Evo Terra (Host): Nearly half of all adults in America have high blood pressure. What can you do about it? And how can you prevent it? Let's find out with Dr. Damon McEnroe, a Cardiologist with Tenet Health Central Coast. This is Healthy Conversations, Tenet Health Central Coast. 

This is “Healthy Conversations,” a podcast presented by Adventist Health.

I'm Evo Terra. Welcome to the show, Dr. McEnroe. 

Damon McEnroe, MD: Thank you so much, Evo. I'm really excited to talk about something important today, especially during heart month.

Host: That is correct. Well, let's start at the beginning of this. What is it that causes high blood pressure?

Damon McEnroe, MD: Blood pressure is regulated by the arteries in the body. The arteries can be influenced to cause high blood pressure by several factors such as hormones, stress, pain, physical activity also can change your blood pressure and then other medical conditions such as high cholesterol, diabetes, smoking, can all influence your blood pressure and trend it upward. Some of these can be temporary, and beneficial like exercise. So, let me explain just a little bit. For example, if you have pain because of some injury that you've sustained, that should be temporary. Yeah, your blood pressure in the short term will be elevated. That's your body's reaction to the pain. But that should eventually normalize is what we would hope.

And so, would exercise. So, as you're exercising, your blood pressure will go up. As you stop exercising, it will return back to its baseline or normal, we would hope, and that's a normal response to exercise. Other things that can be dangerous, such as high cholesterol and diabetes, over time, both of those can make your arteries hard. And that can lead to high blood pressure because the arteries are technically less compliant. And so that is how, over time, these medical conditions can lead to high blood pressure.

Host: You mentioned that the blood pressure returns to a normal level after exercising. And in fact, I've seen that. I've seen a reduction in my own blood pressure, or at least a good number after exercise. But for those that don't understand, what is a normal blood pressure?

Damon McEnroe, MD: Yeah, great question. I kind of have a little bit of a chuckle there because it's kind of like a moving target to a certain degree, but I would take us back, maybe walk in time. 2017 officially there were guidelines that came out saying that we should recognize that a normal blood pressure should be less than 120 over 80.

That's based on the combination of two cardiovascular entities, the American College of Cardiology or the ACC and the American Heart Association, or AHA. So, 2017, the landscape was a little bit shifted. Used to be we were targeting numbers higher, 140 over 90, so no more is that the case. There's been a risk stratification in terms of how we look at normal blood pressure, so to answer your question directly, normal blood pressure is less than 120 over 80.

We do have a pretext that if your blood pressure is 120 to 129, that's the systolic number, that is considered elevated blood pressure, but not diagnostic of high blood pressure or the medical term for high blood pressure which is hypertension. Hypertension we generally reserve for a range of 130 over 80 or higher.

So if you ever see those numbers, that is diagnostic of hypertension. We would want to see it on at least two readings to kind of get the trend and officially diagnose it. But, that's a normal blood pressure less than 120 over 80. Anything higher than 130 over 80 is high blood pressure or hypertensive and we go on from there.

There are different stages. So stage one is what I was referencing, 130 over 80 or higher. Once we get to the 140, systolic over 90 diastolic and higher; that's where we designate stage two. And the distinction that we talk about there is how we would treat somebody with those levels of elevated blood pressure.

Host: Well, I'm happily in the first level of that one. Mine's around the numbers that you gave me. So other than the medications, and we'll talk about those in just a moment, what can people do to keep their blood pressure in that healthy range? Assuming it's healthy now, assuming they don't already have hypertension, what can people do to maintain in the healthy range?

Damon McEnroe, MD: That's great. Lots of things that I think most patients are capable of doing, and would probably all could benefit from doing a little bit more of, but a healthy prescription of diet and exercise would be start with that and that would be first and foremost. So diet specifically, you're going to look to avoid processed sugars that may lead to diabetes. As we talked about, that can raise your blood pressure over time. Looking to use more vegetables, less saturated fats, less animal proteins, and more vegetable proteins if possible. If there is going to be a selection of animal protein, we'd look to be doing lean proteins. Maybe a fish would come to mind.

And exercise. Generally, we talk about 150 minutes weekly of moderate intensity exercise. What is moderate intensity? Moderate intensity, I like to give a reference. If you're walking, for example, with a friend or a partner, you can't really hold a conversation because you would be too short of breath.

