DESCRIPTION

Blood pressure normally rises as you get older; however, this normal increase occurs more quickly in people who have high blood pressure.

When the heart pumps the blood through the arteries, the blood presses against the walls of the blood vessels. In people who suffer from hypertension, this pressure is abnormally high.

Whether blood pressure is high, low, or normal depends on several factors:

• The output from the heart.
• The resistance to blood flow of the blood vessels.
• The volume of blood.
• Blood distribution to the various organs.

All of these factors in turn can be affected by the activities of the nervous system and certain hormones.

If blood pressure is elevated, the heart must work harder to pump an adequate amount of blood to all the tissues of the body. Ultimately, the condition often leads to kidney failure, heart failure, and stroke. In addition, high blood pressure is often associated with coronary heart disease, arteriosclerosis, kidney disorders, obesity, diabetes, hyperthyroidism, and adrenal tumors.

An estimated 50 million Americans have high blood pressure. According to the U.S. Public Health Service, hypertension affects more than half of all Americans over the age of 65. The percentage of the African-Americans between the ages of 24 and 44 are 18 times more likely than whites to develop kidney failure due to hypertension. Men tend to develop hypertension more often than women, but the risk for women rises after menopause and soon approaches that of men. A woman's risk of high blood pressure also increases if she takes oral contraceptives or is pregnant.

Untreated high blood pressure can damage the delicate lining of the blood vessels. Once damaged, fat and calcium can easily build up along the artery wall, forming a plaque. The blood vessel becomes narrowed and stiff (atherosclerosis), and blood flow through the blood vessel is reduced. Over time, decreased blood flow to certain organs in the body can cause damage leading to:

• Heart disease, heart attack, and abnormal heartbeat.
• Kidney (renal) failure.
• Peripheral vascular disease.
• Eye damage (retinopathy).
• Stroke.

People with borderline, or "high-normal," blood pressure, which is now considered "prehypertensive," (120–139/80–89 mm Hg) have a higher risk for developing high blood pressure. A new study has shown that they also have a higher risk of heart disease than those with blood pressure less than 120/80 mm Hg.

In addition, men who have high systolic blood pressure during middle age (50s to 60s) may show a greater decline in mental ability later in life (after age 75) than men who do not have high blood pressure earlier. Short-term memory and attention span are most affected.

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CAUSES

Blood pressure is usually divided into two categories, designated primary and secondary.

Primary (or Essential) Hypertension: This is high blood pressure that is not due to another underlying disease and is the most common type of hypertension. The precise cause is unknown, but a number of definite risk factors have been identified. These include cigarette smoking, stress, obesity, excessive use of stimulants such as coffee or tea, heavy alcohol use, drug abuse, and aging. High sodium (salt) intake, a sedentary lifestyle, stress, low potassium intake, low calcium intake resistance to insulin and the use of oral contraceptives may also cause your blood pressure to rise. Because too much water retention can exert pressure on the blood vessels, those who consume foods high in sodium may be at a greater risk for high blood pressure. Elevated blood pressure is also common in people who are overweight. Blood pressure can rise due to stress as well, because stress causes the walls of the arteries to constrict. Also, those with a family history of hypertension are more likely to suffer from high blood pressure.

Secondary Hypertension: When persistently elevated blood pressure arises as a result of another underlying health problem, such as a hormonal abnormality or an inherited narrowing of the aorta, it is called secondary hypertension. A person may also have secondary hypertension because the blood vessels are chronically constricted or have lost elasticity from a buildup of fatty plaque on the inside walls of the vessel, a condition called atherosclerosis. Arteriosclerosis and atherosclerosis are common precursors of hypertension. The narrowing and/or hardening of the arteries makes circulation of blood through the vessels difficult. As a result, blood pressure becomes elevated. Secondary hypertension can also be caused by poor kidney function, which results in the retention of excess sodium and fluid in the body. This increase in blood volume within the vessels causes elevated blood pressure levels. Kidneys may also elevate blood pressure by secreting substances that cause blood vessels to constrict. Secondary high blood pressure is also caused by medications or other conditions such as pregnancy.

Other subtypes are called Labile Hypertension and Malignant Hypertension.

Labile hypertension is blood pressure that changes rapidly, often in response to stress or activity. This type of high blood pressure is most common in younger people.

