent it. When you look at studies, for example, getting 30 minutes of physical activity on most days of the week lowers systolic blood pressure somewhere between about 4 and 9 mmHg. That is very significant from a public health standpoint and for individuals in terms of lowering risk. Adopting the DASH diet or another diet that is healthy in fruits and vegetables and moderately low in saturated and total fat, gives you about an 8 to 14 mmHg fall in systolic blood pressures.  Such significant reductions in blood pressure make a very meaningful difference.

Dr. Roccella: What kinds of drugs would you recommend to the person who has tried lifestyle modification and is still seeing her blood pressure move forward?

Dr. Black: Right now we have well over 125 or 150 different individual drugs and about 50 to 80 fixed dose combinations, that is two or even three different drugs in the same pill.  We tend to divide them into pharmacologic classes. We have diuretics, which we call diuretics because they do increase urine output, but they really also dilate arterioles (small arteries).  We have drugs that block the renin angiotensin aldosterone  system through at least three or four different mechanisms now.  We have drugs called calcium channel blockers, or calcium antagonists, which prevent calcium uptake into cells.  We also have drugs that affect the peripheral and central nervous systems. Finally, we have drugs that directly act as dilators.  All of these things can effectively lower blood pressure and they have different prharmocologic profiles and side effects. For the most part, a skilled clinician will be able to figure the most appropriate drug or drugs for an individual patient.

Dr. Roccella: You tell me that these drugs work in different ways.  They are not the same drugs?

Dr. Black: No, they are not. They have the same effect -- that is, they lower blood pressure -- but they do it in a whole variety of different ways.

Dr. Roccella: Are you suggesting, too, that you can get more than one drug to lower your blood pressure? Do you need two drugs or more?

Dr. Black: When we say to you we want your blood pressure to be at a certain number, we want that to be your goal. But we now know from several very large and well done studies that there are only a small number of people who are going to reach that goal with a single agent -- maybe 25 to 40 percent at most.  Sometimes people may need two or three and even more medications.  The important thing is that when we treat you, we set out a plan, we set out a target or a goal that we are aiming for, and we add medications if necessary or switch around if necessary until we get you to that goal number.

Dr. Roccella: So you are saying that it is not unusual to be put on two or possibly three drugs to lower your blood pressure?

Dr. Black: No, I think it has become the rule.

Dr. Roccella: The rule plus the lifestyle modification?

Dr. Black: Right, that is the platform where we begin.

Dr. Roccella: A combination of those should make it possible for virtually most if not all people to control their blood pressure?

Dr. Black: There are still going to be some people who do not achieve that, the so-called resistant hypertensive. Still, we can get everybody's blood pressure down to some degree and accordingly reduce their risk when we do that.

Dr. Roccella: What should we know about hypertension in men versus women? Are there any real differences we should know about?

Dr. Black: We actually have some new information about that.  There is a group called the hypertension trialists, which have now collected about 35 large trials. They've put them together to come up with answers and they recently published an analysis of this which showed that when we look at drug classes and outcomes, there are no differences between how men and women responded.  So I think we can probably apply the information we learn about hypertension from one sex to the other.  There are also no differences in the degree of success we achieve in older and younger people.

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Click these links to read more from Sister to Sister’s Expert Roundtable on High Blood Pressure:

Introduction
Blood Pressure Basics
Symptoms & Screening
Treatment Benefits
Treatment Options
Drug Side Effects
Drug Interactions
Medication Costs
Prehypertension
Aging's Impact
High-Risk Groups
Future Goals