So that gives you a perspective on what moderate intensity exercise is. Of course, if you do more than that, great. In general, not going to hurt you unless you sprain something or tweak something, so to speak, but that's more going to be muscles. This overall diet and exercise should help your blood pressure significantly. Also, stress, how we deal with stress, how we sleep. These are other things that all go into it. Unfortunately, people that may be stressed have disturbances in their sleep patterns, so it's kind of an unfortunate circle where they're not getting good sleep because they're stressed and they stress a little bit more. Ultimately, these can have effects on your cardiovascular system; specifically with relation to high blood pressure.

Host: Great tips on keeping blood pressure in that healthy range. But I, I'm going to ask what seems like a dumb question. And that is, why? Why should I keep my blood pressure in a healthy range? What are the problems associated if I do have elevated blood pressure or even hypertension?

Damon McEnroe, MD: So, overall, once you have high blood pressure, you're at increased risk of heart attack and heart failure in relation to the heart specifically. I told you that the arteries feed all the organs in the body, so it stands that all organs are at jeopardy. So that includes your brain. You may be at higher risk of stroke if you have high blood pressure.

Kidneys also, unfortunately, can be damaged. We talk about a condition called chronic kidney disease, which if it stays chronic or lasts for a long time, that will lead to dialysis in a lot of cases. Probably another thing that people don't get a lot of recognition on is that it can affect your vision. So, ultimately, in the worst case scenario, people can lose their vision.

Host: So, those are good reasons to stay in a normal blood pressure range if at all possible. That's helpful. Okay, get specific. How does someone know if they in fact have high blood pressure? Maybe they don't have a blood pressure cuff at home. What should one do?

Damon McEnroe, MD: Yeah, so how do we know is going to be in some extreme cases, you can have symptoms of high blood pressure, such as headache, vision changes. I was telling you it can be vision loss, but just vision changes, blurry vision, headaches. Some people can experience chest pressure. Some people can experience shortness of breath because the blood pressure is too high that it causes fluid to build up in the lungs. Other times, it might not be noticed, and that's why they call blood pressure a silent killer.

Host: Hmm.

Damon McEnroe, MD: Ultimately, the diagnosis is made by checking with the blood pressure cuff, and there are certain techniques to do that with. There's a good reference if you go to heart.org, which is the americanheart.org's website, and if you look up blood pressure reading there, they'll have a good reference for you.

But essentially, maybe four or five points to talk about is you want to be in a seated position in a firm chair that has a seat back. So I always tell patients back to back, put your back to the back of a seat. Then you want to have, ideally the blood pressure cuff be taken on your upper arm. There are also wrist

blood pressure cuffs, but the upper arm is officially the preferred one. You want to be in a seated position and resting quietly for five minutes. And usually, to kind of paint the picture for everyone, I recommend that you be almost, it's kind of at a kitchen table, dinner table situation with a wooden chair is how I describe it.

So you don't want to be, for example, on the sofa or in a recliner reclining because a lot of those conditions or setups that I described wouldn't be able to be fulfilled.

Host: Sure. Okay. That's good information. Let's talk about treatment just a moment. What do we do? Someone has high blood pressure. What is the treatment that is recommended?

Damon McEnroe, MD: So it depends on how elevated the high blood pressure is. So we talked about this, less than 120 over 80 is normal. Between 120 to 130 is elevated. If it's in that elevated range, depending on what you and your doctor's conversation is, it may be reasonable just to try what we call lifestyle modifications.

So diet, exercise, and those other components that we talked about, which would be focusing on your stress levels, how to cope with them better, focusing on getting good restful sleep, and then other things to try and avoid diabetes, cut back and eliminate alcohol and or smoking if that's an issue. If they still have high blood pressure, medicines would be considered.

Generally, I was mentioning that there are certain stages that we talk about. So if your blood pressure happens to be 130 over 80 or higher, it's reasonable to try one medicine. If it's more than 140 over 90 or higher, on average, patients will need about two to three medicines to get it controlled, once it's in that category, we designate a stage two.

So, that's kind of the purposes of why we break them down into stages. If other factors are there, we can tailor certain medicines. So, for example, there are certain medicines, like an ACE inhibitor, which is a class of medicine that's been shown to help people with diabetes protect their kidneys. We call it renal protective.

So, in those cases, your doctor should be able to select a medicine that's more individual than generic, for example. So, we try to select our medicines that we start based on the patient in front of us and based on some of their conditions that we know of.

Host: That all makes sense, and I think I want to make sure I heard this statement properly. Not every single patient who has high blood pressure requires medication. That's correct, right?