Malignant hypertension (also called hypertensive crisis) is high blood pressure that increases rapidly. The cause may be unknown or may be due to medication or another condition. Hypertensive crisis is Hypertensive crisis a state in which blood pressure becomes so high that it is causing immediate danger and needs to be reduced rapidly. A person is said to be in a hypertensive crisis when his or her blood pressure is severely elevated and there is evidence of damage to the brain, heart, kidneys, or other organs.

Typically, a person in hypertensive crisis has a diastolic blood pressure (the lower number in a blood pressure reading) greater than 120 millimeters of mercury (mm Hg). In comparison, normal diastolic pressure for an adult is less than 79 mm Hg. Diastolic pressure refers to the pressure of blood in the artery when the heart relaxes between beats.

Quick-acting medications can be used to reduce blood pressure during hypertensive crisis.

Isolated systolic high blood pressure is when systolic blood pressure is elevated above 140 mm Hg, but diastolic blood pressure stays at less than 90 mm Hg. This type of high blood pressure is more common in older adults, especially older women. If you are over 50, a systolic blood pressure over 140 is a more important risk factor for heart disease and stroke than your diastolic blood pressure.

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SIGNS & SYMPTOMS

Because high blood pressure usually causes no symptoms until complications develop, it is known as the "silent killer." Hypertension develops slowly and can cause serious organ damage, usually without any symptoms. Warning signs associated with advanced hypertension or malignant hypertension may include:

• Headaches.
• Nausea and vomiting.
• Sweating.
• Rapid pulse.
• Shortness of breath.
• Dizziness.
• Visual disturbances.

Malignant high blood pressure (hypertensive crisis), which is hypertension that rises rapidly, if left untreated can damage the brain, heart, eyes, or kidneys. It is a medical emergency that requires immediate hospitalization.

Overt time, if you do not receive treatment for your high blood pressure, you may feel symptoms caused by damage to your heart, kidney, or eyes, including:

• Coronary artery disease, heart attack, heart failure, or abnormal heart beat.
• Kidney (renal) failure.
• Peripheral vascular disease.
• Retinopathy, or damage to the tiny blood vessels that supply blood to the light-sensitive lining of the back of the eye (retina).
• Stroke.

In 1990, nearly 33,000 Americans died of hypertension-related diseases other than heart attack and stroke.

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RISK FACTORS

Several factors increase your risk for developing high blood pressure. Some of them, such as salt intake and alcohol consumption, are lifestyle issues that you can control. Other factors, such as your family history, are not controllable.

Risk factors for primary (essential) high blood pressure include:

• A family history of high blood pressure.
• Aging. Ninety percent of people who, at age 55, do not have hypertension will eventually develop it.
• Black race.
• Sodium (salt) intake.
• Excessive alcohol consumption.
• Low intake of potassium, magnesium, and calcium.
• Obesity.
• Long-term exposure to lead (in men), such as in the workplace.
• Sleep apnea and sleep-disordered breathing.
• Depression.

People who have high blood pressure along with any of the following risk factors are at increased risk of developing complications, such as heart disease, heart attack, abnormal heartbeat, stroke, kidney failure, and eye damage (retinopathy):

• Cigarette smoking.
• High cholesterol or low HDL ("good") cholesterol.
• Diabetes.
• A history of early coronary artery disease in a parent or sibling (before age 45 for men or age 55 for women).
• Male sex.
• Black race.
• Being overweight.
• Enlarged lower left heart chamber (left ventricle).

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PREVENTION

A new study on the prevention of high blood pressure recommends six lifestyle modifications. These strategies are especially important for people who have risk factors for high blood pressure that cannot be changed, including family history, race, and age.

Lifestyle modifications include:

• Maintaining a normal weight, with a body mass index (BMI) of 18.5 to 24.9.
• Reducing sodium in your diet to about 2.4 g (2400 mg) per day, which is about 1 teaspoon of salt.
• Exercise, such as brisk walking, at least 30 minutes a day on most, if not all, days of the week.
• For men, limiting alcohol to 24 ounces of beer, 10 ounces of wine, or 2 ounces of 100-proof whiskey per day. Women and lighter-weight people should limit alcohol to half that amount.
• Getting 3,500 mg of potassium in your diet every day.
• Following the Dietary Approaches to Stop Hypertension (DASH) eating plan, a diet that is rich in fruits, vegetables, and low-fat dairy products, with reduced amounts of saturated and total fats.

