What is High Blood Pressure

Matthew DeVane, DO FACC: [00:00:08] Hi, I'm Doctor Matt DeVane.

Carolyn Lacey, MD FACC: [00:00:09] And I'm Doctor Carolyn Lacey. We are cardiologists at John Muir Health and this is our podcast, Living Heart Smart.

Matthew DeVane, DO FACC: [00:00:16] Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.

Carolyn Lacey, MD FACC: [00:00:24] Thank you for listening and we hope you enjoy our show. Good morning everybody. We're here again today for Living Heart Smart. We're talking about hypertension today. One of the very common problems that we see in our practices every day. We're here with Doctor Christopher Chen. He comes to us from UC Davis. He's newer into our group and we're really excited to have him here. He's taught me a lot in the last year or so already. So welcome. I'm excited to hear from him. Um, doctor Chen, when you think about hypertension, what are some of the thoughts that come to your mind when you start thinking about hypertension?

Christopher Chen, MD: [00:01:11] Sure. First off, thanks so much for having me, guys. It's been wonderful being here for the last year. I don't know what I've taught you, but I'm glad and you have taught me a lot too. So I'm looking forward to talking about blood pressure.

Matthew DeVane, DO FACC: [00:01:25] Appreciate. Yeah. No, it's so many of our patients, uh, need help when it comes to blood pressure. So thank you for joining us.

Christopher Chen, MD: [00:01:32] Absolutely. So hypertension for our cardiologists I think it's bread and butter. Um, and so when we come in and hypertension, someone's coming in for hypertension I think okay, let's think about low hanging fruit that we can address because I think hypertension comes in many different flavors. Everyone's a little bit different. And my goals first are just to see if they understand what hypertension is, why we care about it. And then by the end of it, maybe we'll come up with a couple of things to help adjust things. But, um, on a first visit, I really just want them to understand why they're there and what we can do to help.

Matthew DeVane, DO FACC: [00:02:11] So when someone comes in and you're talking about hypertension, high blood pressure. So let's just start with the very basics. All right. So let's talk about the definition of hypertension. That's kind of changed over time. So we're kind of basing what we think is normal and not normal on some newer guidelines. So can you talk about those guidelines and what the numbers are and how patients can think about it.

Christopher Chen, MD: [00:02:33] Absolutely. So what I generally say is hypertension is just high blood pressure. It's the blood pressure of what's hitting your arteries.

Christopher Chen, MD: [00:02:41] Right. So that's based on a couple factors. How hard is your heart squeezing out and how tight are your arteries holding down on that blood. And so it's the pressure, the driving force of that blood going through your body. If you didn't have any blood pressure, you wouldn't be here today. The new guidelines came out recently in 2017. And so they kind of redefined hypertension a little bit. But the cutoffs now are elevated blood pressure. It used to be 120 to 139. And then most recently on the newer guidelines 120 to 129. Is that elevated blood pressure category. You start reaching hypertension above 130. So stage one is 130 to 139 and stage two is above 140. So those are slight changes compared to the guidelines that were there beforehand. But really anything over 120 which is similar to the old guidelines is abnormal.

Matthew DeVane, DO FACC: [00:03:38] I think this is super important because so many people think anything in the 120 low 130, they're absolutely, perfectly normal with no risk. But can you just say one more time, what is a normal blood pressure.  

Christopher Chen, MD: [00:03:53] We want to see? You're going to make your cardiologist very happy. If your blood pressure is less than 120.  

Matthew DeVane, DO FACC: [00:03:58] ess than 120. Right. Optimal I know. Right. So I think that's very important. Also we're talking about the numbers off real quick here. But we're talking we're throwing out a lot of numbers that are all the systolic blood pressure. Get Doctor Jen do you mind just commenting real quick on what is the difference between the top number and the bottom number and what that means for patients?

Christopher Chen, MD: [00:04:18] Absolutely, so if you looked at blood pressure on a graph, it'd go high when the heart pumps and down when it stops pumping. And so the highest point is the systolic blood pressure. And that's the first sound you hear when you take the blood pressure. The lowest point is the diastolic blood pressure. And that's the sound where the blood pressure disappears when you're listening to it. And so we measure that both using an automated cuff and a manual cuff.

Matthew DeVane, DO FACC: [00:04:45] So the systolic blood pressure and diastolic top versus bottom. So we talked about the normal systolic and how that is defined for blood pressure and high blood pressure. What about the diastolic numbers I don't think we mentioned that.

