Melanie Cole, MS (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And today, we are learning about high blood pressure or hypertension and what patients and providers really need to know. Joining me is Dr. Kevin Hall. He's an interventional cardiologist at the Platte Valley Cardiology Clinic.

Melanie Cole, MS: Dr. Hall, thank you so much for joining us today. I'd like you to tell us really what blood pressure is. What is blood pressure? And then, what is high blood pressure or hypertension?

Dr. Kevin Hall: Well, you know, one of the most dangerous things about high blood pressure is that it doesn't feel dangerous. And people typically expect serious medical problems to come with warning signs, right? So for instance, pain, shortness of breath, a symptom that tells you something is wrong. Well, in fact, high blood pressure just doesn't work that way.

And I've had patients walk into my office and say, "You know, Doc, I actually feel pretty great." Meanwhile, their systolic blood pressure is 180. So, they're feeling fine, but their blood vessels aren't, their heart isn't, their kidneys aren't, their brain isn't, and that's why we call high blood pressure the silent killer. Because sometimes the first sign of high blood pressure is a complication itself, a heart attack, a stroke, or even heart failure.

So when I explain blood pressure to patients, I tell them that the top number does the damage. And when the top number stays above 140 for years, it's quietly damaging what I call the big three. So, what are the big three? The heart, the brain, the kidneys. And while many people think high blood pressure is affecting one part of their body, it's really attacking the organs that you need the most. So again, the heart, the brain, the kidneys. Because a stroke can take away your ability to walk, to talk, to work, to recognize the people that you love. Heart failure can leave you exhausted just simply walking across your living room. And kidney failure can lead to dialysis several times a week just to stay alive.

And here's the part that sticks with me the most, Melanie, is I've never had a patient come into my office asking for dialysis. I've never had a patient tell me they'd like to have a stroke. But every day, I meet people who are unknowingly on that path because their blood pressure went untreated for years. The tragedy is that so much of this is preventable. You know, when people ask why their blood pressure so uncontrolled, I think it's important to start with a little bit of compassion. Managing high blood pressure isn't always as simple as taking a pill and moving on. People are balancing work, family, finances, stress, poor sleep, other medical conditions.

In my experience, most patients care very deeply about their health. The challenge is that high blood pressure rarely causes symptoms. So, life often wins their attention before their blood pressure does. And most people feel completely normal. And because they feel normal, high blood pressure can sometimes be easy to ignore.

Melanie Cole, MS: Doctor, tell us about blood pressure readings and what we need to know about them.

Dr. Kevin Hall: One of the biggest mistakes people make is assuming blood pressure reading is accurate. Blood pressure is really incredibly sensitive. It's affected by stress, by caffeine, by poor sleep, by pain, by rushing through traffic to get to an appointment or work. And I've seen patients sprint across a parking lot, sit down in an exam room, and have their blood pressure checked 30 seconds later. And of course, that elevated blood pressure is not representative of their true blood pressure. Sometimes that's actually their stress level. That's why I tell patients blood pressure is not a photograph. It's actually a movie. It changes throughout the day and it changes throughout the week. And because of that, I care much more about trends than I do about any single number. So, one elevated reading gets my attention, but a pattern of elevated readings really gets my action.

And that's why home monitoring has become so important. In fact, if I could give every patient with high blood pressure one piece of equipment, it would probably be a home blood pressure cuff. And the reason is quite simple. I care far more about what your blood pressure is doing in your living room than what it's doing in my office, because that's real life. That's where blood pressure really lives. And if you're anything like me or any of my patients, whenever we go to the doctor's office, our blood pressure goes up. We call it white coat hypertension. But when you're sitting at home, relaxed in your normal environment, we get a much clearer picture of what's really going on.

The benefit of home blood pressure monitoring is that it puts patients back in the driver's seat. They can see the impact of exercise or the lack thereof. They can see the impact of weight loss, reducing sodium in their diet, medications. The doctor only sees the snapshots. So, home monitoring fills in the rest of the story. But I don't really want patients to panic when you get a single high reading.

A single high blood pressure reading should get your attention. And again, a pattern of high blood pressure should get your action, because most of the damage from high blood pressure occurs over months and years, not hours. And I'd much rather talk with someone today about high blood pressure than meet them six months from now after a preventable stroke or heart attack.

