Blood Pressure – How High is Too High and How Do I Lower it Safely

Blood Pressure: How High is Too High and How Do I Lower it Safely? Graphic © herbshealthhappiness.com Background image: Pixabay (PD)

The numbers don’t lie: According to the WHO, there are an estimated 1.28 billion people all over the world with hypertension, with two-thirds of that number belonging to low and middle-income countries. Half did not know they were hypertensive in the first place! ^[1] In August 2021, the WHO published a joint press release reporting that over 700 million people (a total of 720 million to be exact) were not receiving the treatment they needed. ^[2]

In 2019, the University of California published a popular video on their Youtube channel focusing on hypertension and how to manage it. They featured primary general care internist and Vice Chief of General Internal Medicine at the UCSF Osher Center for Integrative Medicine, Robert Baron. Dr. Baron zones in on how high blood pressure is diagnosed and what you can do to keep it manageable. Dr. Baron states that hypertension is the number one cause of premature deaths all over the world – and the World Health Organization agrees.

What Is Blood Pressure And Why Is It Important To Health?

Blood pressure is a measurement of the pressure exerted by your blood against the walls of your arteries. Blood pressure is made up of two readings, your systolic (the number on top) and diastolic (the number on the bottom). ^[1][3] The higher the blood pressure, the more strain your cardiovascular system – meaning your heart and your vessels – is under.

Measuring Blood Pressure

Dr. Baron mentions several kinds of blood pressure measurement: office, home, ambulatory, and research-grade measurement. The first three were discussed in a study in 2014, published by Niiranen, et. al. in the American Heart Association Journal. ^[4] The first, office measurement, is done at a doctor’s office and is typically the standard used by doctors to diagnose hypertension. However, this type of measurement is affected by the “white-coat effect” or a condition when blood pressure only becomes elevated in a clinic or hospital, or in the presence of a health care worker.

On the other hand, home measurement is affected by factors like cuff size and self-medication. Without the proper guidance of a trained HCW, measurements at home can be inaccurate. In fact, Dr. Baron mentions that one of the major barriers to treating hypertension is that people who measure their blood pressure at home often adjust their hypertensive medications without consulting with their doctors.

The third kind of measurement, ambulatory blood pressure, is the gold standard for diagnosing hypertension (according to Niiranen, et. al. ^[4]) because it is free from the white-coat effect and external factors like cuff size and self-medication. In fact, this type of blood pressure measurement makes it easier to diagnose masked hypertension and nocturnal hypertension. The former is a condition of elevated blood pressure outside of a clinic or office while the latter is nighttime elevated blood pressure. ^[5][6] Ambulatory blood pressure, according to Dr. Baron, is the best predictive measure for cardiovascular disease and heart attacks.

Lowering Mortality By Lowering Blood Pressure: The SPRINT Study

SPRINT – which stands for Systolic Blood Pressure Intervention Trial – was a randomized, controlled, open-label trial in the United States in 2015. The trial was designed to test if treatment targeted towards lowering blood pressure below systolic pressure of 120 would be able to reduce cardiovascular disease (CVD) risk, compared to the recommended goal (less than a systolic pressure of 140). ^[7] The conclusion was that intensive treatment targeting a systolic blood pressure lower than 120 resulted in lower mortality rates. ^[8]

One of the data points derived from the SPRINT study was Dr. Baron’s fourth kind of measurement – research grade blood pressure. There were variations: participants were alone the entire time, never alone, alone for rest, and alone for measurement. Dr. Baron mentions that the results leaned towards robotic measurement, wherein systolic blood pressure measurements taken without human interaction were lower by 12.5 points. However, according to Johnson, et. al., this difference was not significant in changing the results of the study. ^[9]

Preparing To Get Your Blood Pressure Taken

Dr. Baron gives a few tips before getting your blood pressure taken.

1. Sit down for five minutes before measurement.
2. Do not eat or drink anything with caffeine or smoke 30 minutes before your measurement is taken.
3. Do not talk during measurement.
4. Do not have any clothes under the cuff.
5. Your back must be supported with your feet on the ground, and your arm must be level with your heart.
6. Ensure the correct cuff size is used. A cuff that’s too tight can give a higher reading while a cuff that’s too loose can give a lower reading.

