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High Blood Pressure: What You Need to Know About Medications

I'm here this morning with dr. Luke

laughin who's a staff cardiologist in

our section of preventive cardiology and

he's also a clinical specialist in

hypertension and he's here to talk to us

about high blood pressure and control of

high blood pressure and a lot of

questions that patients ask about high

blood pressure doctor laughs and the CDC

says that one in three people in the

United States have high blood pressure

it's just a large population of patients

so the first question that I have is

about medications that seems to be the

biggest question as a nurse that I get

you know how do you even choose

medications how do you start a patient

on medication when do you start a

patient on medications so generally

there's three classes of medications

that are our first line treatment for

hypertension and the guidelines for when

to start medications on patients have

been changing recently but we tend to

say that if they've had elevated blood

pressures two or more visits in the in

the clinic then we should consider one

lifestyle modification but then based on

the level of potential addition of

medical therapies so the three classes

of medications that we prescribe as

first-line therapy are as follows the

first one is Rena angiotensin system

blockers so they're essentially what

they do is they block this hormone

system that regulates blood pressure and

fluid within the body another class of

medicines that people are often on are

diuretics the water pills and they help

get rid of sodium and water via the

urine and then finally there's another

class of medicines called calcium

channel blockers and how they work is

they relax the blood vessels within the

body to provide lower blood pressures as

well now there's other medication

classes there's numerous other ones that

we can use to treat hypertension and in

certain patient populations they'd be

maybe more efficacious

for example patients with certain

cardiovascular disease recent heart

attacks etc they may be prescribed a

beta blocker which is another class of

medicines so there's many different

choices but those are the first-line

therapies and how come some patients are

only on one medication sometimes

patients are two medications how do you

make that choice for a patient so that's

generally based on how much blood

pressure lowering we need there's good

data that being on two medications that

have some synergy so they work together

effectively lowering blood pressure at

moderate doses can be better than just a

maximum dose of one medication right now

the guidelines suggest that anyone that

has multiple blood pressures in the

office that are higher than 140 over 90

generally should be started on

combination therapy so two doses maybe

not at the maximum strength but two

different medications so are there side

effects that people should think about

or watch out for yeah definitely there

is the nice thing about blood pressure

medicines is that they've been around

for a while and are well studied so

these side effects are predictable the

one complaint or the one comment that

oftentimes physicians hear is that oh

I'm tired when I start taking my blood

pressure medicines especially if you

started at a higher blood pressure and

we're significantly lowering it that can

be classified as a side effect but

that's just the body adjusting to the

lower blood pressures in terms of

specific medication classes and their

side effects oftentimes when we begin a

diuretic especially the stronger

diuretics people can complain of

cramping in their legs this generally

tends to last for two to three days it's

oftentimes attributed to low potassium

although it's not always low potassium

it's more likely to be the fluid shifts

the body getting rid of extra water and

salt and so we can see that but the nice

thing that we tell them is that after 2

or 3 days especially if you're on a low

salt diet this cramping tends to

away other medicines that commonly have

that have predictable side effects

include calcium channel blockers so the

most commonly used is one called

amlodipine or the brand name is norvasc

about on the 5 milligram dose which is a

moderate dose about 30% of people

explore experience some degree of lower

extremity swelling so a little bit of

puffiness and their ankles or feet it's

not dangerous

it's just cosmetically some people don't

like it and then at the 10 milligram

dose about a little bit more than half

of people actually have this this side

effect it's important to remember that

that's how the medicine works it's a

vasodilator it increases the size of the

blood vessels so you are going to have

some degree of swelling but as I said

it's not dangerous so are there any of

those side effects that they should

definitely call their doctor for or are

these things that just kind of go away

what time are well I think coming back

to what I said about being tired um you

don't want to be so that you so tired

that you can't get out of bed that just

suggests that perhaps your doctor

overshot in terms of how much blood

pressure medicine that we're giving we

don't want people walking around with

blood pressures under a hundred

millimeters of mercury for their

systolic similarly certain medicines

especially in the class of medicines

called ACE inhibitors so the most

commonly used is lisinopril they can

have effects such as swelling of the

lips the airway those are side effects

that and you need to alert your doctor

promptly and if it's it's significant

and you need to go to the emergency

department

do you ever send patients home with to

do home blood pressure monitoring is

that something that would help with the

medications too yes I think definitely

it's really a cornerstone of my practice

which predominantly involves patients

that have resistant hypertension so

blood pressure not controlled on three

different medicines

and we do it very commonly and that's

actually one of the emphases of the

newer 2017 hypertension guidelines by

the American Heart Association in

American College of Cardiology and what

we recommend is when we've changed

antihypertensive therapy to check three

to four times per week in the morning

before you take your medicines and then

what I have is I have patients send them

to me about two or three weeks after

their they might keep it on an Excel

spreadsheet or they may just write it

down on a piece of paper and they send

it to me via via our electronic medical

record so we can make adjustments in

between appointments rather than waiting

three or six months till we see them

again and it can be very helpful in

terms of guiding what we do if we add

subtract or change medicines okay so you

said just once a day in the morning

because I know patients sometimes they

like should I take it not in the morning

should I take it three times a day so

you're just really saying they could

take it once a day in the morning right

that's that's generally what we

recommend throwing in an evening blood

pressure is fine every once in a while

however we know that in the majority of

people blood pressure tends to decrease

at night it drops about ten to fifteen

percent then starting at 4:00 a.m.

