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This is the seventh in a weekly series of diaries that deal with healthy positive approaches to the process of ageing. They all carry a tag of [ageing gracefully] and can be found by searching on that tag.

Archive to All Aging Gracefully Diaries

Blood pressure and problems with its management becomes more and more an issue of concern for people the older they get.

Blood pressure (BP), sometimes referred to as arterial blood pressure, is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, blood pressure varies between a maximum (systolic) and a minimum (diastolic) pressure.[1] The blood pressure in the circulation is principally due to the pumping action of the heart.[2] Differences in mean blood pressure are responsible for blood flow from one location to another in the circulation. The rate of mean blood flow depends on both blood pressure and the resistance to flow presented by the blood vessels. Mean blood pressure decreases as the circulating blood moves away from the heart through arteries and capillaries due to viscous losses of energy. Mean blood pressure drops over the whole circulation, although most of the fall occurs along the small arteries and arterioles.[3] Gravity affects blood pressure via hydrostatic forces (e.g., during standing), and valves in veins, breathing, and pumping from contraction of skeletal muscles also influence blood pressure in veins.
This is the current medical diagnostic classification for systemic BP readings.
Problems with BP are divided between too high, hypertension and too low hypotension. Unless chronic hypotension is causing problems with dizziness and fainting it isn't likely to get active medical intervention. A sudden onset of it can be a sign of a serious illness that requires treatment. For people who are on medications for the treatment of hypertension it is usually a sign of over medication.

Most of the people confronted with the problems of BP management are dealing with hypertension.

Hypertension is classified as either primary (essential) hypertension or secondary hypertension; about 90–95% of cases are categorized as "primary hypertension" which means high blood pressure with no obvious underlying medical cause.[1] The remaining 5–10% of cases (secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart or endocrine system.

Hypertension puts strain on the heart, leading to hypertensive heart disease and coronary artery disease if not treated. Hypertension is also a major risk factor for stroke, aneurysms of the arteries (e.g. aortic aneurysm), peripheral arterial disease and is a cause of chronic kidney disease. A moderately high arterial blood pressure is associated with a shortened life expectancy while mild elevation is not.

 Dietary and lifestyle changes can improve blood pressure control and decrease the risk of health complications, although drug treatment is still often necessary in people for whom lifestyle changes are not enough or not effective.

Hypertension is often referred to as the silent killer. Most people do not have immediate direct symptoms resulting from it that they are aware of. The way they find out about it is through BP checks. Measuring BP with a home monitor is easy and simple and the monitors are fairly inexpensive. For anybody with even borderline BP regular monitoring problems should become part of their personal routine. The frequency of that depends on stability and control.

As with other chronic health conditions treatment and management involves diet, weight loss not smoking and exercise supplemented with medication as necessary. Not all approaches work equally well in all people. People who are dealing with other chronic conditions such as diabetes need to find approaches that cover all bases. Various approaches to exercise have been shown to be effective in reducing BP. The most effective one for you is likely to be the one that you can manage to do on a very frequent basis. If you have physical limitations such as arthritis that has to be accommodated. Bike riding is my choice.

The first line in dietary modification is the reduction of sodium. That goes beyond just not eating salt. Many other foods contain sodium. The nutritional information on food packages is a helpful guide. Reduction of sodium has a mild diuretic effect which makes a slight reduction in blood volume and thus in BP. For many people with borderline hypertension weight control, regular exercise and sodium reduction may be sufficient to achieve adequate control. For people needing more extensive dietary intervention the DASH diet is an effective approach.

The DASH diet was designed to provide liberal amounts of key nutrients thought to play a part in lowering blood pressure, based on past epidemiologic studies. One of the unique features of the DASH study was that dietary patterns rather than single nutrients were being tested.[4] The DASH diet also features a high quotient of anti-oxidant rich foods thought by some to retard or prevent chronic health problems including cancer, heart disease and stroke.
This is the recommended daily balance of nutrients.


Here is a useful pyramid illustration that shows the emphasis that should be given to various types of food. The graphic says women, but it applies equally as well to men.
There are various reasons why people may need BP medications. One is because they are unwilling to make necessary lifestyle changes. However, there are medical reasons why even someone who is conscientious about weight loss, smoking, diet and exercise may still need medication. The likelihood of some of those problems increases with age. Blood pressure medications are grouped in terms of the type of chemical mechanism they use to reduce BP. There are 6 basic types.


Angiotensin-converting enzyme (ACE) inhibitors

Angiotensin II receptor blockers

Beta blockers

Calcium channel blockers

Renin inhibitors

Each of these drug groups have several different specific generic drugs. The various types can be used in combination with each other. Most of them have some types of side effects, some annoying, others potentially serious. Anybody who is able to control BP with lifestyle changes alone is well advised to do that as long as possible. The day may come when you need them no matter what you do, but putting it off spares you of some unpleasantness and gets you in the habit of doing things that will limit the amount of medication that you might eventually have to take.  


