How I Treat Patients with Elevated Blood Pressure

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Elevated blood
pressure, or hypertension, is associated with serious health problems,
such as strokes, heart attacks, and kidney failure. Most people
believe the problem with hypertension is that the elevated pressure
damages the arteries and the body’s organs. Actually, it is
more often the other way around. The rise in blood pressure is a
response to a sick body – the blood pressure goes up as a natural
and proper adaptation – as an attempt to compensate for a plugged
up cardiovascular system. After years of consuming the rich Western
diet, the blood vessels develop blockages referred to as atherosclerosis,
the artery walls stiffen, and the blood itself becomes viscous.
All this change creates a resistance to flow, resulting in a decrease
in the ability to deliver nutrients to the tissues. The body responds,
as it should, with a rise in blood pressure.

The correct
action for the patient to take is to decrease the resistance to
flow by eating a healthy diet and exercising. Most people who follow
the McDougall diet find their blood pressure decreases within a
few days. Based on several collections of results from my clinic,
the average reduction of blood pressure is about 14/11 mmHg in seven
days, and at the same time medications used for treating hypertension
are usually stopped. My customary protocol is to stop all blood
pressure-lowering medications the first day of the Program, except
for beta-blockers, which I slowly discontinue by cutting the dosage
in half every two to three days. Unfortunately, not every patient
experiences the reduction in numbers they desire. Despite their
best efforts some people may need medications.

These blood-pressure-lowering
drugs function by poisoning the body in various ways. “Poison”
is the correct word. In chemistry poison means to inhibit a substance
or a reaction. Beta-blockers inhibit the action of adrenalin on
the heart muscle, calcium channel blockers inhibit the contraction
of the blood vessels, ACE inhibitors and angiotensin receptor blockers
do just that (inhibit and block) the blood pressure regulating hormones
produced by the adrenal glands, and diuretics poison the water and
electrolyte conserving functions of the kidneys.

These five
major classes of medications are discussed in more detail below.

Take Measurements
at Home for Months before Starting Drugs

Before starting
medications in non-emergency situations, people with concerns about
their blood pressure should first, buy a good quality blood pressure
cuff (an oscillometric monitor for $50 to $100) and use it to monitor
their blood pressure at home. I suggest they then record the values
several times a week and take these numbers to their private doctor
for further discussion.

A sustained
elevation of blood pressure to 160/100 mmHg or greater over months
suggests the need for treatment with medication. A word of caution:
If you do start blood pressure-lowering medications, avoid overly
aggressive treatment. In general, reducing blood pressure below
140/90 mmHg with medication is not beneficial and actually will
increase the risk of heart attacks, strokes, and death. A recent
review by the well-respected Cochrane Collaboration concluded with:
“Treating patients to lower than standard BP targets, ±140–160/90–100
mmHg, does not reduce mortality or morbidity.”

Chlorthalidone
Is the Drug of Choice

Chlorthalidone
is an oral diuretic (a water pill taken by mouth) with a prolonged
action of 48 to 72 hours and low toxicity. Diuretics lower blood
pressure by reducing fluid volume, which decreases the output of
the heart causing the blood pressure to fall. Doctors and patients
often believe that all diuretics have similar benefits. This is
not the case, and chlorthalidone is the preferred kind of diuretic
for most patients. In 1990, the Multiple Risk Factor Intervention
Trial (MRFIT) reported a reduction in nonfatal cardiovascular events
when the diuretic treatment was changed to replace hydrochlorothiazide
(HCTZ) with chlorthalidone in men at high risk for coronary heart
disease. Chlorthalidone is also more effective at lowering systolic
blood pressure (the top number) than HCTZ. The starting dosage used
was 12.5 to 25 mg daily; but the dosage can be increased to 50 to
100 mg daily. All patients receiving chlorthalidone should be checked
after one month for evidence of fluid or electrolyte imbalance:
namely, low sodium, low chloride, and low potassium (by blood tests).
Other periodic laboratory tests should be performed to look for
adverse effects from this potent diuretic. For example, blood levels
of cholesterol, triglycerides and uric acid can be increased by
this medication. Chlorthalidone is inexpensive; a 30-day supply
is $4 and a 90-day supply is $10 for 25 or 50 mg tablets at Walmart.

Why I No
Longer Routinely Prescribe Beta-blockers

For many years
beta-blockers were considered one of the first line therapies for
the treatment of hypertension. Current evidence suggests that beta-blockers
(like Atenolol) should not be prescribed unless there is some other
reason for their use (like atrial fibrillation, heart failure, or
myocardial infarction). A recent Cochrane Collaboration concluded:
“The available evidence does not support the use of beta-blockers
as first-line drugs in the treatment of hypertension. This conclusion
is based on the relatively weak effect of beta-blockers to reduce
stroke and the absence of an effect on coronary heart disease when
compared to placebo or no treatment.”

Examples of
commonly prescribed beta-blockers are: acebutolol (Sectral), atenolol
(Tenormin), betaxolol (Kerlone), betaxolol (Betoptic, Betoptic S),
bisoprolol fumarate (Zebeta), carteolol (Cartrol), carvedilol (Coreg),
esmolol (Brevibloc), labetalol (Trandate, Normodyne), metoprolol
(Lopressor, Toprol XL), nadolol (Corgard), nebivolol (Bystolic),
penbutolol (Levatol), pindolol (Visken), propranolol (Inderal, InnoPran),
sotalol (Betapace), and timolol (Blocadren).

Read
the rest of the article

December
4, 2009

John McDougall,
MD [send him mail],
a board-certified Internist, is the founder and medical director
of the nationally renowned McDougall
Program
, a ten-day, residential program located at a luxury
resort in Santa Rosa, CA – a place where medical miracles occur
through proper diet and lifestyle changes. He has been studying,
writing and “speaking out” about the effects of nutrition on disease
for over 30 years. Dr. McDougall is the author of 11 national bestselling
books, writes a monthly newsletter, and co-founded Dr. McDougall’s
Right Food’s Inc., a producer of high-quality vegetarian cuisine.
You may subscribe to the free
McDougall Newsletter
.

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