If you measure your blood pressure at home: Bring the machine you use, and if possible show the nurse or doctor how you take your reading. This can help correct any mistakes and improve your blood pressure measurement skills. An incorrect reading can lead to misdiagnosis and a lifetime of medications, so correct blood pressure measurement is very important in the diagnosis and treatment of hypertension.

How High Is Too High? Blood Pressure Readings That Diagnose Hypertension

The guidelines from the International Society of Hypertension published in 2021 emphasize several key points for practice for doctors: ^[10]

– Use 140/90 for office diagnosis of hypertension, 135/85 for home, and 130/80 for ambulatory measurement.

– For people with grade 1 hypertension and no other comorbidities, try non-pharmacologic treatments (see below) for 3 to 6 months before starting medication.

– Once medication is started, doctors should target blood pressure to be less than 140/90 within three months, and less than 130/80 in patients younger than 65 years.

For the Eight Joint National Committee or JNC, these were the guidelines: ^[11]

– For people over 60 years old, “cut off” (hypertension diagnosis) is a systolic blood pressure of 150 rather than 140
– For people under 60 years old, cut off is a systolic blood pressure of 140

What Are The Treatments For High Blood Pressure?

There are two kinds of treatment for hypertension: pharmacologic and non-pharmacologic. Dr. Baron’s opinion is that medications outperform non-pharmacologic treatment but that the latter can slow the need for medication or improve blood pressure enough to reduce medication.

Non-Pharmacologic Management Of High Blood Pressure:

In the University of California’s video, Dr. Baron has 4 main recommendations for non-pharmacologic management of hypertension.

1. Weight Control:

Weight control is an important part of controlling hypertension because obesity and weight gain are linked to elevations in blood pressure. Seravalle and Grassi in 2017 list alterations in the sympathetic nervous system, renal function, and insulin resistance as the mechanisms that contributed to hypertension. ^[12] Keeping your weight down with the proper diet and exercise can help dock off a few points off your blood pressure reading.

2. Alcohol Intake Reduction:

While many studies support that occasional intake of alcohol can be beneficial (like red wine), Puddy, et. al. in 2019 examined the causal relationship between alcohol and hypertension. They discuss the effects of alcohol on the body, namely vasoconstriction and oxidative stress, which increase blood pressure and could increase your risk for hypertension. ^[13]

3. Salt Restriction And The DASH Diet:

The adage “where salt goes, water follows” applies to hypertension, where a diet high in salt intake causes fluid retention and elevates blood pressure levels. This is why a low salt, low fat diet is often advised to people who suffer from hypertension. The DASH (Dietary Approaches to Stop Hypertension) diet is another option, or a diet that is rich in vegetables, fruits, whole grains, fat-free or low-fat dairy products, fish, poultry, beans, and nuts. This kind of diet also advises that you avoid food high in saturated fat, like fatty meats and full-fat dairy products. ^[14]

4. Exercise:

The fourth recommendation is linked to the first: Exercise. The American Heart Association recommends at least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic activity each week. ^[15] Even a few minutes of not sitting down can help reduce your risk for CVDs.

Pharmacologic Management Of High Blood Pressure:

Dr. Baron also discusses four major pharmacologic treatments for hypertension: ACE-inhibitors, ARBs, Thiazides, and Beta-Blockers.

– ACE-inhibitors lower blood pressure by inhibiting the angiotensin converting enzyme, which causes vasoconstriction. An ACE-inhibitor effectively relaxes the vessels, lowering blood pressure. ^[16]

– ARBs are angiotensin receptor blockers, which, unlike ACE-inhibitors, do not inhibit the enzyme itself, but rather, inhibit their receptors on the cells. An ARB will also relax your blood vessels, thereby lowering blood pressure. ^[17]

– Thiazides are diuretics, or a kind of medication that expels salt and water from the body by increasing urination. ^[18]

– Beta-blockers work by inhibiting the beta-receptors in the heart, which can reduce heart rate and blood pressure by relaxing the smooth muscles of the heart. ^[19]

These treatment guidelines vary with each organization and vary even more with each physician but more or less, the methods used – either pharmacologic or non-pharmacologic – remain the same. Typically, in the orthodox medical world, non-pharmacologic treatment is advised for the first few months if the patient isn’t high risk, and only if those methods don’t work do doctors prescribe medication. Keeping your heart healthy by proper weight management, diet, and exercise can help manage your blood pressure effectively.