Originally posted to KosAbility on Tue May 27, 2014 at 03:00 PM PDT.

Also republished by Kitchen Table Kibitzing.

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Comment Preferences

  •  Thanks for great info (7+ / 0-)

    I have a diary in my draft queue "Fending off the Silent Killer" which is a little more about personal experiences and a bit of anthropology about hypertension.

    I'll make sure to reference this.

    [But it's on no particular schedule to publish, like several that inhabit the queue.]

  •  According to that chart (5+ / 0-)

    my diastolic pressure would at least send me into the ER every week or so and my systolic is stage 2 almost always. If diastolic is over 100 and systolic over 160 I feel it. Can't focus, get exhaustedand tired very easily  and am also very forgetful.

    When I take one Lisinopril and half a Furosemide it's ok. I just am not very disciplined in taking them. My diastolic never gets under 90 though, 85 when I am really, really lucky.

    Well, all this will change soon. When I retire I will be living completely healthy and be rejuvinated in no time. Sleeping enough, no more dailykos reading, nor more TV and daily walking and garden work is all it takes. I am not overweight (well I could lose 15 pounds, but not more).

    We know a hell of a lot, but we understand very little.- We are simply dramatically stupid - Manfred Max-Neef - I agree with him.

    by mimi on Tue May 27, 2014 at 05:10:27 PM PDT

    •  That is significant hypertension. (7+ / 0-)
      Recommended by:
      weck, FG, Ahianne, vzfk3s, Miggles, Munchkn, James Wells

      You need to take your medicine. Don't count on retirement making it entirely go away.

      •  I tried to joke a little (1+ / 0-)
        Recommended by:
        James Wells

        and try to become more reasonable as well.

        I think my high blood pressure is caused by a minor heart attack when I was 20 years old. But apparently that is hard to prove. I tend to dry cough a lot and there was one doctor who seemed to think its mild heart asthma. All I know is that when I am well rested I cough less and the blood pressure seems to be a little better.

        We know a hell of a lot, but we understand very little.- We are simply dramatically stupid - Manfred Max-Neef - I agree with him.

        by mimi on Tue May 27, 2014 at 05:43:24 PM PDT

        [ Parent ]

        •  There are many things that cause it (1+ / 0-)
          Recommended by:
          James Wells

          but keeping it under good control can prevent it from doing any damage.

        •  Your dry cough is probably caused by (1+ / 0-)
          Recommended by:
          Richard Lyon

          the Lisinopril you're taking. It can also cause really bad fatigue. I wasn't aware either of these things were potential side-effects and suffered through 3 months of misery before someone who knew enough finally switched me to Carvedilol (Coreg). No more cough; no more fatigue.

          Talk to your physician.

          “…The day shit is worth money, poor people will be born without an asshole.” – Gabriel Garcí­a Márquez, The Autumn of the Patriarch

          by mikidee on Wed May 28, 2014 at 06:03:09 AM PDT

          [ Parent ]

          •  I've been taking lisinopril (0+ / 0-)

            for a long time without any problems. BP meds are complex and they effect people differently. They definitely require ongoing monitoring.

            •  True. Unfortunately, too many (1+ / 0-)
              Recommended by:
              Richard Lyon

              physicians don't inform their patients about common potential side effects and too many patients don't think to ask (I was one of them). Most new BP med takers would not think to associate a dry cough with their meds.

              I learned about it through Googling the symptoms, thinking something potentially horrible was causing post-nasal drip. It was not a minor problem for me - it caused constant and chronic coughing that interfered with sleep and with my job (among other things, I train groups of temporary employees).

              Med monitoring as well as BP monitoring is an ongoing thing for people on BP meds. Weight loss can be as serious as weight gain for some people.

              Thanks again for this series, Richard.

              “…The day shit is worth money, poor people will be born without an asshole.” – Gabriel Garcí­a Márquez, The Autumn of the Patriarch

              by mikidee on Wed May 28, 2014 at 06:40:26 AM PDT

              [ Parent ]

  •  A couple of weeks ago, I had an unusually (10+ / 0-)

    stressful day. Way beyond what I am used to dealing with. Late afternoon I got home and was feeling very strange. Impossible do describe in words. Not lightheaded or dizzy, and not painful. Just very strange. I got the cuff and took my blood pressure. It said 300/145.  I thought it was a mistake so tried again. Got 300/141.   Then tried the other arm. Same thing. Thinking it was a malfunction of the cuff, I got another cuff and tried it. Same thing. About that time, CelticLassie got home, took one look and announced, "Get in the car. You are going to the ER."