TREATMENT

DIAGNOSIS & TESTS

If a health professional suspects you have hypertension, he or she will conduct a physical exam and medical history. In most cases, extensive tests are not needed to diagnose high blood pressure. If there is reason to suspect that the blood pressure measurements taken in the health care provider's office do not represent your accurate blood pressure (if, for example, you have white-coat hypertension), measuring blood pressure away from the health care provider's office may be needed. Your blood pressure can rise more than 20 mm Hg systolic and 10 mm Hg diastolic from white-coat hypertension. Even routine activities, such as attending a meeting, can raise your blood pressure by that amount. Other factors that can raise your blood pressure include commuting to work, exposure to cold, and drinking large amounts of alcohol.

In some cases, you may be asked to check your blood pressure at home 3 times a day and keep a record of the readings. If you are not able to measure your blood pressure accurately at home, you may need to wear an automated blood pressure cuff that periodically inflates and takes blood pressure measurements during the day. This is called ambulatory blood pressure monitoring.

High blood pressure screening tests and programs vary widely in reliability. Results from automated blood pressure testing, such as you might do at a grocery store or pharmacy, may not be accurate. Any high blood pressure measurement discovered during a blood pressure screening program needs to be confirmed by a health professional.

To diagnose high blood pressure, a health care provider or midwife uses a device called a sphygmomanometer. Blood pressure is represented as a pair of numbers. The first is the systolic pressure (the higher number), which is the pressure exerted by the blood when the heart beats, forcing blood into the blood vessels. This reading indicates blood pressure at is highest. The second reading is the diastolic pressure (the lower number), which is recorded when the heart is at rest in between beats, when the blood pressure is at its lowest. Both figures represent the height (in millimeters, or mm) that a column of mercury (Hg) reaches under pressure exerted by the blood. The combined blood pressure reading is then expressed as a ratio of systolic blood pressure to diastolic blood pressure. Thus, in a person with normal blood pressure, the systolic pressure measures 120 mm Hg and the diastolic blood pressure measures 80 mm Hg; together this is expressed as 120 over 80, or 120/80. Both the systolic and diastolic readings are important; neither should be high. Normal blood pressure readings for adults vary from 110/70 to 140/90, while readings of 140/90 to 160/90 or 160/95 indicate borderline hypertension. Any pressure over 180/115 is severely elevated.

Important Note!: Millions of people whose blood pressure was previously considered borderline high (130-139/85-89 mm Hg) or normal (120/80) now fall into the "prehypertensive" range, based on new, more aggressive high blood pressure guidelines from the Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Because new studies show the risk of heart disease and stroke begins to increase earlier than previously believed, health experts lowered the acceptable normal range to promote more aggressive and earlier treatment of high blood pressure. The new ranges set to determine high blood pressure:

Level	Systolic	Diastolic
High blood pressure is:	140 or above	90 or above
Prehypertension is:	120 to 139	80 to 89
Normal adult (age 18 or older) blood pressure is:	119 or below	79 or below

It is impossible for your health care provider to make a correct diagnosis of high blood pressure with a single reading except in very severe cases. You will be diagnosed with hypertension if your blood pressure measurements are high (above 140/90 mm Hg) on three or more separate occasions. They are usually measured 1 to 2 weeks apart. The test must be repeated throughout the day to be accurate. Home testing is best because it enables you to monitor your condition periodically. Measuring blood pressure at home on a regular schedule may:

• Help determine whether your blood pressure is high only when taken during a medical visit, sometimes called "white coat hypertension" and for some individuals, just being in a medical setting or during a visit to their health care provider's office causes their blood pressure to rise (for example, in a medical office where a nurse or a doctor may be wearing a white lab coat). This type of hypertension is more common in people who have high blood pressure. It tends to diminish with repeat measurements.
  
  
• Enable you to collaborate with your health care provider in controlling your high blood pressure.
  
  
• Reduce the frequency with which you need to visit your health care provider for blood pressure evaluation.

