Episode Transcript
Interviewer: Your doctor just told you that your blood pressure is a little too high and you could have hypertension. But what does that mean for you and your health?
Dr. Tom Miller from the University of Utah Health, when you have this conversation with a patient, what's the first question you generally get asked?
Diagnosing Hypertension
Dr. Miller: Well, first, you have to make the diagnosis of hypertension. That's the biggest thing. And actually, we don't really make too many diagnoses of hypertension in the office as much anymore.
Interviewer: Really?
Dr. Miller: . . . and why? Because there are so many cuffs that you can purchase on the market now where you can monitor your blood pressure at home. The other problem is many people come into the doctor's office rushing in from their car, and their blood pressure is high, and they're wearing a white coat. It makes people anxious. So we call this white-coat hypertension. It's really not high blood pressure. It's really not hypertension. It's just normally elevated blood pressure from the anxiety of the visit. And some people may not even feel anxious and still have white-coat hypertension.
So we use home pressures when we can to ascertain whether somebody has elevated blood pressure. If we see an elevated blood pressure in the office, then we basically ask folks to go home, and if they have a cuff or if they can afford a cuff, we have them take blood pressures at home, average those, and then based on the average, we can make a decision about whether they have high blood pressure or not.
And for those who don't have a blood pressure cuff or cannot purchase one, we also, in some clinic settings, have 24-hour ambulatory monitoring of blood pressure. So we put that on the patient, and it collects blood pressure over 24 hours. We analyze that, and then, based on the results, we can decide whether the person has high blood pressure.
Interviewer: The days of going into the doctor's office, getting the blood pressure taken, and then being immediately told you probably have hypertension, those days are kind of done.
Dr. Miller: Pretty much. I mean, we still make diagnoses of high blood pressure in the office when it's extremely high on repeat measurements. And if someone is not able to have a cuff or if you're not able to do 24-hour ambulatory blood pressure monitoring, we'll do sequential office visits, and we have the patient rest before we check the blood pressure.
The Impact of Hypertension on Health
Interviewer: So then after going through this process, if it does then finally come back that, yeah, this person might have some increased blood pressure, then where do we go from there? First of all, are they experiencing any symptoms that would have indicated that this was the case, or is it just really all about that reading?
Dr. Miller: Well, hypertension has been called the silent killer. People don't really know that they have high blood pressure. Sometimes there may be symptoms when it's quite high. But usually elevated blood pressure or hypertension, people don't know they have it until they have a problem.
Interviewer: Yeah, the importance of that checkup is to maybe get that first indication and then do those follow-up cuffs at home.
Dr. Miller: Right, so . . .
Interviewer: It's how you find out.
Dr. Miller: . . . one thing to remember is that if someone does have hypertension, most of the time that blood pressure is mild to moderately elevated. And it takes years of that elevated pressure to cause problems. So it's not something that has to be corrected immediately, but it does need to be managed.
Consequences of Prolonged Hypertension
Interviewer: Yes, okay. So how does it impact a person's body? What's going on inside that's causing these problems if I have prolonged hypertension?
Dr. Miller: There are certain direct reasons that people can have high blood pressure. I won't discuss those. But basically, most high blood pressure, and hypertension are multifactorial. It's family. It's diet. It's all kinds of things coming together to create hypertension.
Interviewer: Yeah. And then how is that impacting my body? What's it doing inside that's so detrimental to my health?
Dr. Miller: Over the long haul, it increases the risk of heart attack and stroke. Those are the two major issues with folks who have hypertension. And, of course, it's years of having high blood pressure generally that cause that kind of an outcome. And so that's why it's so important to get on top of it early and manage high blood pressure.
Interviewer: Yeah.
Dr. Miller: We know that when we do manage it and bring it back into the normal range, that those folks have a much lower incidence of heart attacks and stroke.
Managing Hypertension
Interviewer: So then what is done about it if somebody does get diagnosed with hypertension? What are the next steps for them?
Dr. Miller: In cases of mild to moderate elevated blood pressure or hypertension, we treat that with diet and lifestyle initially. Those can have very big impacts on lowering blood pressure. So weight reduction, eating correctly, and then the adequate amount of physical exercise all work together to decrease blood pressure and quite significantly, I might add.
Interviewer: Yeah. Are we talking about a significant amount of weight loss or a significant lifestyle change in a lot of cases? Or can little changes make a big difference?