Now, if your blood pressure is extremely elevated, we're talking about systolics, you know, 160s to 180s or higher, and you're having symptoms like chest pain, shortness of breath, severe headache, vision changes, confusion, weakness, numbness, or symptoms concerning for a stroke, well, that's not something to monitor at home, right? That's an emergency. That's a reason to seek immediate medical attention. And the way I summarize it for patients is this, really don't ignore it, but don't panic over one number either. Pay attention to the patterns.

Melanie Cole, MS: Dr. Hall, tell us about some lifestyle changes that really make a difference.

Dr. Kevin Hall: So, this is actually one of my favorite conversations to have with patients because it really gives them some control back. Now, one of the biggest misconceptions about high blood pressure is that lifestyle changes don't really work. And really, the truth is that some of the most powerful treatments for high blood pressure don't come from a pharmacy. They actually come from daily habits, from daily discipline. Not motivation, because honestly, motivation really fades with the wind. You have to be disciplined in your choices and in your habits. And these are the choices we make over and over again every single hour, every single day of our lives. Weight loss, should I exercise, reduce sodium, getting better sleep. These things matter.

So, here's where some patients get it wrong. They think success comes from dramatic change, when it usually comes from small decisions repeated consistently on a daily basis. In fact, one of the biggest mistakes people make is trying to change everything at once. They decide that they're going to lose 30 pounds, eliminate all sodium, exercise every day, and never touch dessert again. And that motivation usually lasts for about two weeks, even in the best of us. Then, life shows up. And what I typically tell patients is this, "I don't need perfection, I need consistency" or maybe the better word is discipline, because when it comes to blood pressure and most healthy habits, discipline beats intensity almost every day of the week.

So when I think about healthy living, I don't think about massive changes. I think about small decisions repeated thousands of times. Should I get up a little earlier and go for a walk before work? Should I eat that blueberry muffin or the slice of pizza, or should I make a better choice and choose minimally processed natural whole foods higher in protein and fiber, foods that we know will keep you fuller for longer? Should I make a conscious effort to cut back on smoking, or better yet, just quit altogether? Should I turn off the TV and go to bed a little earlier tonight so I can get more sleep? Those decisions may seem small, but over months and years, they really add up.

And one of the biggest examples of that is dietary sodium. When most people think about sodium, they picture the salt shaker sitting on the kitchen table. When the reality is, is that for most Americans, that's not where the majority of sodium is coming from. In fact, one of the things I tell patients is, "It's not always the salt that you're adding, it's the salt already added for you." It's the restaurant meals, the fast food, the canned soups, the processed packaged foods, the sauces, the dressing, the foods that don't necessarily taste salty but contain a tremendous amount of sodium.

And here's why sodium matters. Your kidneys have this immensely important role to maintain balance. So when we consume too much sodium, the body naturally holds onto more water. And more water means more volume in the bloodstream, and more volume means more pressure inside the pipes.

And I sometimes tell patients to think of it this way. Imagine that you're stranded in a desert with very little water. Your body will do everything it can to hold on to every drop. Sodium sends a similar signal. It tells the body to retain fluid, and that extra fluid increases blood pressure. Now, I'm not telling patients that they can never enjoy Thanksgiving dinner or Christmas dinner or Fourth of July barbecue. Life is meant to be lived. But what I am saying is that what happens between those holidays matters far more than the holiday itself. It's the daily habits that move the needle, not the occasional celebration. And most people don't get high blood pressure from Thanksgiving dinner. They get it from having Thanksgiving dinner every single day.

Now, weight loss remains one of the most effective ways to lower blood pressure, and there are many different ways to achieve it. Some people do well with portion control. Some focus on improving food quality. Some find success with approaches like time-restricted eating or intermittent fasting. The specific strategy matters less than finding something safe, sustainable, and realistic for your life.

The goal isn't to look different. The goal isn't to live longer. The goal is to lower your risk of stroke, lower your risk of heart attack, heart failure, and kidney disease.

Melanie Cole, MS: Dr. Hall, what's the biggest challenge to patients staying on track?

Dr. Kevin Hall: I think the biggest challenge is that success is invisible, because nobody really wakes up one morning and says, "Wow, my stroke didn't happen today." Nobody feels the heart attack that they prevented, and nobody feels the kidney disease that they avoided. And that's what makes high blood pressure so different from many other medical conditions.

