To know my patient Frank is to love him. He has a big, boisterous, salesman’s personality—perfect for LA’s highly competitive garment industry. At forty-five years old, he’s already considered an “elder” in this youth-centric business. A classic Type A, he’s outgoing, ambitious, rigidly organized, highly status conscious, sensitive, impatient, anxious, proactive, and concerned with time management.
In short, Frank is a high-achieving “workaholic.” He’s also had several coronary events in which he felt chest pains—the classic symptom of a heart attack. But we know through the miracle of modern-day diagnostics that he has had silent heart disease for several years; diagnostic images reveal multiple scars on his heart, the telltale sign of the disease. He also has several risk factors, including a family history of heart disease and the stress and related anxiety that comes with his personality type.
But his biggest problem is hypertension, or high blood pressure. Perhaps of all the major risk factors, hypertension is the most common, affecting nearly one in two adults. What’s more, it’s often the “silent killer” in coronary disease, because about one in three people with high blood pressure don’t even know they have it. Like silent heart disease itself, this silent killer is usually asymptomatic.
There’s a standard profile for patients most at risk for hypertension: men are at greater risk than women, African Americans and South Asians have higher incidences than other groups, and the mean age for acute hypertension is sixty years old. (However, increasingly, younger adults are suffering from it; more on this later in the chapter.)
Is hypertension an inherited condition? There’s likely a genetic factor to hypertension, but medical science isn’t quite sure why. From numerous studies, we do know that if your parents or close blood relatives have had high blood pressure, you are at a higher risk of developing it too.
Hypertension, often referred to as high blood pressure, occurs when the force of blood against the artery walls is too high. Blood pressure, or how hard your blood is pushing against your arteries as it moves through your body, is measured using two numbers. The first number, called systolic blood pressure, measures the pressure in your blood vessels when your heart beats. The second number, called diastolic blood pressure, measures the pressure in your blood vessels when your heart rests between beats. If the measurement reads 120 systolic and 80 diastolic, you would say, “120 over 80,” or write, “120/80 mmHg.”
That particular measurement, 120/80 mmHg, is significant because traditionally that’s been the benchmark of whether a patient has normal or healthy blood pressure. Patients with higher measurements were considered, depending on how much higher, as having prehypertension (between 120/80 and 139/89 mmHg) or bona fide hypertension (anything above 139/89 mmHg).
However, recently, the American College of Cardiology and American Heart Association task force updated guidelines for doctors and their patients with the hope of better outcomes for people at risk for or living with this condition. Released on November 13, 2017, they are the first full set of guidelines for blood pressure in the United States since 2003. The aim is to help patients reduce their risk of developing high blood pressure and improve health outcomes for those already living with it. Below are key points that every patient should know about the update.
The most important aspect of the new guidelines is that now there are four traditional blood pressure categories:
•Stage 1, or elevated blood pressure (prehypertension), is 120/80 to 139/89 mmHg.
•Stage 2, or mild hypertension, is 140/90 to 159/99 mmHg.
•Stage 3, or moderate hypertension, is 160/100 to 179/109 mmHg.
•Stage 4, or severe hypertension, is 180/110 mmHg or higher.
It’s important to note that the new guidelines replace the term “prehypertension” with “elevated blood pressure.” This label includes patients with an elevated blood pressure who are at higher risk for developing full-blown high blood pressure.
What’s behind these changes? Research shows that adults with blood pressure readings considered prehypertensive under the old guidelines are already at up to double the risk of having a major cardiovascular event—a heart attack or stroke—compared to those with normal blood pressure. In addition, recent clinical trials have shown that lowering systolic blood pressure to 120 mmHg results in significant cardiovascular benefit in high-risk patients compared with patients with blood pressures less well controlled.
Of those who fall into the new elevated blood pressure and stage 1 categories, only a small number will need blood pressure–lowering medication. However, everyone in this group should be aggressively treating all their abnormal cardiac risk factors.
Having elevated or stage 1 high blood pressure is a red flag signaling that you must make purposeful lifestyle changes. Based on a number of studies the following changes—though not always easy—are proven to lower blood pressure, protect heart health, and also carry other health benefits: maintaining a healthy weight, eating a heart-healthy diet (which may include lowering your salt intake and boosting your potassium intake), limiting alcohol intake, and engaging in regular physical activity. We’ll tackle each of these risk factors in the next section of the book.
Based on the new guidelines, gauging someone’s risk for heart or vascular disease can help determine how to best manage blood pressure—that is, whether risk factor management alone will suffice or whether these therapeutic changes should be coupled with medical interventions such as cholesterol-lowering or blood pressure–controlling medications. These risk factors include age, gender, total and LDL levels, cigarette smoking, diabetes, and obesity.
Using this risk estimate helps us pinpoint who is likely to benefit most from blood pressure–lowering medications. If your risk of having a heart attack or stroke is 10 percent or higher—meaning that you have a one in ten chance of developing cardiovascular disease or more—you should be taking a blood pressure–lowering medication in addition to adopting heart-healthy lifestyle changes. Regular medical evaluation is recommended at least every one to three weeks, or until blood pressure has become well controlled.
Back to our friend, Frank. As I told him, the good news was that while hypertension is among the most serious of risk factors for silent heart disease, it’s also among the most treatable. After a complete physical, he enthusiastically embraced (as only a Type A personality can!) a healthy lifestyle regimen, complete with a Mediterranean-style diet, regular exercise, and meditation to reduce his stress levels and ensure a restful night’s sleep. OK, he embraced almost everything. I can still hear him now. “Aw, Doc, do I have to? Meditation is like torture to me. How about a cut back on the afternoon espressos instead?” And, oh, yes. Frank is no longer indulging in his after-lunch coffee drinks.