Dr. Miller: Little changes can make a big difference. But in general, it depends, of course, on how much one weighs, how much one exercises, and what other things a person does. If they're taking too much alcohol or they're smoking, those are things that need to be dealt with and managed. You have to quit smoking. You've got to get your exercise up and cut your drinking or eliminate it. Those all impact blood pressure and can make a big difference before you even start talking about medications.
Interviewer: Okay. So how long do you usually wait for lifestyle changes? Should somebody do that before they would expect to see their blood pressure getting into a healthier place or consider doing something else?
Dr. Miller: Well, initially, we assess a patient's desire to manage their lifestyle. So if someone is really excited about following a program of weight loss and exercise, as well as stopping offending agents, then great, we can give that a try for a few months. But if that's not successful, then we move to medication.
Medications and Treatment Plans for Hypertension
Interviewer: All right. And tell me about the types of medications that you might consider. I don't know that we need to get into detail, but like, you know, what are some of the considerations somebody might want to have?
Dr. Miller: Well, there are currently a number of medications to assist in lowering blood pressure. And selecting that medication just depends on the person's other issues that are ongoing. And that is a selection that would occur between the physician and the patient in terms of which medications. And then, of course, you would follow the person up and check blood pressure either at home ideally, or in the office to see if that's made an impact. And the idea is to follow the person fairly closely until the blood pressure is controlled.
The other point that I would make is that as someone is managing their lifestyle, so if they're reaching their target goals, they may be able to go off blood pressure medication if they reach the goals, their lifestyle goals. That's important for people to understand that blood pressure doesn't always have to be treated if you are able to manage the lifestyle goals that are set up for you.
Interviewer: Are there some people that are just going to have to have medication?
Dr. Miller: Yes, of course.
Interviewer: Yeah. Is that usually because of genetic reasons for hypertension or . . .
Dr. Miller: Yes, and as we get older, our blood pressure tends to rise a little bit.
Interviewer: Right. So sometimes that just has to be part of the equation.
Dr. Miller: Yeah. Yeah, it does.
Interviewer: All right. So would you say, as a general rule, that for the most part, high blood pressure, is very treatable?
Dr. Miller: With either lifestyle, medication, or both, we can treat the vast, vast majority of hypertension.
Interviewer: If a patient is talking to their physician and they're having this conversation about hypertension, is there something that somebody might forget to ask or that you would recommend that they have a conversation with their provider about?
Dr. Miller: They might ask what the side effects of the medications are. They might ask how often they need to check their blood pressure. They might want to know what devices they can purchase at home so they can check their blood pressure and how to check their blood pressure properly at home. Those are all important factors so that that person can take on the responsibility of checking their blood pressure and managing hypertension.
Interviewer: Sometimes when I think of lifestyle changes, I think of giving up all the things I love. Is that the case? I mean . . .
Dr. Miller: That depends on what you're doing and . . .
Interviewer: Yeah, sure.
Dr. Miller: . . . how that goes, right?
Interviewer: Right.
Dr. Miller: So if you're a two-pack-a-day smoker and you enjoy that, I'd say, "Well, we kind of have to give that up."
Interviewer: That's kind of non-negotiable.
Dr. Miller: Well, it's always negotiable because we are just consultants, but we would advise you strongly to quit smoking, and we would offer you aids and ways to do that. It's not easy to quit smoking.
Interviewer: Yeah, but if I enjoyed like some particular food that had some salt in it, for example, on occasion, like I like to get salt on my baked potato, I could do that once in a while or . . .
Dr. Miller: Yes, you can do that once in a while. I'm giving you permission.
Self-Monitoring and When to Seek Professional Medical Guidance
Interviewer: When you're talking about hypertension or high blood pressure, what are the numbers we're talking about? What are the different degrees?
Dr. Miller: There's a little bit of debate about what level of blood pressure constitutes high blood pressure, but, in general, blood pressures greater than 130 over 80 are considered to be high blood pressure.
Interviewer: Right. Another reason why you would want to consult with a medical professional and work as a team to figure out what's best for you.
Dr. Miller: Right. Also, again, you don't necessarily need to go to a doctor to find out if you have high blood pressure. You could, based on the numbers I gave you, purchase a blood pressure cuff, one that fits correctly around your arm, and check pressures at home. You need to be sitting, resting quietly for five minutes, feet flat on the floor. You want to check two to three measurements twice a day, average those over three to five days. Look at that average blood pressure. You know, if it's elevated, that is consistently greater than 130 over 80, then I would consult a medical provider about the next steps.