If you have a headache, you take medicine, the pain gets better. If you have an infection and you take antibiotics, you feel better. High blood pressure doesn't work that way, and most people feel completely normal. So after a few weeks or a month, it's natural to start asking, "Well, do I really need this medication? Do I really need to keep doing all of this?" The answer is yes, because we're playing a long game. What we're trying to prevent isn't tomorrow's problem. We're trying to prevent the stroke five years from now, the heart failure 10 years from now, and the dialysis 20 years from now.

And honestly, the patients who do the best aren't necessarily the smartest, the most disciplined, or even the most motivated. They're the ones who make treatment simple. They take their medications at the same time every day. They use a pill box. They keep a blood pressure cuff at home. They build habits that fit into their lives instead of relying on willpower. Because your blood pressure isn't keeping score of your best day, it's keeping score of your average day.

Melanie Cole, MS: Thank you so much, Dr. Hall. When is it important to see a specialist?

Dr. Kevin Hall: Most patients with high blood pressure can be managed very successfully by their primary care provider. In fact, primary care physicians do an outstanding job treating the vast majority of patients with hypertension. But there are times when it makes sense to take a deeper look. One of the most important things I tell patients is this, sometimes high blood pressure is the diagnosis, and sometimes it's a clue. If someone is taking multiple medications and their blood pressure is still not controlled, then that's a clue. If their blood pressure suddenly becomes difficult to manage after years of being stable, then that's a clue as well. If we're seeing signs that high blood pressure is affecting the heart, kidneys, or blood vessels, that's a clue.

Those are the situations where we start asking a different set of questions. Is sleep apnea playing a role? Is there an issue with the kidneys? Could there be, for instance, hormonal calls driving the blood pressure? Is there something we're missing? And that's where a specialist comes in. The good news is that patients don't need to figure out all of this on their own. If you're taking your medicines, making lifestyle changes, and your blood pressure still isn't where it should be, it's okay to ask whether it's time for a deeper evaluation. Sometimes controlling blood pressure isn't about adding another medication. Sometimes it's about finding the reason it was high in the first place.

Melanie Cole, MS: Well then, tell us about medications out there today for hypertension and high blood pressure. What works? What have you seen in your practice?

Dr. Kevin Hall: One of the first things I tell patients is that needing medication is not a failure. The reality is that high blood pressure is caused by a combination of factors, whether it's genetics, age, weight, diet, activity level, stress, kidney function, and many things that are completely outside of a person's control.

So if someone needs medication, I don't view that as a weakness. I view it as another tool. In fact, I often tell patients, "You know, I really don't care whether we lower your blood pressure with discipline, with medication, or both. I care that we lower it before it lowers your quality of life." Because at the end of the day, that's the goal, right? Protecting the heart, protecting the brain, protecting the kidneys. Blood pressure medications are a lot like members of a team. Each one does a different job. Some help the body get rid of excess salt and water, some relax blood vessels, some slow down the heart rate, and some block hormones that cause blood pressure to rise.

They're all working toward the same goal, but they're doing it in different ways. And that's one reason many patients end up needing more than one medication, not because their blood pressure is unusually bad, but because using two or three medications at lower doses is often more effective and often causes fewer side effects than pushing one medication to the maximum dose.

One of the biggest misconceptions I hear is, you know, "Doc, the medicine is working." And sometimes that's true. But more often, there's another explanation. Maybe doses are being missed. Maybe sodium intake is still very high. Maybe another medication is raising blood pressure. Maybe sleep apnea is contributing. Maybe we're treating the wrong cause. And that's why when blood pressure isn't controlled, I don't immediately blame the medication. I step back and I ask why. Because medicine works best when we're treating the cause, not just treating the number

Melanie Cole, MS: Very well said, Dr. Hall. So when we think of hypertension, lifestyle modifications, medications, all the tools that we have now in our toolbox to help people with this hypertension, what would you like them to know about some new options that are expanding for those treatments and the modalities you have available

Dr. Kevin Hall: So, Melanie, this is where it gets really interesting. Most patients with high blood pressure can achieve good control with lifestyle changes, medications, or a combination of both. But sometimes we encounter patients whose blood pressure remains elevated despite doing many of the right things, and that's what we call resistant hypertension.