Blood pressure monitoring devices fall into two basic categories:

Mechanical Gauges: The mechanical gauge is the type most often used in a health care provider's office. It consists of an instrument to measure the pressure, an air bladder (inflatable cuff), and a pressure bulb with a release valve to pump up the cuff. The standard-size arm cuff on blood pressure monitors fits arms up to 13 inches around (if your arm is larger than this, you will need to obtain a larger cuff). With most of these devices, the pressure is read on a gauge dial. Mechanical gauges are much less expensive than electronic ones and many health care providers and midwives feel they give more accurate readings, at least in the hands of an experienced user. However, if you use this type of device to take your own blood pressure, you must pump up the cuff with one hand, read a dial, and listen with the a stethoscope more or less simultaneously. In other words, using these devices correctly requires dexterity, good eyesight, acute hearing, and some training and practice.

Automated Electronic/Digital Gauges: An alternative to the mechanical gauge is the digital sphygmomanometer. With this device, the machine automatically gauges your blood pressure when the cuff is inflated and presents the result in digital format (some will also give you a pulse rate reading along with your BP). These are more expensive than the mechanical types, but because they are much easier to use accurately, they are generally preferred for home use. There are other electronic devices available, including wrist and finger cuff monitors. Although they are easy to operate, most health care providers do not recommend them because they tend to be less accurate and also more sensitive to the effects of temperature and poor blood circulation.

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CONVENTIONAL MEDICAL TREATMENT

A physical exam and medical history are routinely used to evaluate high blood pressure. Additional blood tests and urine tests, such as urinalysis, also may be done before starting treatment to determine whether there has been damage to organs and to check for complications. These lab tests may include measurements of potassium, sodium (a component of salt), glucose (blood sugar), cholesterol levels, and tests to measure kidney function. Electrocardiography (EKG, ECG) also may be done to determine whether there is any damage to the heart. Your health care provider may want to check your risk of coronary artery disease.

In most people who have high blood pressure without any complications, routine lab test results will be normal. Sometimes, findings may suggest the presence of kidney disease, diabetes, or a hormone disorder.

If there is reason to suspect that blood pressure measurements taken in the health care provider's office do not represent your accurate blood pressure (for example, if you may have white-coat hypertension), measuring blood pressure away from the health care provider's office may be needed.

In some cases, you may be asked to check your blood pressure at home 3 times a day and keep a record of the readings. If you are not able to measure your blood pressure accurately at home, ambulatory blood pressure monitoring may be needed. Ambulatory blood pressure monitoring can help in diagnosing and treating elderly patients and pregnant women.

Other tests may be done to determine whether high blood pressure has started to damage the heart (echocardiography, electron beam computed tomography [CT] scan), lungs (chest X-ray), or other organs.

The U.S. Preventive Services Task Force recently recommended that people with high blood pressure or high cholesterol be routinely screened for diabetes. This recommendation is based on studies that show early detection and treatment of diabetes substantially decreases the risk of coronary artery disease in these people.

If you fall into the prehypertension range (120–139/80–89 mm Hg), your health care provider will likely recommend lifestyle modifications, including losing excess weight, exercising, limiting alcohol, cutting back on salt, quitting smoking, and following the Dietary Approaches to Stop Hypertension (DASH) diet. The DASH eating plan is a low-fat and low-saturated-fat diet that emphasizes eating more fruits, vegetables, whole grains, and low-fat dairy foods.

If you have high blood pressure (140–159/90–99 mm Hg) and you do not have any organ damage or other risk factors for heart disease (uncomplicated high blood pressure), your health care provider will likely recommend lifestyle changes and possibly medications. Most people with high blood pressure will need two or more medications, including a thiazide-type diuretic, to lower their blood pressure to below 140/90 mm Hg, the goal for people with uncomplicated hypertension. If you have other conditions, such as diabetes, heart failure, or chronic kidney disease, your goal blood pressure is lower: 130/80 mm Hg.

If your blood pressure is 160–179/100–109 mm Hg or higher, you and your health care provider may need to try various combinations of medications to find what works best for you. You will also need to make aggressive lifestyle changes.

Overall, your treatment will depend upon how high your blood pressure is, whether you have other medical conditions, such as diabetes, and whether any organs have already been damaged. Your risk of developing other diseases, especially heart disease, will be another important factor your health care provider will consider.

Strategies for treating high blood pressure in pregnant women are quite different. See the topic Preeclampsia and Hypertension During Pregnancy for more information.

