AT A GLANCE: Here are the key things you will learn about high blood pressure from Marc R. Lewin, MD, a family physician with Advocate Health, in this article:
- High blood pressure often has no symptoms, which is why it is important to check your numbers regularly.
- Home monitoring can give a clearer picture of your blood pressure over time, especially when readings are taken correctly while relaxed.
- Untreated hypertension can raise the risk of heart attack, stroke, and damage to the kidneys and eyes.
- Treatment may include lifestyle changes such as following the DASH diet, reducing sodium, exercising regularly, managing stress and quitting nicotine.
- Patients should talk to their doctor if blood pressure averages above 130/80 mm Hg and seek urgent care for a reading of 180/120 mm Hg with symptoms such as chest pain, trouble breathing, severe headache or vision changes.
Almost half of all adults in the U.S. have hypertension, also known as high blood pressure. But the tricky part is that a lot of people don’t know they have this condition. This is because when a person’s blood pressure numbers are high, they might not feel any symptoms. That’s why it is important to understand high blood pressure.
The AMA’s What Doctors Want Patients to Know™ series gives physicians a platform to share what they want patients to understand about today’s healthcare headlines.
For this installment, Marc R. Lewin, MD, a family physician at Atrium Health Primary Care Family Medicine, which is part of Advocate Health, shared what he wishes patients knew about high blood pressure.
Advocate Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Hypertension is when your blood pressure is high
“If you think of your circulatory system and blood pressure as a garden hose in your body and there’s the pump, which is your heart, that pumps blood to the whole body through this garden hose,” Dr. Lewin explained. “If the water pressure in that garden hose gets too high, that can hurt the hose itself.
“It can hurt the pump, which is the heart, and it can hurt the nozzle at the end, which is all your organs,” he added. “So, when that pressure is too high, that’s hypertension.”
A normal blood pressure for adults is less than 120/80 mm Hg while elevated is 120–129 systolic and less than 80 diastolic. Meanwhile, stage 1 hypertension is 130–139/80–89 mm Hg while stage 2 hypertension is 140 or higher systolic or 90 or higher diastolic.
For most, there are no symptoms of hypertension
“One of the hard parts of managing high blood pressure or hypertension is that for most people, there are no symptoms,” Dr. Lewin said, noting that hypertension is “called the silent killer” because there are usually no symptoms of high blood pressure.
“People think they’ll know because of having a headache or flushing, but the vast majority of people will not know when their blood pressure is high,” he said. “This is why the only way to know that your blood pressure is high over time is to be checking it.”
Know your blood pressure numbers
The only way to know if you have high blood pressure is to measure your BP at home or have it measured by a health professional. Your doctor can then look at your numbers and determine if you have high blood pressure.
“If your blood pressure is too high on average, then that can cause injury to your body,” Dr. Lewin said. Noting “it can put you at an increased risk of a heart attack or a stroke.”
“It is important for you to be checking your numbers because when blood pressure is high, generally most people don’t feel it,” he said. “So, you could be having injury to your body without even knowing it and that’s why the only way to know is for you to check it periodically.”
Your BP is recorded as two numbers
When taking your blood pressure, keep in mind that your BP has two numbers: systolic and diastolic.
“The top number we call that the systolic blood pressure. The bottom is the diastolic,” Dr. Lewin said, explaining that “your heart has essentially two phases. The heart pumps and then that pushes blood out to the whole body, and then it relaxes.
“So, when it pumps, that’s the systolic phase and that’s when we record the top number,” he added. “And when the heart relaxes, that’s diastolic. That’s your bottom number.”
“What we’re aiming for is that your average blood pressure over time is under 120/80 mm Hg,” Dr. Lewin said. “If your blood pressure is a little higher than that, 120 to 129 on the top number, then that’s considered elevated blood pressure, but we may not do anything about it just yet.”
“When your blood pressure gets high enough—130 to 139 on the top number or above 80 to 89 on the bottom number—that’s called stage one hypertension,” he explained. “Then stage 2 hypertension is even high than that when the top number is 140 or above and 90 or above on the bottom number.”
Measure BP accurately
Since your numbers are used by your doctor and care team to make decisions, it is vital that your blood pressure is measured accurately.