Christopher Chen, MD: [00:04:58] So diastolic blood pressure abnormal is above 80. And we talk about a lot of patients ask me oh my diastolic is high. But my systolic is okay. Is there anything to do about it? Yes. And that's maybe a topic on its own, but um, but definitely we look at both numbers.

Matthew DeVane, DO FACC: [00:05:17] We do. So anything above 80 is high blood pressure on the diastolic side. Right. So that is 90% of our patients that we see in the cardiology office or you know, so we'll have to talk about why it's so important to track blood pressures outside the office. But we'll get to that in a minute. So high blood pressure. We talked about normal. We talked about elevated and the different phases of hypertension, the different classes.

Carolyn Lacey, MD FACC: [00:05:41] Maybe we should talk about low blood pressure just to get it out of the way. Yeah.

Matthew DeVane, DO FACC: [00:05:45] Yeah we need to talk about that. Yeah. We don't we we actually deal with that quite a bit based on medications and young people and those sort of things. So I personally think of, you know, a lot of people come to me and say my blood pressure is only 90 over 60. Is that good or bad or different? And so I spend a lot of time trying to talk about symptoms with numbers. But, um, Doctor Chen, why don't you tell us what is hypotension? That's low blood pressure.

Christopher Chen, MD: [00:06:10] So hypotension is low blood pressure. And I like to share a story on this one where we're rounding on the wards. And one of my attendings, cardiology heart failure attending, said, I don't really care how low the blood pressure gets, as long as you're thinking standing and urinating. And it's a little bit of a cardiologist joke. But truly, low blood pressure is okay as long as you're asymptomatic. Now, we define low blood pressure specifically as a systolic less than 90 and a diastolic less than 60. So depending on what your blood pressure is and your cardiologist may adjust things depending on what your symptoms actually are and why we need to or don't need to get you there.

Matthew DeVane, DO FACC: [00:06:55] Okay, let's jump back to high blood pressure or hypertension.

Matthew DeVane, DO FACC: [00:06:58] So why do we care if someone's blood pressure? I mean, there's so much emphasis. High blood pressure. What's your number? Do you know your number? Are you being treated. You know, are you taking your medicines? Why do we even care about high blood pressure? What are some of the things that high blood pressure does to the body that we don't like?

Christopher Chen, MD: [00:07:15] The long and short of it is that it's associated with a lot of poor outcomes and what we say, what categorizes those strokes? Heart attack, cardiovascular death. You know, those risks double with every 20 point increase in blood pressure. And we found that out in the 40s. 50s 60s 70s where people had really bad blood pressure like two hundreds, two 50s. And we're passing away early from that. And since then we've come up with a lot of treatments aimed at targeting that, that have, you know, shown a lot of reduction in terms of heart attack and stroke. So when we talk about high blood pressure and wanting to treat it or really wanting to do is prevent those bad outcomes, those heart attacks, those strokes, those heart, those deaths that could be prevented from from hypertension.

Carolyn Lacey, MD FACC: [00:08:04] As I was preparing for this particular recording today, I came across a statistic that I found. I found a number of statistics that are staggering. However, in 2010, one of the statistics that I found was that hypertension was the leading cause of death and disability in what they call disability-adjusted life years worldwide. Wow. Staggering.

Matthew DeVane, DO FACC: [00:08:30] It is staggering. And just in the US alone, there's almost 700,000 deaths per year associated with high blood pressure. And you know, about at least half the population of adults has high blood pressure that's not adequately being treated for most people. So yeah, you think about the blood pressure and how it's squeezing in your and your arteries are pretty sensitive. I mean, they're fragile little structures, especially when they get down to the smaller vessels like the capillaries and things like that, which are the vessels that dominate in, you know, things like your eyes and your kidneys, those vessels that are being pushed, pushed, pushed by high blood pressure, they'll get damaged over time. And so when you talk about strokes and heart attacks and kidney failure and loss of vision and erectile dysfunction and the list goes on and on, that's when the blood pressure just keeps damaging those arteries over years, and which is why we care so much about treating it aggressively.

Carolyn Lacey, MD FACC: [00:09:22] What are some of the symptoms that patients come in and tell you? Oh, I think I have high blood pressure because I'm having these symptoms. What are have you do you have any symptoms that you hear over and over or.

Christopher Chen, MD: [00:09:36] Absolutely. I think the most common ones are headaches, right? They think, okay, I'm having a headache. My blood pressure must be high. And let me go ahead and check it. And the majority of the time it may or may not be associated. So patients may have headaches, decide they check their blood pressure and it's high. But it could be that the headache happened first and that triggered some high blood pressure. So often there are a lot of triggers of blood pressure. Pain is one of them. Um, but for I'd say at least 80% of the cases, blood pressure is silent.