Although you may have your blood pressure checked outside of a health care provider's office, you must see a health professional to confirm that you have high blood pressure, so that you and your health care provider can develop a treatment plan that's right for you. A family practice health care provider, internist, nurse practitioner, or physician's assistant can diagnose and treat your high blood pressure. If you have extremely high blood pressure or heart problems, you may also need to see a heart specialist (cardiologist).

If you have primary (essential) hypertension, you will first need to look closely at the foods you eat. Your health professional may recommend that you follow the DASH diet. Losing weight if you need to and exercising will also be important for lowering your blood pressure.

If you smoke cigarettes, you will need to quit. If you are a heavy drinker, you will need to severely cut back on your consumption of alcohol. Also, it may be necessary for you to learn to check your blood pressure at home.

High blood pressure treatment, whether it involves medication or lifestyle changes, usually is a lifelong process.

Whether you need medication depends on the severity of your high blood pressure and whether you have other health problems or conditions, such as heart failure or diabetes, or are pregnant.

If your health care provider prescribes medication, it is extremely important to take your medications as prescribed.

Treatment of primary high blood pressure, especially moderate or severe high blood pressure, decreases the risk of heart failure, coronary artery disease, heart attack, abnormal heartbeats, stroke, and kidney disease, and reduces the risk of death from these conditions.

Overall, goals of treatment are to:

• Reduce systolic blood pressure below 140 mm Hg and diastolic blood pressure below 90 mm Hg. Two recent studies show that lowering high blood pressure even further in people with diabetes reduces the risk of death. In these people, blood pressure should be reduced to less than 130/80 mm Hg.
• Prevent death and disease associated with high blood pressure (heart disease, stroke, and kidney disease). High blood pressure is associated with 35% of heart disease caused by coronary artery disease and 49% of all cases of heart failure.
• Control other risk factors, such as smoking, lack of exercise, and high cholesterol, that can lead to complications such as heart attack and stroke.
• Minimize side effects of medications.

People with high blood pressure who require special treatment considerations include:

• Older adults.
• African-Americans.
• Children.
• Pregnant women.

High blood pressure cannot be cured, but it can be controlled with lifestyle changes and medication. Treatment is a lifelong process.

MEDICATIONS

High blood pressure is a lifelong disease that, if not controlled, can lead to heart or kidney disease and stroke. Even though you may not feel sick when you have high blood pressure, you must take your medication or combination of medications daily according to the prescription.

The amount and types of medications you take will depend on your blood pressure reading, whether you have organ damage from high blood pressure, and whether you have other medical conditions. Follow your doctor's recommendations carefully, and do not skip any of your medications.

Make your medication schedule as simple as possible. Plan times to take your medications when you are doing other things, like eating a meal or getting ready for bed. This will make it easier for you to remember to take your medications.

Take a list of your medications or bring your medications with you when you visit your health care provider. Include any medications that were prescribed to you by other health care providers and any nonprescription medications. Review the list with him or her and discuss any side effects you are having or need to watch for.

Talk with your health care provider if you are having problems with your medication schedule. Your health care provider may be able to change your medications or change the times you are taking them.

Talk with your health care provider if you have any changes in your health that might affect your blood pressure, such as weight gain, side effects of medications, or another medical condition.

Use any tools, like daily or weekly pill containers, that make taking your medications simple.

Follow healthy lifestyle habits, including maintaining a healthy weight; exercising; and following an eating plan that emphasizes fruits, vegetables, low-fat dairy foods, and less salt. This may allow your health care provider to reduce the amount of medication you take and will help the medications work better.

Deciding whether to treat high blood pressure with medication and choosing the best medication are based mainly on:

• Your blood pressure measurement.
• Whether there are signs of organ damage caused by high blood pressure in other parts of your body, such as an enlarged heart or early damage to your arteries, kidneys, or eyes.
• Whether you have other medical conditions, such as heart disease, diabetes, or kidney or lung disease, or risk factors for heart disease, such as diabetes or high cholesterol.
• Whether you think you can be successful in making lifestyle changes.

Health care providers may have different opinions about when to start medications for high blood pressure.

