HIGH BLOOD PRESSURE - Full extract 

Max is in his late forties and runs a hardware business. His family have attended our practice for many years but I see him very rarely.

His secretary rang for an appointment after he accidentally cut his finger at work. Max made it fairly obvious he was not enthused about being at the surgery and that he was keen to get back to work. His finger was easily attended to with a light dressing and he was given a tetanus booster.

While he was sitting on the examination couch I took his blood pressure. It was 185/100. Max did not want to know about it. " What do you expect...I've cut my bloody finger and my whole day has been screwed up." I explained that even allowing for this his blood pressure was too high. Reluctantly, he agreed to call back later in the week for a general check-up. I did wonder whether he would turn up.

Max did appear. His blood pressure on the second occasion was 195/100. On closer questioning, Max said that his mother died from a stroke after years of high blood pressure. " That's the main reason I'm here, " he said. Aside from being a little overweight, Max is otherwise quite well. His diet is reasonably good and he is a non-smoker. After discussing the various options he was started on a small dose of blood pressure medication.

A number of basic tests were arranged. The only abnormality was his cardiograph which showed evidence of early heart enlargement, presumably as a result of his high blood pressure. In particular there was no underlying cause that we could demonstrate for his high blood pressure.

On his last check-up, Max told me that he had taken up cycling and was feeling very well. He was having no untoward effects from his medication and his blood pressure was 135/85. He had also lost 4 kg in weight. We now see him every three months for a blood pressure check. 

High blood pressure, or hypertension as it is properly called, is the most common reason Australian adults see their doctor for a regular check-up. It is a major risk factor for coronary heart disease and stroke, and frequently causes damage to the arterial blood vessels, the eyes and kidneys. Prolonged hypertension also causes enlargement of the heart and may lead to heart failure.

The improved treatment of hypertension is one of the real success stories of medicine over the last few decades; the 60% drop in the death-rate from stroke is thought to be largely due to better control of blood pressure.

About 20% of Australian adults have hypertension. By the age of 65 the incidence rises to about 40%. Yet only 50% of people with high blood pressure are aware that they have the condition. Most people with high blood pressure feel perfectly well. There are no reliable warning signs to prompt the person to see the doctor in the first place; more often than not it is picked up by chance on a routine medical examination.

Our circulation works because blood is pumped around the body by the heart. ( see also Heart Foundation). The flow and pressure of blood in the arteries rises with each pump or pulse; this is the systolic or higher pressure reading. The resting or lower pressure between each pulse is called the diastolic pressure. A person's blood pressure reading includes both figures, systolic/diastolic, expressed in millimetres of mercury...eg.145/95 (mild hypertension) or say 225/115 (severe hypertension).  Although 140/90 was long regarded as the upper limit of the normal range, the most recent guidelines suggest that we aim for 130/85 or lower. This is especially important if there happens to be other risk factors present, such as diabetes or a high blood cholesterol level. In elderly patients a slightly higher figure may be quite acceptable.

The precise cause of hypertension is usually never identified. About 5-10% patients might be shown to have some some uncommon medical disorder or perhaps a kidney condition. But for the vast majority no specific cause is found. Sometimes the person is overweight and there may be a family history. Current research suggests that hypertension, high blood cholesterol, being overweight and even adult-onset diabetes may have some causal thread linking the conditions together. Resistance of the body to the action of its own insulin appears to be a factor. No doubt the full story will be unravelled in years to come.

Once a diagnosis of hypertension is made, several basic investigations are usually done, such as a chest X-ray, cardiograph, blood and urine tests. If the person is very young or the blood pressure elevation is particularly high, further more sophisticated tests might be arranged. 

The successful treatment of hypertension requires close cooperation between the patient and the doctor. Regular exercise and losing excess weight are discussed, as is reducing any unnecessary stress. Smokers are also advised about how to quit. If the blood pressure remains high, or happened to be very high initially, then treatment with medications may be necessary.

The newer anti-hypertensive medications are very effective and generally well-tolerated. However, some patients are troubled by side-effects like facial flushing, unsteadiness, swollen ankles and even an irritating cough. These symptoms should always be mentioned to the doctor so that the dosage can be altered or a different medication substituted. A suitable medication can usually be found for every patient.

Although hypertension is readily treatable, it still remains a major cause of death and disability. Awareness of the condition is the key issue.

Health tips:
 * All adults should have a regular blood pressure check. 

* If the blood pressure is mildly elevated try exercise, losing excess weight and attending to other lifestyle factors. But keep your follow-up appointment with your doctor to see that the blood pressure has improved.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001