Transcription:
Blood Pressure Medications 101

Melanie Cole (Host): If your doctor’s told you that you have high blood pressure, they may recommend blood pressure medication to help control that hypertension. The array of medications available can be quite confusing. My guest today is Dr. Joseph Kummer. He’s a cardiologist at Bryan Heart. Welcome to the show Dr. Kummer. So first, just give a quick definition of hypertension.

Dr. Joseph Kummer (Guest): Hi, Melanie. Thank you very much for having me here. Well, hypertension is something we all hear about. It’s a very common thing. Basically, it’s high blood pressure which seems kind of self-explanatory. But, exactly how high is too high? Well, it’s kind of a work in progress. I talked about that before. As a general rule, you want your blood pressure to be less than about a 140/90. Some people with different medical conditions, we might go for about a 150/90 or less but it kind of depends upon your age, depends upon your other factors with your health, your heart health, et cetera.

Melanie: So, then, if somebody comes to you and you’ve determined that they have hypertension even if it’s not really very high but maybe you want to put them on medication, Dr. Kummer, what are some of these various medications? As I said in the intro, they can be a little bit confusing. People aren’t sure what the medications are even intended to do.

Dr. Kummer: Well, the bottom line is we want the blood pressure to be a little bit lower. Again, we kind of have our goals and those goals are a little bit different for each individual. And, there are a lot of different medications out there that can achieve those. And, exactly what the best one is for an individual is kind of a moving target in a way because there are some that are better for certain people, there are some that are better for others. And, again, that depends upon how high your blood pressure is. It depends upon your heart health. It depends upon your kidneys. A lot of the medications that we use work. Well, each one basically works in different mechanisms or different ways. You kind of have to look at the whole picture as far as what are the other things that you’re trying to accomplish with the blood pressure medication. As a heart doctor, a lot of my patients obviously, have blocked arteries; they’ve had heart attacks before. There’s a category medication called “beta blockers” and those are pretty universally used. There are a lot of different types of them. There one called or the more common generic names are Metoprolol, there’s Atenolol, Nebivolol. These are pretty common for my patients because they work very well. They’re good at lowering the blood pressure. They do tend to cause some side effects in some people. Now, those aren’t extremely common but they do slow everything down. So, the way that the beta blockers work, they tell the heart to beat a little bit slower. When the heart beats, it pumps blood forward that pumps into the arteries. The more blood is pumped into the arteries, the higher the pressure is in them. So, when you slow the heart rate, the heart pumps a little bit less blood overall and that lowers the pressure in the arteries. That’s how they work as far as lowering the blood pressure. Plus, the beta blockers relax the heart a little bit, too, so it doesn’t pump quite as strongly. If your heart is now somewhat weak, if you’ve had a heart attack before, that can actually be beneficial for the heart; it kind of helps to relax the heart itself. Another medication category that we use more commonly are medications called “ACE inhibitors”. Lisinopril is a very common one. We use that quite a bit. There are several different ones. The way to remember the ACE inhibitors is that they almost always end in -pril, P-R-I-L, like Lisinopril. These are great medications. They work very well. They’re usually very, very well tolerated. So, they work in mechanism that helps. . .It works on a certain hormone system inside the body that the kidneys are largely in charge of. So, it kind of blocks a certain hormone pathway and it ultimately goes on to tell the kidneys to pull more fluid in the body. And, again, the more fluid in the body, the more it stays inside the arteries. That increases the pressure and kind of like when the heart pumps more blood into the arteries and stretches them and expands the pressure there. So, the ACE inhibitors are kind of designed to keep the kidneys from pulling quite as much fluid in the body. And then, also, just at the level of the arteries themselves, the ACE inhibitors work on kind of relaxing those arteries themselves to bring the blood pressure down as well. Another very common category are called “angiotensin-receptor” blockers. Those are very similar to the ACE inhibitors. Losartan is an example of one of those. These are still pretty affordable as are the ACE inhibitors for the most part. They work very, very similar to the ACE inhibitors and these are considered to be first-line agents for high blood pressure. They work in a little different pathway with the mechanism that tells the body to pull more fluid into the body. I’m sorry. It tells the kidneys to pull more fluid into the body. But, ultimately, it ends up being a very, very similar effect. The other thing you’ll hear a lot about that a lot of people are taking are diuretics, and these are simply medications that make you pee. They just make you urinate more. Again, if you think about pressure inside an artery, if you think about it as a balloon, you keep on pouring, pushing more and more air into the balloon, you’re going to see it stretch out, the pressure increases. Well, the same thing with more fluid into an artery. The more and more fluid there is in the arteries, the higher the pressure. So, if you urinate more, that gets rid of more fluid throughout the whole body and, in particular, within the arteries. That’s how they work for lowering the pressure inside the arteries. So, they do work very well. They’re tolerated very well except they do make you urinate more frequently. So, hydrochlorothiazide and furosemide are a couple of examples of those. So, those are very effective. We use them a lot. But, keep in mind that they might make you just kind of run to the bathroom a little more often than you would otherwise. Sometimes people have more profound effects, too. But, I guess the last major category that we use relatively commonly are called “calcium-channel blockers”. These work mostly just by relaxing the arteries themselves. It’s more of a direct action on the arteries that cause them to relax. They expand out and then that lowers the pressure inside the arteries, lowers the blood pressure. Amlodipine is a very common example of those. Most of those end in –pine, like Amlodipine, P-I-N-E. So, again, these are actually pretty affordable medications and calcium-channel blockers are usually very well tolerated so not many major side effects for the most part. Really, when you look at the first medication, when you go to your doctor and they check your blood pressure and they say, “Well, it’s high,” usually we’re going to have the patient come back a month later, a couple weeks later, check it again and just see. If it still is above that 140/90, which is our general category that we’d like to see, we’ll often start with medication. The ones that we would start with now, generally, are going to be the diuretics, the angiotensin-receptor blockers, the ACE inhibitors, or the calcium-channel blockers. The beta blockers, we usually like to hold those off unless there some other direct reason like if you’ve had a heart attack before. They’d be more beneficial there. If your heart muscles are weak, it’s more beneficial there. But for the most part, any of those other four medication categories we start off with are usually pretty well considered to be first-line.