• If you have prehypertension (120–139/ 80–89 mm Hg) or high blood pressure (140/90 mm Hg), you do not have other risk factors for heart disease, and there's no evidence of organ damage, lifestyle changes alone may be tried before medication.
• If you have other risk factors for heart disease, there is evidence of damage to organs, or you have stage 1 or 2 high blood pressure, treatment with medication is often started in addition to lifestyle changes.

Health care providers usually prescribe a single, low-dose medication first. If blood pressure is not controlled, he or she may change the dosage, or try a different medication or combination of medications. It is common to try several medications before your blood pressure is successfully controlled. Many people need more than one medication to get the best results.

Medication choices include:

• Diuretics: Diuretics cause the kidneys to remove more sodium and water from the body. This decreases the volume of blood circulating through the body, which lowers blood pressure, especially systolic blood pressure. These drugs may also have a direct effect on blood vessels, causing blood pressure to decrease. Diuretics are often combined with other blood pressure medications.
  
  
• Beta-blockers: Beta-blockers decrease heart rate and the amount of blood the heart pumps out with each beat, which, in turn, reduces blood pressure.
  
  
• ACE inhibitors: Angiotensin-converting enzyme (ACE) inhibitors block an enzyme needed to form a substance that causes blood vessels to narrow (constrict). As a result, blood vessels relax and widen (dilate), making it easier for blood to flow through the vessels, which reduces blood pressure. These medications also increase the release of water and sodium to the urine, which also lowers blood pressure.
  
  
• Calcium channel blockers: Calcium channel blockers work by reducing the amount of narrowing of the blood vessels caused by high blood pressure. This makes it easier for blood to flow through the vessels and lowers blood pressure.
  
  
• Angiotensin II receptor blockers (ARBs) (such as losartan [for example, Cozaar, Hyzaar]): Angiotensin II receptor blockers (ARBs) block the action of a hormone that causes blood vessels to narrow. As a result, blood vessels may relax and open up. This makes it easier for blood to flow through the vessels, which reduces blood pressure. These drugs also increase the release of sodium and water into the urine, which also lowers blood pressure.

Two recent important clinical trials—ALLHAT and the Second Australian National Blood Pressure Study (ANBP2)—compared several medications to determine which is most effective in lowering blood pressure and reducing the risk of heart attacks and stroke in elderly people. Although somewhat similar in their approach, the studies came to different conclusions about the effectiveness of the medications.

ALLHAT compared a diuretic to an ACE inhibitor and a calcium channel blocker. Results showed that diuretics were equally as effective as ACE inhibitors in preventing fatal and nonfatal heart attacks, and are unsurpassed in lowering blood pressure and preventing stroke. The study recommends diuretics as the cornerstone of treatment for people with high blood pressure who do not have other medical conditions.

ANBP2 indicated that ACE inhibitors and diuretics are similar in their ability to reduce blood pressure, but ACE inhibitors may be more effective than diuretics in reducing fatal and nonfatal heart attacks and stroke in elderly men.

New high blood pressure guidelines from the Seventh Report of the Joint National Committee (JNC 7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommend that, for most people, one of the medications be a thiazide-typed diuretic.

Treatment for high blood pressure must be highly individualized and based on your risk factors, such as diabetes, smoking, and heart disease. Although one study may recommend a particular medication as the first line of treatment, that may not be what's best for you based on your medical condition. What's most important is that you work with your health care provider to find what's most effective for you.

Other expert studies recommend people with high blood pressure who don't have other risk factors for heart disease or stroke, such as smoking, diabetes, family history, or high cholesterol, first be treated with a diuretic and/or a beta-blocker medication.

If other conditions, such as heart failure or diabetes, are present, ACE inhibitors or ARBs often are used as the first line of therapy because the other medical conditions also may benefit from these medications. However, isolated systolic hypertension may respond best to diuretics alone.

If the above medications are not effective in lowering blood pressure, or if side effects of the above medications are serious, other medications called vasodilators may be tried.

MEDICATION CONSIDERATIONS

Experts recommend using calcium channel blockers and/or ACE inhibitors only if diuretics and beta-blockers fail to control blood pressure and if certain other risk factors are present. For example, a type of calcium channel blocker works well in older people with isolated systolic hypertension. ACE inhibitors are often prescribed if you have heart failure or diabetes as well as high blood pressure.