Matthew DeVane, DO FACC: [00:10:10] Silent killer, right?

Carolyn Lacey, MD FACC: [00:10:11] Silent killer. Correct.

Matthew DeVane, DO FACC: [00:10:13] So when we say silent killer, what does that mean? Well, it just means that most people have no symptoms whatsoever. You could be walking around for years with blood pressures, systolic blood pressures, 160, 170 or higher and not even feel it. It's not until organs really start getting damaged that you start having symptoms or problems from it. So that's the very scary part about high blood pressure, which is why we want to be so proactive. Getting to your doctor, talking to your doctor, getting a blood pressure cuff at home and those sort of things. Right. Silent killer. Not good.

Carolyn Lacey, MD FACC: [00:10:43] How do you tell your patients to check your blood pressure? I think we are. How often do you tell your patients to check your blood pressure? I think we talk about this. We probably all manage it a little bit differently and definitely differently depending on the patient that's in front of us. But do you have anything you typically say?

Christopher Chen, MD: [00:11:02] Um, I typically ask them to check it twice a day, so I usually ask them to check it once in the morning and once in the evening. Um, I actually have a dot freeze for this, so I tell them that they need to be sitting, resting, relaxed. They hopefully haven't exercised recently, beforehand, or just had their morning coffee and in a chair with a straight back. Um, and I ask them to take it a couple times and average it. Not every patient's gonna gonna be able to do that. So I kind of adjust accordingly. Um, but I don't know. What about you guys? What do you guys counsel your patients on?

Carolyn Lacey, MD FACC: [00:11:37] Well, I think the instructions. Your dot freeze is excellent. Because, you know, when you look at when I did a Google search online, I do use Google. Yeah. Um, but when I did a Google search online, you know, there's a lot when you say, how do I check my blood pressure? There's a lot of variability out there, but the things that I've seen be constant amongst all the places where I've looked at how to check your blood pressure, just like you said, sitting quietly upright, feet flat on the floor, um, making sure your arm is relaxed, taking the blood pressure a couple of times, um, and sort of either averaging them or taking the best or taking the last two. There's a lot of there's a lot of, um, differences in opinion on what is the best for that. Um, I tell my patients to take it. It depends on the patient. I mean, but sometimes it's only a couple times a week if it's somebody that we've been pretty well controlled for a while and they we haven't changed any medicines. You just want to know that it's about the same. Um, but sometimes the patients who were just getting started on therapy, or they feel like there's a lot of, a lot of drastic changes in their blood pressure. And sometimes of the day it's very high. Sometimes it's the day it's low. We may check it a little more often than that.

Matthew DeVane, DO FACC: [00:13:03] Um, you were talking about what you guys are recommending for home blood pressure monitoring. And of course, home blood pressure monitoring is critical for us to help manage your blood pressure. I mean, when you come to the office, it's going to be high. If you're in the ER with problems, it's going to be high. If you're having pain, it's going to be high. You're anxious, it's going to be high. So for us to get an adequate assessment of what your average blood pressure is at home, you need a home blood pressure cuff. Fortunately, there are many out there that are very effective, very accurate and inexpensive to buy. So that is helpful for us. You. But I often get the question you were mentioning how they should do it. Blood pressure cuff size does matter. So how do you size matters. Yeah. So it has to it.

Carolyn Lacey, MD FACC: [00:13:41] Has to fit. So the the biggest part with the blood pressure cuff there are a number of parts to the blood pressure cuff. But you you really want a cuff that really sits on your upper arm. Um, that fits appropriately. If you have a cuff that's too small, it can artificially elevate your blood pressure, and you may not get good data from that. I get a lot of questions about what company to use. Do you have do you guys get that question as well?

Christopher Chen, MD: [00:14:07] I do get that question quite a bit, and I don't usually make too many recommendations on the company side of things.

Carolyn Lacey, MD FACC: [00:14:16] I never have.

Matthew DeVane, DO FACC: [00:14:17] Either. Oh, I always do. I always say you do. I don't know why always I always get the Omron Omron copters. They have three different types. And I tell them to get the middle one, which is, you know, they have the cheap one that's like 30 bucks and the expensive one, that's 120. But there's a middle of the road, one that's 40 or $50. So they're they're accurate. And I've had good experience with them. I and I don't work for them nor do I. Yeah. So anyway that's that's when I tell. But there's a ton out there.

Carolyn Lacey, MD FACC: [00:14:43] The American Heart Association actually talks about on their website. They talk about a different website called validatebp.org. And so I looked up this, I clicked on to this website. And they make recommendations on different blood pressure cuffs. I didn't know that.