“Our blood pressures go up and down during the course of the day, and that’s normal,” Dr. Lewin said. “When we’re excited, our blood pressure goes up, and it should be. But when we’re relaxed, that’s our resting blood pressure and that’s when we want to check it, when we’re relaxed.”
“You don’t want to check your blood pressure when you have stress—good or bad—or if you’re excited, laughing or exercising. That’s not when you check it,” he said. Same with “negative stress. If you’re in pain, you’re sick or have bad emotional stress, that’s no time to check your blood pressure.”
Whether it is in your doctor’s office or at home, “you want to check your blood pressure when you’re relaxed, seated with your feet flat on the floor and you don’t have a full bladder,” Dr. Lewin explained. “It’s ideal to be resting in that position and wait five minutes before you check.”
“The other part of measuring your blood pressure is to have your arm out at heart level and supported. So, your arm is outstretched in front of you, resting on a table at heart level and not talking,” he noted. “That’s the way to get an accurate blood pressure.”
Skip nicotine and caffeine before BP readings
“There are several things you want to do to avoid getting a falsely elevated blood pressure, such as avoiding stress,” Dr. Lewin said. “One of those stressors on the body is stimulants like caffeine or nicotine.”
“You don’t want to have a coffee, and you don’t want to use any nicotine products within 30 minutes before checking your blood pressure,” he said. “Or exercise. That’s a stimulant too, in a good way, of course, compared to other things.”
Home BP measurement helps everyone
Measuring blood pressure at home “is the most accurate way to know what your blood pressure actually is rather than relying on when you go to the drugstore or medical office,” said Dr. Lewin. “You can control your environment a lot more easily at home and it’s a lot more likely you’re going to be in a relaxed environment that you can control.”
“It’s much more important to get an accurate reading over time to be checking your blood pressure at home,” he said.
Patients benefit from measuring their blood pressure at home too because you may learn more about your own BP patterns and numbers, and you can share your observations and thoughts with your doctor and care team.
There are long-term risks of uncontrolled high BP
Long-term risks of uncontrolled hypertension are “quite serious over time,” Dr. Lewin said. “When blood pressure is high, it can affect every organ in the body, but some organs are more at risk or more sensitive to hypertension than others.”
“The heart itself is the first one. So, heart attacks are more likely with hypertension,” he said. “The brain is another one, and that’s why strokes are more likely with hypertension.”
Additionally, “the eyes are very sensitive to elevated blood pressure, and the kidneys are as well,” Dr. Lewin noted.
Know your goals and treatment plan
For treating hypertension, “the big picture is your doctor and care team want to help prevent the still No. 1 killer, which is heart disease,” Dr. Lewin said. “And this is why we worry about high blood pressure, because it’s one of the biggest factors leading to the No. 1 killer of heart disease.
“So, the goal is generally to get your average blood pressure under 130/80 mm Hg, but that’s not true for everybody, so you will work with your doctor to come up with a goal and how to get there safely,” he said. “Generally, starting with lifestyle changes, diet and if needed, moving on to perhaps medications.”
Follow the DASH diet
“There actually is a best diet and this has been shown in many studies,” Dr. Lewin said. “It’s called the DASH diet, which stands for the Dietary Approaches to Stop Hypertension.
“It really focuses on unprocessed foods, so real whole foods, fruits, vegetables, whole grains, lean proteins and minimizing processed foods, salt intake, saturated fats and sweets and sugars,” he added. “This type of diet has been shown again and again to help lower blood pressure.”
Lifestyle change is part of treatment
For all patients, making healthy lifestyle changes should be a key part of the hypertension treatment plan.
“I work with patients when we’re first having our conversations about getting blood pressure under control and sometimes we don’t even talk about medicines,” Dr. Lewin said. “We talk about lifestyle changes because lifestyle changes can be very powerful and sometimes just as potent as starting medication.”
“So, sometimes all a person has to do to go from being in the hypertension range to getting blood pressures normal is make some of these lifestyle changes,” he explained. “That includes the DASH diet, quitting smoking and other nicotine products, managing stress, cutting back on alcohol, exercising regularly and managing weight.”
“All of these changes are what we call the lifestyle changes that will help lower blood pressure and very often get it under control without even needing medication,” Dr. Lewin noted.