Damon McEnroe, MD: That is correct, yeah. It can change for the better, generally though, something has to change, so it wouldn't be an appropriate strategy to watch, wait, and have no intervention. So, the intervention that we're talking about is either going to come in the form of diet, lifestyle modifications, or medicines. But it is reasonable if it's, for example, 130 over 80 just on the border and a patient by their own admission thinks, you know what, I've been eating a certain way that I can change. I've been living a certain way that I can change for the better. Cut back on maybe alcohol, process sugars, sleep better, and lo and behold, maybe a few months after being dedicated to that lifestyle, their blood pressure is in the normal range. 

Host: That's an amazing fact that you can actually get this under control just by lifestyle change. But I also want to sure everybody understands, I mean, I'll ask the question pointedly, I mean how much does that lifestyle change, diet, exercise, stress, how much does that play into high blood pressure? And if that's corrected, how much can people who suffer from high blood pressure realistically expect to improve their blood pressure by?

Damon McEnroe, MD: Yeah, great question. So, specifically, I think in terms of the diet, there's a lot of diets out there for the purposes, I feel like, of weight loss, but one that's particularly interesting to me is the DASH diet and the H there, D-A-S-H, the H is for high blood pressure ore, hypertension, as we say. In that particular study, it was a cohort of patients that doesn't apply to everybody in the world, for example, but it does apply to a good number of patients that have high blood pressure, that have not ever had a stroke or a heart attack, do not have diabetes, and are over 50 years old. In this group of patients, these were patients that had high blood pressure and were at risk of cardiovascular disease. What they did was they studied them. One of the control groups was allowed to eat what they wanted.

The other studied group was given this prescribed diet called the DASH diet, and the DASH diet essentially tries to track a more unsaturated fat diet, thinking leafy vegetables, for example, more olive oils rather than animal fats, such as butter, and in those two groups of patients, the patients that had particularly a prior diagnosis of high blood pressure, they stood to gain the most benefit.

Their blood pressure systolically decreased by about 11 points. And so what they stand to gain or what the effects of that is, long term; they're at lower risk of heart disease, stroke, kidney disease, and vision changes or vision loss. So, huge importance that what we bring into our bodies ultimately affects our health.

And it really just drives home the point that, you know, with your conversation with your doctor, if you think that you're capable of changing enough things in your lifestyle, it is possible if one of your goals is to stay off of medicine, that it is possible. Now, in those certain groups of patients, particularly stage two or higher, it's not as likely that they will benefit significantly that blood pressure will decrease significantly and stay decreased.

Host: Well, it sounds like I'm doing all of the right things I should be doing. Dr. McEnroe, before we leave, was there anything else you wanted to add to this conversation?

Damon McEnroe, MD: So, I think one of the interesting trends in cardiology is lower, maybe better in a lot of cases. The more we study it on a bigger scale, we see that cholesterol being lower is probably a better benefit than it being where it was targeted in the past. Blood pressure tracks the same way. There's maybe two studies that kind of show that.

One is the SPRINT trial. There was a trial for systolic blood pressure specifically, and this came in the era that I was telling you about around 2017, 2015, where one group that was formerly recognized to be a leader on blood pressure, which was the Joint National Commission or the JNC. It was kind of a government health care funded project, unfortunately lost funding.

But while they were in kind of prominence as the reigning authority on blood pressure, their recommendations were officially systolic blood pressures of 140, elsewhere around the world where there were others somewhat, I would say, compared to what we recognize today, more lenient blood pressure targets.

And so this interesting trial called the SPRINT trial targeted blood pressure systolically of less than 120. And after three years, they saw that patients lived longer and had less risk of heart disease, heart attacks, and strokes. For that reason, it was actually stopped or terminated early because we designated in three years they were able to show significant difference.

So I think the take home point here is that while blood pressure is one of the most common medical conditions that we see in practice and it leads to a huge number of downstream complications, if we get it early and if patients are willing to adopt therapies, either in the form of lifestyle changes, medicines, or both, that there stands to be a huge change in their trajectory of their health for the rest of their life.

Host: And that's the good news right there. Dr. McEnroe, thank you very much for the information today.

Damon McEnroe, MD: My pleasure. Thank you so much, and thanks everybody for listening. Hope you guys enjoy the rest of this Heart Month.

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Disclaimer: This program is a community service and is not intended to be a substitute for medical advice. Listeners having questions about their health should make an appointment to see their personal physician. Any opinions or statements made during the program are those of the individuals or physicians making the statements and are not the opinions or statements of the hospital.