there's a sharp upward rise in blood

pressure Peaks in most people between

6:00 a.m. and noon not coincidentally

that's when the majority of strokes and

heart attacks between 6:00 a.m. and noon

so what we try and do is we try and

catch that peak blood pressure and make

sure you're protected throughout the day

one common mistake that I see patients

making is they say okay well I'm going

to take my blood pressure medicine and

then I'm going to check two or three

hours after taking I don't think that's

the right strategy to take because that

can give people a false sense of

security that's when the medication is

having its peak effect is about two

although it works all day it's having

its peak effect two to three hours after

but we want to know when it's the

highest and treat so that it's under

that so a lot of times patients ask

should I take my blood pressure medicine

at night or in the morning that's a very

timely question because there's actually

a trial released

in the past week looking at this it was

published in the American Heart

Association as hypertension journal

called the Harmony trial and what they

did was they said one group of patients

can take their blood pressure medicine

in the morning all in the morning or all

at night and they look to see if there

was a difference in 24-hour blood

pressure so they wore a monitor for 24

hours and they showed no difference

whatsoever I was lucky enough to have

the opportunity to write the editorial

in that that accompanied that paper and

what it comes down to likely is that the

medicines we use are our long-acting

the majority of them so they work over

24 hours so it probably doesn't make a

difference when we're taking our

medicines in the morning right now there

is one caveat to that and that is

there's certain medicines that we

probably don't want to take it at night

because they're going to disrupt our

sleep and we know that disrupted sleep

can lead to elevated blood pressures so

for example if someone's taking a

diuretic a water pill they shouldn't be

taking that at 7 o'clock 8 o'clock at

night because it's going to have a peak

effect when you're going to bed at 10:00

or 11:00 o'clock

similarly the class of medicines calcium

channel blockers if someone has

significant acid reflux or heartburn if

they're taking that at night it can

sometimes relax the muscles in the

esophagus on the stomach and the

connection between those and so it can

worsen acid reflux so if that's the case

we recommend they take that medicine in

the morning as well I'm sure that you

get this question a lot can I come off

my medicine once I start a blood

pressure medicine is that ever a chance

that I could take less or get off that

medication yes it's a very common

question that we get and it really

depends on the patient themselves now if

there's if someone is overweight has a

sedentary lifestyle so they're not

exercising or active and has a high

sodium diet then there is a possibility

and that they can come off blood

pressure medicine it depends obviously

how high their blood pressure is there's

good data that shows that by losing

weight exercising and a low sodium diet

in combination

we can drop our systolic blood pressure

by at least 15 millimeters of mercury

maybe even more and that's oftentimes

all patients need now there is a subset

of patients that there may be 7075 they

have stiff blood vessels and that's an

effective aging and somewhat at genetics

as well those patients they may not be

overweight and they may be active and

they may be watching their sodium but

their blood pressure is still high those

patients I tell them no they cannot come

off medicines but we try and keep them

at the same number of medicines just try

and optimize the dosing for them get

them on the most potent medicines to

control their blood pressure while also

minimizing side effects very interesting

so if you could leave this with the

three most important points you would

want to give your patients who have high

blood pressure what would that be I

think the the first thing is that it's

understandable no one likes to take

medicines I don't like to take medicines

however that's the problem with

hypertension is that oftentimes we don't

know when our blood pressure is high

that's why they call it the silent

killer and it's the number one risk

factor for things like stroke so so when

we start medicines and move someone from

let's say a blood pressure of 160 or 170

systolic down to 140 or 130 yes you may

feel tired when that when you start

taking the medicine that's natural it's

just the body adjusting to living at a

lower blood pressure but that effect

goes goes away after 10 days to two

weeks and so that's important to know

that don't give up on it just because

you're a little bit more tired because

it's gonna you're gonna feel better in

the long run and you're gonna protect

your major organs your kidneys your

heart and your brain so that would be

point number one point number two is

have a discussion with your doctor about

the side effects associated with some of

these men

because often comes it can be a

trade-off and just because one person

can tolerate lower blood pressures for

the systolic you maybe can't so have a

have a discussion with them and then the

third thing I'd say is that for those

patients that may be taking three or

more medicines hopefully in let's say

when the next five to ten years we'll

have therapies that are not medicine

based that they're more device based

therapy I actually have a call right

after this podcast talking with a

company that we're looking to to start

at least do some clinical trials than

that so there is the possibility in the

future of device based therapy for

hypertension where we'll eliminate the

need for medications very interesting

well thank you so much for being here

today

I want to thank dr. laughin for being

with us to answer questions about high

blood pressure great thanks very much

for having me