Resistant hypertension is blood pressure that remains above goal despite multiple medications, typically three or more medications working through different mechanisms. And when I see that, my first thought is not "What medication can I add next?" My first question is, why? Because resistant hypertension is often a clue, it's the body's way of telling us that something else may be contributing. Sometimes it's excess sodium, sometimes it's sleep apnea, sometimes it's obesity, sometimes it's kidney disease, or sometimes it's medications that unintentionally raise blood pressure. And occasionally, it's something more uncommon that requires a deeper evaluation.

And one of the biggest mistakes clinicians can make is assuming every patient with resistant hypertension simply needs another prescription. Sometimes they do, but sometimes what they really need is a diagnosis. When something doesn't behave the way it's supposed to, the answer isn't always another prescription. Sometimes the answer is understanding what's driving the problem in the first place, and that's where a careful evaluation becomes incredibly important. So when it comes to new and emerging treatments, this is one of the most exciting areas in hypertension right now.

For decades, our primary tools were lifestyle changes and medications, and those remain incredibly important. But we're now entering an era where we have additional options for carefully selected patients. One of those options is a procedure called renal denervation. The kidneys play a major role in blood pressure regulation. They communicate with the brain and nervous system through a network of nerves that run along the renal arteries. And in some patients, those nerves are overactive and contribute to persistently elevated blood pressure. Renal denervation works by reducing the activity of those nerves. The procedure is minimally invasive and performed through a catheter inserted into an artery in the groin, similar to many of the procedures we perform on a daily basis in cardiology.

Now, it's important to understand what renal denervation is and what it isn't. It's not a cure, and it's not for everyone, and it doesn't replace healthy habits or medications. But for carefully selected patients with resistant hypertension, it can provide another valuable tool to help lower blood pressure and reduce cardiovascular risk.

What excites me the most is that we're finally moving beyond a one-size-fits-all approach, and we're recognizing that hypertension isn't the same disease in every patient, and different people have different drivers of high blood pressure. The future of hypertension isn't really choosing between procedures and medications. It's really finding the right treatment for the right patient. And the more precisely we can identify those drivers, the more effectively we can treat them.

At the end of the day, whether we're talking about lifestyle changes or medications, sleep apnea treatment, weight loss, or renal denervation, really the goal is always the same: lower blood pressure, protect the heart, protect the brain, protect the kidneys, and ultimately help people live longer, healthier lives.

Melanie Cole (Host): What are some really important key takeaways you'd like to leave the listeners with?

Dr Kevin Hall: If there's one thing I'd like people to remember, it's this: high blood pressure is incredibly common, but it is one of the most treatable risk factors that we face. The biggest improvements in health rarely come from one dramatic decision. They come from the choices we make over and over and over again. Choosing to take a walk, choosing water instead of another sugary drink or alcohol, choosing to stop smoking, choosing to prioritize the most important hours of your day, which are your sleeping hours, choosing a healthier meal more often than not.

And the good news is that these changes don't have to be perfect to make a difference. So give yourself grace. Most of us already know what healthy choices look like. The goal isn't perfection. The goal is simply making those choices a little more often than we don't. Even modest weight loss can lower blood pressure. Regular physical activity also helps. Better sleep helps. And for some people, simply being more intentional about when they eat, not just what they eat, can help as well.

Small improvements add up. And when lifestyle changes aren't enough, we have excellent medications and excellent new options like renal denervation that can help patients gain control of their blood pressure. But at the end of the day, the foundation remains the same. Your future health is being built by the choices that you make every single day, not once, not when you're motivated, but over and over again. That's how blood pressure improves, that's how hearts stay healthy, and that's how lives are changed.

Melanie Cole, MS: Great information. Dr. Hall, thank you so much for joining us today and really sharing your incredible expertise for us today. I'd like to thank our Bryan Foundation partner, NRC Health. To listen to more podcasts from our experts, please visit bryanhealth.org/podcasts. That concludes this episode of Bryan Health Podcast. Please always remember to subscribe, rate, and review Bryan Health Podcast on Apple Podcasts, Spotify, iHeart, and Pandora. Until next time, I'm Melanie Cole.