As I mentioned earlier, Frank is in many ways typical of those at risk for high blood pressure—male, prone to stress, with a sedentary lifestyle and unhealthful diet—but just a generation ago, he would have been considered an outlier. His demographic profile would not have been average because he would have been too young. Just ten years ago it would have been relatively uncommon for me to see a patient in his or her forties experiencing significant hypertension, but that’s changing, and researchers aren’t quite sure why. There seems to be a correlation between obesity and hypertension in people younger than fifty years old.
And here’s the real problem: young people tend to think they’re invincible, especially when it comes to a condition like high blood pressure, which they associate with parents or grandparents. But dismissing the possibility of hypertension can be a dangerous gamble. Young adults with even slightly above normal blood pressure may be more likely to have heart problems later in life, according to a new study in the Journal of the American College of Cardiology. The study focused on nearly twenty-five hundred men and women who were eighteen to thirty years old when the study began. Researchers kept track of them for twenty-five years, taking closer looks at the participants’ health seven times. The checkups included blood pressure readings.
Near the end of the study, participants also had heart-imaging tests. Some people had slightly above normal blood pressure (120/80 to 139/89 mmHg) when they were still under age thirty. (Again, this level, which is not high enough to be considered high blood pressure, is known as elevated blood pressure or prehypertension.) But the researchers found that people with above normal blood pressure were more likely to have signs of heart disease in middle age. In particular, they were more likely to have problems with the left ventricle of the heart.
Which brings us to women. Again, the poster child for patients with dangerously high blood pressure is the aging, overweight, white male. Indeed, according to the latest research, by their mid-fifties, about one in four men and only two in five women still have normal blood pressure, and about half of men and women have a blood pressure that is above normal but not yet high enough to be considered hypertension. Studies also show that men are more prone to hypertension than women below the age of fifty. But here’s the point: after the age of fifty, women are at a slightly higher risk for the disease because of menopause. To frame it another way, at sixty-five and older, women are more likely to develop high blood pressure than men.
What about younger women? Half of women who develop high blood pressure by their early forties will develop heart disease or increased risk of stroke later in life (and statistically, many of those will develop silent heart disease). Even younger women aren’t immune to the dangers of high blood pressure since 7 percent of women between twenty and thirty-four have high blood pressure. While the rate is low compared to men, young women are far less likely to be diagnosed with and treated for the condition.
Bottom line: For young women and men, keeping blood pressure in check reduces the risk of stroke by 48 percent.
Let’s go back to Frank one more time. His white, male archetype for high blood pressure masks another reality: high blood pressure affects people of color more than white people. In particular two groups at heightened risk for hypertension are African American adults and adults of Southeast Asian descent.
Black adults are up to two times more likely to develop high blood pressure by age fifty-five compared to whites, with many of these racial differences developing before age thirty, concluded a study recently published in the Journal of the American Heart Association. Known as the Coronary Artery Risk Development in Young Adults (CARDIA) Study, it tracked the blood pressure of U.S. adults from young adulthood through middle age. It included 3,890 adults between the ages of eighteen and thirty, all of whom were free of high blood pressure at baseline and followed for up to thirty years. Participants were from four U.S. cities (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California) and enrolled in the study during the mid-1980s. The goal of the recent analysis was to see how many black people developed high blood pressure and at what age compared to white people, and it revealed that black participants face significantly higher rates of hypertension compared to white adults. By the end of the CARDIA Study, 75 percent of black adults had developed high blood pressure, compared to just 55 percent of white men and 40 percent of white women. Depending on a participant’s initial blood pressure, this difference translated to 1.5 to 2 times greater risk for hypertension among black adults compared to white adults. Researchers noted that many of these differences developed by age thirty, highlighting the need for early intervention. The take-home message, according to the authors, is the importance of high blood pressure prevention in black people beginning at a young age.
Another study found that African Americans are also more prone to hypertensive crisis, a complication of high blood pressure in which blood pressure quickly soars to life-threatening levels. This condition is particularly dangerous because it can lead to permanent organ damage as well as heart attacks and cardiac arrest. All patients with hypertension should follow a prescriptive regimen for a healthy lifestyle and diet, but patients who have experienced a hypertensive crisis must also assiduously follow a regimen of medications as prescribed by their doctor.
While there is a foundational awareness in the black community and among medical professionals of the risk of hypertension for black adults, that’s not the case with American adults of Southeast Asian descent. Generally, the medical community views Asian Americans through a single lens: that is, Asian Americans compare favorably with other ethnic groups in terms of overall health and especially when it comes to heart disease. That poses an inherent danger that both patients and their doctors will overlook high blood pressure based on implicit bias.
A published study evaluated South Asians living in the United States—3.4 million people mostly from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka, who make up one of the fastest-growing ethnic groups in the United States. The results reveal that this group experiences heart disease at a younger age and has higher rates of heart disease than their white counterparts. While heart disease is the leading killer of all Americans, data suggests that Southeast Asians face especially high rates of heart disease in the United States. Southeast Asians living in the United States also are at increased risk for a cluster of risk factors associated with heart disease, including hypertension as well as diabetes and high cholesterol.
Now, all the warnings about the dangers of high blood pressure discussed in this chapter might seem dire, and without a doubt, high blood pressure is a leading factor in the genesis of heart disease. Worse, the disease is widespread (with one in two adult Americans suffering from it) and “silent,” without any easily recognizable symptoms. But the good news is that it’s highly treatable. We have decades now of research and clinical practice that show us how changes to diet and lifestyle, together with medications when needed, can control high blood pressure.