Take The Pressure Off

Thirty-five years ago, at his office in Kochi, Kerala, young scientist E. Vivekanandan felt terribly giddy soon after lunch. "It was a normal day and I wasn't under any stress," recalls Vivekanandan, PhD, now 65 and widely noted for his research on climate change. Hours later, when the giddiness still hadn't left him, he went to a doctor who found nothing amiss. "At 135/90, my blood pressure was only nominally high, according to the doctor. Yet my dizzy spells continued and no one could explain it."

Months later, a hospital in his hometown of Chennai diagnosed hypertension, or high blood pressure (BP). A week of taking the prescribed pills made Vivekanandan feel better. But when he stopped the medication, the dizzy spells returned.

Again, for a while, Vivekanandan was irregular with his medication and his BP steadily climbed. Even before he turned 35, he was contending with readings as dangerously high as 220/110 mm Hg despite reverting to regular medication. (Normal BP is about 120/80 mm Hg, and mm Hg is the unit used to measure BP. Also see the portion subtitled "How is BP measured?" later in this article).

According to the World Health Organization's statistics for India, approximately 23 percent of both men and women over age 25 suffer from hypertension. The risk rises with age. It affects nearly half of all Indians above age 40, estimates Dr V. V. Muthusamy, Madurai-based cardiologist and president of the Indian Society of Hypertension. He adds that genetics is one of the most common causes. Among Dr Muthusamy's major endeavours--he is also director of the World Hypertension League--is to educate the public about the seriousness of "uncontrolled hypertension," when the condition remains undiagnosed and untreated. Recent studies estimate that for every Indian diagnosed with hypertension, there could be two with either undiagnosed hypertension or pre-hypertension, where the BP is slightly elevated, but not high enough for concern.

"Uncontrolled hypertension increases the risk of heart disease and brain attacks (strokes), kidney failure and blindness," he says. "It can also cause cerebral hemorrhage-a leakage of blood in the brain, a condition that may lead to strokes and is often fatal."

"Hypertension is usually a symptomless disease. However, some people may experience headaches, giddiness, nosebleeds, blackout, blurred vision, or breathlessness. These symptoms generally appear when the disease advances. Detection is often accidental, since most Indians don't take routine health checks. Unfortunately, many hypertension sufferers reach a hospital only to treat an aftermath of the disease-a heart attack or stroke perhaps. Hence early detection and treatment of this silent condition is vital," says Dr Rajendra Agarkar, founder-president of the Society for Prevention of Hypertension & Diabetes in India, who is also the medical head at Tata Institute of Fundamental Research, Mumbai.

For research scientist Vivekanandan, those high BP readings, way back when he was in his mid-thirties, were the start of lifelong care. Bringing his blood pressure under control at such a young age meant constant effort and monitoring-which went beyond regular BP medication. He needed to change his lifestyle too. He made a focused effort to eat more fruit and vegetables, cut down his rice intake, and replaced his old favourite mutton with leaner choices like fish and chicken. He also reduced salt and oil to a minimum, and made regular morning and evening walks a habit.

Today his blood pressure is still slightly higher than normal, hovering between 140/90 and 150/90, but that's a safe range, says his doctor. Though Vivekanandan has never experienced any major side effects from over three decades of medication, he feels drowsy occasionally and tires more easily than others. "But the dizzy spells have gone and for the most part, I feel good," he says. "I'm happy I can manage the condition effectively and find the energy to travel frequently on work."

Vivekanandan's story, the experts will agree, is a model for anybody diagnosed with high BP. Not only did he get the right treatment at an early stage, he has, despite some irregularity at first, done a good job of taking control of his own health. Looking back, his early dizzy spells were a warning-but not everybody is so lucky. Without routine health checks, this condition could remain silent till it reaches a dangerous level.

So it is critical that patients are made aware of the importance of monitoring and controlling BP. Also, since Indians are very prone to diabetes, they are at increased risk of hypertension, experts maintain. Another fact is that hypertension is not debilitating or even troublesome at first. So patients often stop taking their medicines without telling their doctors. "Many patients mistakenly feel that once their BP returns to normal, they no longer need to take their medication. Only a doctor's constant monitoring of their medication can help them manage the condition," says Dr Chandan Kedawat, a senior consultant cardiologist in New Delhi.

Here are nine facts you should know:

1. How does hypertension do its damage?

Just as a garden hose that is under too much pressure can develop bulges and blowouts, and be too forceful when aimed at delicate plants, blood flowing through our blood vessels under too much pressure can weaken blood vessel walls, causing bulges and ruptures, as well as damage delicate organs, like the heart, eyes or the kidneys, that receive the flow. It can force the heart to work harder, contributing to eventual heart failure.

2. What causes high BP?

In 90 per cent of cases, there is no direct cause. Doctors attribute it to genetic predisposition. "If your parents had blood pressure at a certain age, you will be at risk of contracting BP when you reach that age too," says Dr Muthusamy. This is called "primary hypertension." Obesity, lack of exercise, high alcohol and salt consumption, stress, smoking and family history are all risk factors. "It's considered normal if a 60-year-old person has a BP of 140/90. However isolated high readings are often seen in the elderly, and must not be ignored," says Dr Agarkar.

In about five percent of the cases, high BP is actually caused by another illness or medication. This is "secondary hypertension." Kidney disease and problems related to the thyroid and adrenal glands, or other rarer diseases can cause it. Medications and supplements that may cause a rise in BP include oral contraceptives, common cold medications, non-steroidal anti-inflammatory drugs for pain relief, and herbal supplements like ginseng and St John's Wort.