Melanie: Do you sometimes have to combine medications?

Dr. Kummer: The vast majority of people need at least two medications to control the blood pressure. We’ve changed the guidelines here and there throughout the course of the years, of course, as new information that comes about. But, the general thought is most people are going to need two medications. The guidelines now say that for the majority of people, it’s even reasonable to start with two medications in some instances. You never have to but it’s always something that you have to keep in mind. So, there are a lot of combination pills. They work just the same as taking two different pills. It’s just two different medications combined into one. So, it’s a little more simple. A lot of those do cost a little bit more, so sometimes we avoid them for that purpose but it is more convenient because it might just be one pill a day rather than two to one. Don’t be at all surprised. Don’t think that you’re an exception to the rule at all if you have to be on more than one medication because most patients do require that.

Melanie: If they’re not working, how often do you tell people to keep track of their blood pressure? And, if they’re not working, do you something have to change the dosages?

Dr. Kummer: Well, we usually start off with a lower dose and then kind of titrate up. We never want to put you on more than you need, of course. So, we’ll start out with something more conservative. And one thing that really can help is getting a blood pressure cuff to check your blood pressure at home, especially if there’s sometimes where it seems a little bit high and at other times it looks great. A lot of times when you come in a doctor’s office, it’s a little bit elevated just by the stress of being in the doctor’s office. So, sometimes it’s better to get one of those machines where you check at home. Now, we like to see patients, at least when we’re titrating the medication, a lot of times you go to the doctor every month or so to see how it’s working and then go up on the dose as needed. But it’s very, very helpful if you can have a machine that you can pick up at pretty much any drugstore or any pharmacy. They work great and it’s really helpful because you check your blood pressure at home in a relaxed environment. We generally want you to be sitting still in a relaxed environment for at least five to ten minutes. That’s what we consider to be the most accurate blood pressure. So, if you have that ability to check it on your own at home, check at different times of the day because your blood pressure’s always changing. And then, you can bring that into your doctor’s office and then say, “Well, here’s what my average readings are doing.” You can see a much more accurate assessment over the course of the time rather than just that one moment when at the doctor’s office.

Melanie: Dr. Kummer, what’s all the fuss with salt about? If somebody does suffer from hypertension, even if they’re on medications, do they need to worry about sodium levels and food?

Dr. Kummer: That’s a great question. The answer is simply yes. Salt, as a matter of fact, if you look at the real mechanism of how the ACE inhibitors and the angiotensin-receptor blockers work and even the diuretics, a lot of them, basically, their goal is to ultimately keep the kidneys from pulling more salt into the body. The body uses salt to regulate blood pressure because water in fluid follows salt. So, the body pulls more fluid, the kidneys pull more salt in the body, more fluid comes along with that, the pressure increases. So, when you take a pill to get rid of salt, to get rid of fluid, the other aspect of it is well if you don’t consume as much salt, you don’t need to get rid of it as much; your blood pressure won’t be as high. So, two things to keep in mind: first of all, salt is in very, very large amount of the food that we eat. Processed food has a ton of salt. I like it, everyone likes it. It makes food taste better so processed food has a ton of salt in it to make it taste better, to make the product sell more. So, you really have to be conscientious to look at the label which, fortunately, almost everything does have a good label on now, so you can see how much salt you’re consuming. But, if you can keep your salt intake very low, try to keep it at a more natural level rather than all the processed foods, that will help the blood pressure. The other thing to keep in mind, though, is that it’s not going to make your blood pressure go from a 150 down to a 110. You’re going to get some improvement but it’s not going to be dramatic. Some people can get by just by limiting their salt intake and lower their blood pressure to an acceptable level but most people are still going to need medication to help them a little bit with that additionally, too.

Melanie: In just the last few minutes, Dr. Kummer, are these medications you’re discussing lifelong medications or are there ways to fix your blood pressure and get off the medication?

Dr. Kummer: Well, either one is certainly a possibility but the most common cause of blood pressure, we call it “central hypertension” and that basically just means that the arteries are getting stiffer as time goes on. So, there are just some changes within the artery itself where it’s not as elastic so it gets firmer. It’s more like a lead pipe rather than a rubber balloon. And so, with that being the case, that’s not something we can really, truly fix. So, a lot of times, people still will need to be on medications lifelong. Making the changes on your diet, exercising more, limiting your salt intake--those things are all going to help quite a bit but, nonetheless, it’s still pretty likely that a lot of people will need to be on medications for a long time. That being said, if you do all those things the right way, you probably won’t need to be on as many medications. You may not need to be on as high of a dose of medication. So, those are all fundamentally the most important things that the patient can do from their standpoint and still try to control those variables that they can. There are some people, especially if they have really have a poor appetite or very poor diet and really don’t exercise or are overweight, if they do all the things to control those risk factors, a lot of times we can keep people off medications or at least limit the amount that they’re on.

Melanie: Well, it’s certainly great advice and so important for listeners to hear. If you’re concerned about your blood pressure, you can schedule an appointment with the Bryan Heart Lipid and Prevention Clinic by calling (402) 483-3333. That’s (402) 483-3333. Thank you so much, Dr. Kummer, for being with us today. For more information, you can go to bryanheart.com. That’s bryanheart.com. You’re listening to Bryan Health Radio. This is Melanie Cole. Thanks so much for listening.