    I knew full well I was well into stroke and nosebleed territory, so did not argue. They kept me under close observation for about four or five hours and when it had come down to the high end of the normal range, I was discharged. The ER doc gave me some beta blockers, which have an anxiolytic effect. Also, it gave me some time to relax and I was OK. But I never, ever, want to do that again.

    The ER doctor said he had only seen BP that high once before, and that was a surgery patient. We both agreed that the systolic probably wasn't right, because a consumer grade cuff may not be accurate above 230-250. Regardless of the exact number, we both agreed it was way too high.

    Moral of this story is that it is a good idea to have a blood pressure cuff and know how to use it. Take your blood pressure once in a while no matter how you feel.  Hypertension is the "silent killer," because there are not usually any perceptible symptoms.

    Rudeness is a weak imitation of strength. - Eric Hoffer

    by Otteray Scribe on Tue May 27, 2014 at 05:15:51 PM PDT

    •  Normally it can get a lot higher (4+ / 0-)
      Recommended by:
      weck, mimi, Otteray Scribe, James Wells

      than what it should be without feeling anything. For people who have or have had problems checking it at least a couple of time a week when it is stable is a good idea. If it is not stable more often than that would be indicated.

      Most people's BP fluctuates over the course of the day. Checking it at different times is useful.

    •  that's very, very high ... my mother (4+ / 0-)

      had sometimes over 200, and then it needed treatment in the hospital as well.

      We know a hell of a lot, but we understand very little.- We are simply dramatically stupid - Manfred Max-Neef - I agree with him.

      by mimi on Tue May 27, 2014 at 05:49:50 PM PDT

      [ Parent ]

    •  The most common and overlooked cause... (0+ / 0-)

      The most common and most often overlooked cause of severe or treatment-resistant hypertension is adrenal dysfunction or disease resulting in a hormonal condition called hyperaldosteronism, which occurs in a small handful of different variations and more specific causes and precise formal diagnoses.

      All by itself, hyperaldosteronism accounts for 10-15% of all hypertension, even before counting other forms of secondary hypertension.  So the overall 5-10% figure for total secondary hypertension is out of date and is responsible in large part for the common failure to recognize hyperaldo when it occurs.  Doctors were taught the condition is a zebra and that they should spend their time looking for horses.  But in fact hyperaldosteronism is a relatively common horse -- not your usual chestnut or black, but you will find at least one and normally several in nearly every stable (i.e. medical practice) where you look, as long as you understand what you're looking for.

      Most of the usual antihypertensives will worsen or at best be ineffective against hypertension caused by excess aldosterone.  Some worsen it almost immediately (normal diuretics in particular) and others over a longer term (most notably beta blockers, but some experts claim alpha blockers and calcium-channel blockers as well).  ACE inhibitors and ARBs are completely ineffective in this condition, though they might seem promising on superficial consideration of the mechanisms involved.

      Experts in the condition say that at a bare minimum, anyone who shows up at the ER for severely elevated BP with no obvious cause should be tested.  (But such patients almost never receive the needed tests.)

      There are varying degrees of rigor in available testing protocols, and some endocrinologists like to do a series of dog-and-pony tricks demonstrating classic oddities of the condition.  But for initial recognition and getting as quickly as possible onto a treatment track that will help rather than harm the patient, most who treat the condition regularly say that blood tests of Plasma Aldosterone Concentration numerically divided by Plasma Renin Activity will give a definitive yes or no pointing to (or away from) some form of hyperaldosteronism and indicating the prescription of aldosterone-blocking medication.  

      At least one now-retired endocrinologist who has specialized in the condition probably longer than any other living doctor in the United States (and who worked with Jerome Conn at the University of Michigan, who first recognized the condition) has stated that dramatic initial response to spironolactone (trade name Aldactone), the first widely available aldosterone-blocker, is all-but-definitive proof that you're dealing with hyperaldosteronism.  Certainly that was my experience, dropping from a systolic of 190 to 120 over less than an afternoon on the minimum standard dose.  All the doctors uninitiated in hyperaldosteronism who have witnessed such a response have been astounded that this medication could cause it, but that is actually common, which is why it's such a useful diagnostic tool.  The first-dose response fades unless you subsequently escalate to a more typical aldosteronism-specific dosage, but that initial dramatic response lights the way forward. (However, failure to see such response does not prove the condition is not present.)

      Aldosterone is principally (with other functions or effects) a salt-retention hormone.  People with hyperaldosteronism almost always have clinically low potassium or high sodium, or in the worst case both.  (The difference between low potassium and high sodium is only a difference of hydration/dilution.  Add water to the blood and both concentrations go down.  Remove water and both go up.)  Any doctor who sees low potassium should be asking if hyperaldo is the reason.  It's the most common trigger for recognizing the condition but it's still often overlooked because of the misconception mentioned above that this is some kind of exotic illness a doctor will see at best once in a career.