3. How is BP measured?

The device is called a sphygmomanometer. With the arm supported and the patient keeping still, a cuff is inflated around the upper arm, at the level of the heart. In the manual method, the doctor pumps up the cuff until the blood flow in the arm is stopped. Then watching the dial or column of numbers, the pressure on the cuff is slowly released until, with a stethoscope, the doctor hears the first tapping "Korotkoff sounds" representing the top number (120 in a fraction like 120/80 mm Hg), which is the "systolic pressure." After that, the pressure is released until all sounds disappear. The reading taken now will represent the bottom number (80), or "diastolic pressure." Accurate machines are now available to take these measurements automatically.The systolic pressure is the force exerted on your blood vessel walls when your heart beats and squeezes out blood. The diastolic pressure is the force exerted on your vessels when the heart relaxes between beats. Optimal BP is when the numbers are at or a few points under 120/80 mm Hg. If the BP rises over 140/90 mm Hg, you have hypertension. "Frequent monitoring is important and everyone should know their blood pressure readings," says Dr Muthusamy.

4. How often should BP be measured?

Take tests at least once every year. Indeed, most patients have their hypertension detected when they see the doctor for something else. "The patient may have to visit the family physician more frequently during the initial phase of the diagnosis. Once medication is started, the patient should visit the doctor every month initially for a check-up and once or twice a year for follow ups," advises Dr Muthusamy.

5. How many readings should you have?

All the guidelines recommend that doctors make patients sit quietly for the first reading and then take one or two more, a minute or two apart, then average those measurements, particularly if the readings are high. When hypertension is in the mild to moderate range, a follow-up appointment should be made to take those readings again. "The main goal of treatment for hypertension is to lower blood pressure to less than 140/90," says Dr J.S.N. Murthy, vice-chancellor and professor of cardiology at Sri Ramachandra University, Chennai.

A small percentage of people have abnormally high readings when their blood pressure is taken at a doctor's office-when they are more anxious-but are fine at home. This is called "white-coat hypertension." Others may have normal readings at the doctor's office but are actually hypertensive at home. This is called "masked hypertension." Our BP is not fixed-it rises and falls throughout the day in response to what we are doing and what is happening around us. "If a patient is very anxious, his systolic blood pressure can rise considerably, by as much as 30 mm Hg," reveals Dr Murthy.

"Taking BP readings at home with a digital monitor is an excellent way to keep a check on the condition," says Hyderabad cardiologist Dr Sharath Reddy Annam. He warns that there could be slight calibration differences between your home monitor and the one your doctor uses, which means slightly different readings. "I advise patients to bring in their digital monitors during check-ups, so I can note any such difference. It helps dispense the right dose of medication," Dr Reddy says.

6. What else should be done if your readings are high?

Any hypertension reading should trigger a careful medical history. Other risk factors must be investigated with blood and urine tests, and investigation done for any cardiovascular disease, diabetes, kidney damage, gout and arthritis. Also, a careful family history should be taken. What's basic here is to get your BP back in the normal range.

7. What lifestyle factors make a difference?

Five key behaviours can have a big impact on BP: exercise at least five times a week, reduce alcohol consumption to not more than two drinks a day for men and one for women, reduce salt consumption (particularly by avoiding processed foods), maintain a healthy weight, and increase fruit and vegetable intake. Also stop smoking and manage stress. Recent studies suggest that cutting sugar intake, even without weight reduction, reduces BP. "Making healthful changes to your lifestyle can not only delay the onset of hypertension, it can have significant beneficial effects on other aspects of your health as well," says cardiologist Sharath Reddy Annam.

8. Is it ever too late to make lifestyle changes?

No. During the past year, Usha Periakaruppan, 61, a Mysore homemaker, decided to make small, yet significant lifestyle changes. At age 42 she had been diagnosed with Stage 2 hypertension (readings of 170/100 mm Hg) and has since been on medication. This year, she decided to limit her sugar intake, gradually cutting back on ice cream, sweets and biscuits, even though she isn't diabetic. She also started 20 minutes of moderate walking and "energization" exercises. The result: Usha has since lost five kilos in six months and her doctor has scaled down her BP medication to a minimal dose. "I've never skipped my medication even for a day," she says. "That has always helped me keep my blood pressure under control." It is best to make major lifestyle changes when the hypertension is still in its mild or moderate stage. It can be hard, but remember it's all for your future wellbeing.

9. Will there be side effects if I take BP meds?

Many types of medication are now available, so a doctor should find the drug, or a combination, that controls BP with minimal-to-no side effects. Some hypertension drugs may cause diarrhea or other gastrointestinal problems. Tell your doctor about any side effects so that he or she will work with you to find the right medication.

Sometimes it calls for a bit of work on the doctor's part, even if there are no side effects, especially if other illnesses complicate treatment. Kumudini Bhat, 53, a Mumbai homemaker, was diagnosed with both diabetes and hypertension in 1990 after suffering intense bouts of dizziness and fatigue. Her doctor found her initial BP readings, of 190/100, alarmingly high. She was treated for both conditions, but prescriptions had to be constantly altered over the years to contend with other medical problems, including the side effects of her diabetes medication. In January, she was prescribed Lasix (furosemide), a diuretic pill that prevents the body from absorbing too much salt, thereby controlling her  blood pressure, which is now within the normal range.

"There have been significant strides in this area," says Dr Muthusamy. "Cost effective medication that combines several drug formulations are now available so even the most resistant cases can be controlled. As education and literacy increase, greater awareness about BP can help save more lives."Take climate scientist E. Vivekanandan's case. The longtime BP patient has proved that it is possible, with awareness and care, to live a full, productive life.

Adapted from an article by Anne Mullens