Reduce your sodium intake
“Sodium is not the enemy for people without hypertension. But what sodium does if there’s excess sodium in your bloodstream, it retains water, so it increases the pressure in that system,” Dr. Lewin said. “Minimizing sodium for people with hypertension is very important.”
“Most of our sodium isn’t at the table from the saltshaker, but of course that is the first way to minimize or decrease your sodium intake,” he said. Instead, “most sodium comes from processed foods.”
“Cooking without salt, trying to eat more unprocessed foods and looking at labels and for low sodium options is important,” Dr. Lewin noted. “Also consider instead of salt, using fresh herbs, for instance, to flavor your foods. It is very helpful in decreasing salt intake and then helping to lower blood pressure.”
Additionally, also keep in mind that when you buy prepackaged breads from the grocery store, they often have excess sodium included. This is the same with eating out at restaurants.
“It’s flavor and flavor sells. Breads taste better with salt, but that’s not the only way to get flavor into bread,” he said, emphasizing that cooking at home from scratch is “the only way to know for sure that you’re not getting a ton of salt added to your meals.”
Medications help patients reach BP goals
“Despite our best efforts, despite eating a healthy diet and doing all these lifestyle changes, many people still have high blood pressure for a lot of different reasons,” Dr. Lewin said. “Sometimes it’s just genetics—it’s not your fault.”
“Or sometimes a genetic mutation, which means nobody in the family has it, you’re doing everything right, and you still have high blood pressure,” he said. But “if these lifestyle changes and dietary changes aren’t getting you there, then we have medication.”
“High blood pressure is always treatable and manageable, and we always manage it with the mildest, safest possible treatment plan,” Dr. Lewin said. “Very often, that involves medications. There are several different medications available to treat hypertension … and your doctor or other healthcare provider can help determine which is the right one for you.”
“We always start with the lowest possible doses. We always know what the likely side effects are that a given medication can cause,” he said. This helps doctors and other health professionals “watch for them, so we don’t have to worry about the medications themselves.”
“Many people are hesitant to start a medication for high blood pressure because they’re worried about side effects when really the thing to worry about is the side effects of high blood pressure,” Dr. Lewin said. “We can always find a medication and sometimes a combination of medications to get blood pressure under control without side effects.”
“If we do have side effects, we stop it and we find a different one. We have so many options available and they protect the heart in other ways rather than just lowering blood pressure,” he said. “People don’t need to be afraid that we’re not going to be able to get blood pressures under control. We always will.”
Treating hypertension is a marathon, not a sprint
“Treating high blood pressure is a marathon, not a sprint. Once people start getting their blood pressure under control, in my experience, a lot of times people will stop checking,” Dr. Lewin said. For example, “let’s say we get them started on lifestyle changes or a medication, their blood pressures get to goal and then they forget about it and they may not see their doctor for a year.
“Then they show up and it’s high. Well, how long has it been high? It’s possibly been high for 11 months and could be causing damage,” he added. “It’s important to be consistent and manage this every day long-term. So, consistently checking blood pressures—ideally three times a week—continuing a healthy diet and lifestyle changes.”
Share any concerns with your doctor
“It's a good idea to be checking blood pressure periodically. And if you see that your average is above goal, so above 130/80 mm Hg in a month, not just a high reading here and there, that's fine,” Dr. Lewin said. “It should be high periodically during the course of our day, especially with stress, but if over time you see that your average blood pressure is above 130 over 80 … that's when you want to meet with your doctor and care team over time.”
“Blood pressure does not cause injury over days and weeks. It's over months and years,” he noted. “So, it's not an emergency, but there are what we call hypertensive emergencies when you want to meet with your doctor right away and that number's 180 over 120.”
“If you have a blood pressure reading of 180/20 mm Hg, but you feel fine, you want to reach out and see what your doctor’s office recommends,” Dr. Lewin said. “But if you’re having a single blood pressure of 180 over 20 with symptoms and very specific symptoms, this is called a hypertensive crisis or a hypertensive emergency where you need to be seen right away.
“That’s blood pressure that’s high along with chest pain, difficulty breathing, severe headache or any changes in vision,” he added, emphasizing the importance of calling your doctor right away.