Matthew DeVane, DO FACC: [00:14:59] There's a ton of data out there. Okay. So we've talked about the emphasis of how home blood pressure monitoring is helpful. Let's talk a little bit about, you know, so anyway, we're seeing somebody with blood pressure for the first time or in follow up. And we always want to look at their history and some of the factors. So both modifiable risk factors I'll call them and non-modifiable risk factors that may help drive blood pressure. Doctor Chen can you can talk about it a little bit about those types of factors driving people's blood pressure.

Christopher Chen, MD: [00:15:28] Absolutely. We'll start with the non-modifiable ones. Non-modifiable ones are non-modifiable they come from your family history or your genetics. They may be related to the area that you live in. If you're in an area that is heavy pollution and you're not, you're planning to stay there, then that may be non-modifiable, but generally these things contribute to your blood pressure. And I have patients who are healthy, eat well, normal weight, exercise normally no stress and their blood pressure is 160, right. Those are non-modifiable risk factors. Modifiable risk factors a little bit different. So modifiable risk factors those are the things we tend to focus on because we can change them. Um and a lot of those revolve around there's a couple pillars obesity, diet, alcohol consumption, sleep quality, stress, exercise and meds. That's seven things. That's a lot of things to focus on. A lot of pillars. Yes. And so you know, trying to address those throughout one visit is difficult when you're seeing a physician for 15 or 30 minutes. And so.  

Matthew DeVane, DO FACC: [00:16:47] That's why they all have to listen to the podcast.

Carolyn Lacey, MD FACC: [00:16:49] Ooh, that was a good set up there.

Matthew DeVane, DO FACC: [00:16:52] Doctor Chen.

Carolyn Lacey, MD FACC: [00:16:54] He'll be on again don't worry.

Matthew DeVane, DO FACC: [00:16:56] No. Absolutely. And so we try to identify at the first visit what are the targets for your modifiable risk factors that we should address first. What's the low hanging fruit. Right. And and we start from there in every visit we try to address something and work on things and give you something to work on. But those are the things that we're all thinking about in the back of our mind. And specifically, when I talk about sleep, we're talking about how much sleep are you getting? Is it quality sleep? And do you have sleep apnea? Right. So when people are coming at this point to a cardiologist for hypertension management, um, they may have tried a couple things already. And sleep apnea is usually pretty high on our differential. And sleep is so important. And so many people have sleep apnea that don't fit that classic category that, um, it is important to think about and ask them the questions or have them, you know, tell us if they're feeling fatigued throughout the day so we can start screening them for it. Another thing about sleep is when you sleep, right, there's so many studies that have shown that people who work night time jobs, right? Graveyard shift. Just the fact that you're not abiding by a typical circadian rhythm causes changes in your metabolic patterns, in your weight, and in your blood pressure.

Matthew DeVane, DO FACC: [00:18:17] I think that also just ties into the, um, how these things play on each other. Right? So you're not sleeping well, you're more stressed. You're more stressed, leads to poor eating. Poor eating leads to less exercise, less exercise leads to more weight. And the cycle just repeats itself and feeds on itself.

Christopher Chen, MD: [00:18:37] Absolutely. And sometimes when we mention that in the office, it seems like an insurmountable problem. When, when when we bring that up. And what I think is important to remember is just to keep things simple for the patients, right? For, you know, work on one thing at a time. And eventually, if you work on one thing at a time every day, you'll be able to overcome your obstacles. Yeah, don't have to try to tackle everything at once.

Matthew DeVane, DO FACC: [00:19:03] Excuse me. Yeah, yeah, that's that's nice. It is overwhelming. So yeah that's a that's a great way to tackle it. Let's just focus on one thing. And maybe it's just getting out and doing a walk one day or whatever and just focusing on that for the next month and then moving on to, you know, plan B, C and D.

Matthew DeVane, DO FACC: [00:19:19] So great. Um, you mentioned something earlier about one of these pillars is being medications. And what you're talking about is medications that can actually increase blood pressure. Yeah. Can we maybe talk about a few of those classes of medications in general? Because that is one of the first things I'm going to be scanning for when someone comes in with high blood pressure as to what medicines they're already on, that could be contributing to that.

Christopher Chen, MD: [00:19:42] Absolutely. And so there's a couple categories of those medications. One of the common ones is when people take things for pain, right. They're on NSAIDs ibuprofen, naproxen and ibuprofen and naproxen, they raise your blood pressure. So if you're taking it every day for pain, which a lot of people do for knee and back pain, then it'll raise your blood pressure and and that aloan can can put you in the hypertension category.