      But there is a stage at which patients may have potassium in-range and sodium in-range, but each near the edge of acceptability (low for potassium, high for sodium).  I was unfortunately told on several occasions that there was no clinical significance to such a result, but I later learned it is a common precursor to diagnosis.  For me, the condition was present for at least 10 years prior to its diagnosis (evidenced by multiple indicators, not just these borderline results), and I had to force my then-doctor's hand by ordering the tests myself.  Such resistance to considering this condition is more the rule than the exception.

      Anybody who struggles with severe or treatment-resistant hypertension needs to be aggressive in discussing the possibility of hyperaldosteronism with their doctor.  The risks of failing to do so are much higher than the potential embarrassment (which is really unfounded) of finding this was not the answer.  If there is a likelihood then it is well worth your insurance company's or your own money to investigate by one means or another.  If the cost of blood tests is prohibitive, then there is at least the spironolactone-response method, which costs only pennies for the medication.  There is no combination of other medications without an aldosterone-blocker that can effectively treat hypertension over the long term when it is caused by excess aldosterone.  And even if some such  combination could be found, it would not treat the other serious effects of that hormonal excess.

      Ideology is when you think you know the answers before you know the questions.
      It infests hollow spaces where intelligence has died.

      by Alden on Wed May 28, 2014 at 08:35:32 AM PDT

      [ Parent ]

      •  Thank you for this post (1+ / 0-)
        Recommended by:

        My stepfather has been struggling with extremely high blood pressure for a few years.  And they don't seem to have really resolved the problem.

        This may not be what he has, but because he is in a community with limited health care expertise, it is worth checking further.  I think my mother mentioned that he had low potassium, too.  But I'll check with them to make sure this has been considered by his doctor.

        Understanding is limited by perspective. Perspective is limited by experience. America is a great place to live but it limits our ability to understand.

        by CindyV on Wed May 28, 2014 at 09:26:46 AM PDT

        [ Parent ]

        •  Let's hope it will be his breakthrough (0+ / 0-)

          People in the hyperaldo support group on Yahoo frequently express amazement at how many times the obvious was overlooked or even considered but rejected without testing before, after years, they finally got the right diagnosis.

          The main thing is awakening doctors to the reality that hyperaldo isn't rare but instead is statistically almost certain to be present in multiple cases in almost every medical practice that has hypertensive patients.  It would have to be a very small practice or a statistical fluke for a practice not to have any patients with some form of the condition.

          In a substantial minority of cases, tens of percents, an operation can cure it outright, resulting in elimination or near reduction of the need for antihypertensive medication. The rest of the cases respond like magic to spironolactone or eplerenone.

          Ideology is when you think you know the answers before you know the questions.
          It infests hollow spaces where intelligence has died.

          by Alden on Wed May 28, 2014 at 01:47:19 PM PDT

          [ Parent ]

  •  All I know is that high blood pressure has (2+ / 0-)
    Recommended by:
    Richard Lyon, Ahianne

    impact on my capability to concentrate, focus and get things done without feeling "fuzzy". It has impact on memory too.

    We know a hell of a lot, but we understand very little.- We are simply dramatically stupid - Manfred Max-Neef - I agree with him.

    by mimi on Tue May 27, 2014 at 05:52:54 PM PDT

  •  Always had low blood pressure when younger (2+ / 0-)
    Recommended by:
    shayes, JamieG from Md

    Once, when I was pregnant, my doctor noted that my blood pressure was 90 over 70. "Well, you're not tearing up your vascular system," he said cheerfully.

    But now I'm officially "old," and my bp is creeping upwards. I hate this. Don't want to take bp medication.

    "Religion is what keeps the poor from murdering the rich."--Napoleon

    by Diana in NoVa on Tue May 27, 2014 at 06:22:56 PM PDT

  •  I'm confused (3+ / 0-)

    So one doctor a couple of years ago was telling me that 126/70 was too high, that I needed to get it down to 120 or below. That's consistent with what I read everywhere.

    Last week I saw my primary. BP was 132/70. He said it was fine. I said, what about anything over 120 being pre-hypertension? He said, there are new guidelines - you're fine.

    What new guidelines? Since when? I'm not finding them anywhere.

    Today at a different doctor I was 136/72. She didn't blink.

  •  I take Lisinopril every day (2+ / 0-)
    Recommended by:
    James Wells, Richard Lyon

    I had a mild stroke two years ago and know high blood pressure is nothing to fool around with.  Fortunately, the medication helps keep my BP in the normals range.

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