Matthew DeVane, DO FACC: [00:20:09] Well, let me say real quick that's just a bad combination because pain also raise blood pressure, right? The medicines they're taking for pain increases blood pressure. They're not exercising. They're not sleeping because of pain. So again just once again your cycle the cycle just feeds on itself. It's bad. Absolutely.

Carolyn Lacey, MD FACC: [00:20:24] And a medicine that people think is pretty safe. Right. It's over the counter. It's safe. We should be able to take this. But the nonsteroidals, the NSAIDs, they have a lot of significant side effects that come along with it. So they're not the one people who are taking them every day are much more likely to have some of those side effects versus someone who takes it rarely if needed for pain.

Christopher Chen, MD: [00:20:48] Absolutely. So one of the things I think about is, okay, like for people that have a lot of pain and they're on NSAIDs chronically, can we change something about that? Can we give them topicals? Right. Because topical absorption, even if you're using a topical Nsaid, is way less than systemic absorption when you're taking it by mouth. And so working on some of those small regimens might be helpful.

Matthew DeVane, DO FACC: [00:21:11] I also see talking about another class of medications if we're going to um, is the even commercials on TV about decongestants that don't cause high blood pressure. How common is as decongestant raising blood pressure and how worried should patients be about it?

Christopher Chen, MD: [00:21:28] Um, there's the main category of decongestants that cause that are either in the pseudoephedrine category or in the phenylephrine category, and they come by many different brand names, but they definitely do cause an increase in blood pressure. And you'll see that around, um, allergy season.

Matthew DeVane, DO FACC: [00:21:45] What I try to tell people when they're taking them is, listen, it's easy enough to track, right if you need them for allergies to get through the season, just keep it and you want to try something before I say don't use them at all, I say just track your blood pressure. If you see crazy changes in blood pressure, then we have to reconsider or try a different brand or something like that. But for most people, short use doesn't have a huge effect. But it's something that, again, may contribute and be one of those pillars we're talking about.

Carolyn Lacey, MD FACC: [00:22:07] I like how you say that. I like how you say just track it and try it and see. I think that a lot of patients get the they get the sense that if we tell them something's going to raise their blood pressure, that they can't use it at all. But it's not that. It's not that we're saying, no, you can't. It's we need to see how this is going to affect you. We need to collect some more data and sort of understanding that it's not an all or nothing phenomenon. It's really important for patients to learn.

Matthew DeVane, DO FACC: [00:22:38] And I say to tell patients the numbers tell the story. So if you do have an accurate home blood pressure cuff, you just track it. I mean, that solves everything. And I love it because that empowers the patient, right? They see what happens. They learn about how their body reacts to things, and then they can decide at the end.  

Matthew DeVane, DO FACC: [00:22:54] Empowering patients. That's what I like. That's what it's all about. It's good. Nice.

Carolyn Lacey, MD FACC: [00:22:58] They can do a lot. People can do a lot to take care of themselves. Outside of what, uh, of what the doctor can tell them to do. And just learning about that is really important.

Christopher Chen, MD: [00:23:08] I agree, I think that's part of our role.

Carolyn Lacey, MD FACC: [00:23:10] So I think that we've had a really good review there of some common medications that can raise the blood pressure. I think just in sort of review of where we're at from this episode, you know, our a normal blood pressure is less than 120 over 80. That's optimal. That's where we want us to be. And the the definition of low blood pressure is really driven more by the numbers, more so than it is by the symptoms. I'm sorry. The low blood pressure is driven more by the symptoms.

Matthew DeVane, DO FACC: [00:23:39] Say that part again okay.

Carolyn Lacey, MD FACC: [00:23:41] Low blood pressure is driven more by our symptoms. More so than just the numbers. And paying attention to your numbers to help prevent the long terme effects that can come with having high blood pressure. High blood pressure is the silent killer in the United States and worldwide. Um, so, Doctor Chen, thank you so much for being with us this morning. I think you've given us a lot of really great information and more empowering of your patients has it's important to do that. And so we're really appreciative.

Matthew DeVane, DO FACC: [00:24:11] I'm going to really remember those seven pillars. And I think we should maybe dedicate a whole episode to how we can attack those in the future. So thank you, Doctor Chen. Appreciate you being here.

Christopher Chen, MD: [00:24:19] Thank you so much for having me.

Matthew DeVane, DO FACC: [00:24:24] This is Doctor Matt DeVane and on behalf of my co-host, Doctor Carolyn Lacey and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living heart smart.

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