Some people who develop a cough while taking ACE inhibitors do well with ARBs, which usually do not cause a cough.

Some experts believe a combination of medications, each given in a lower dose, is better for reducing blood pressure than a higher dose of a single medication. Because the medications that are combined are given in a lower dose, there are fewer side effects from the drugs.

Check with your health care provider before taking any nonsteroidal anti-inflammatory drugs (NSAIDs) with high blood pressure medications. Some NSAIDs may reduce the effectiveness of your blood pressure medication.

WORKING WITH MEDICATIONS

Medications do not cure high blood pressure. Medications used to treat high blood pressure work in various ways and are used in different combinations.

Medications work in a delicate balance with each other and with your body. However, some medications should not be combined with other prescription or nonprescription medications. Make sure your health care provider knows all of the medications you are taking.

A combination of medications given in a lower dose than a single medication may work better to lower your high blood pressure and may cause fewer side effects.

Finding the right combination of medications with the fewest side effects can take some time, so it is important to take your medications in the right combination and at the right time, as your health care provider has prescribed. If you don't take your medications properly:

• Your blood pressure may not be controlled, which can lead to kidney and heart disease and stroke. According to the National Stroke Association, hypertension is the most important controllable risk factor for stroke, increasing the risk of stroke by 7 times.
• You may develop retinopathy.
• You may develop peripheral vascular disease.

Develop a medication plan: Work with your health care provider to develop your medication plan. Talk with your health care provider about the following:

• Names of all medications. Get a clear explanation of the actions and purpose of each medication that your health care provider prescribes for you. If you understand what you are taking and how it is helping you, it may be easier to stick to your schedule. Write down both the prescription and generic names for your medications. Have your health care provider check the list. You can use this list to verify that the medications you get from the pharmacy are correct.
  
  
• Medication schedule. Be sure you understand how much of each medication to take and when to take each one. Ask your health care provider if you can simplify your pill schedule. This may make it much easier for you to remember to take your medications as directed. You may be able to substitute longer-acting medications for shorter-acting ones. Longer-acting, once-a-day medications are easier for people to remember to take.
  
  
• How to handle missed doses. Talk with your health care provider about what you should do if you accidentally miss a dose of a medication. Discuss what to do for each medication—it may be different for each one.
  
  
• Medication costs. If cost is a consideration in developing your medication plan, ask your health care provider if less expensive, equally effective generic brands would be appropriate for you. Compare prices between several pharmacies and consider mail-order pharmacies.
  
  
• Medications to avoid. You may need to avoid certain medications. Many nonprescription medications and drugs can aggravate symptoms of heart failure and react with prescribed medications. Use the list of medications to avoid to write down those that you should not take. Check with your health care provider before taking any medications on this list.
  
  
• Get organized. Taking medications properly means taking the right dose of the right medication at the right time. When you are taking several different medications, it may be hard to keep the times and dosages straight. To be sure you are taking your medications properly, you may want to develop a system to keep track of when and how you take your pills.
  • Make a list of all your medications. Complete the master list of medications and keep it up-to-date. Review your master list of medications with your health care provider at every visit.
  • Plan a daily schedule of medications. List your daily medication schedule on a daily planner. Post this where you can see it near your medicine cabinet or wherever you store your medication. Take your daily medication planner along with you when you travel.
  • Use a pillbox. Get a pillbox that holds a week's worth of pills. This may be especially helpful if you are taking pills every other day. You can also label an empty egg carton and use it to organize one day's or one week's worth of pills.
  • Post reminders. Get sticky note pads and post reminders to take your medications near clocks or on the bathroom mirror to keep you on schedule.
  
  
• Taking your medications: Keep the following in mind as you follow your medication plan.
  • Store medications properly. Keeping medications in a location that is too hot or too cold may decrease the effectiveness of the medication. Find out from your health care provider or pharmacist how to properly store your medications. Always remember to store medications out of the reach of children.
  • Watch for side effects. Ask your health care provider or pharmacist about what side effects to expect. Be sure to tell your health care provider if you are having side effects from your medications.
  • Avoid other medications. Post your list of medications to avoid in a place where you can refer to it whenever you need to. Always check with your health care provider before taking any additional medications, prescription or nonprescription. This includes any herbal or "natural" supplements.
  • Review your master medication list. Take your master list with you for each visit with your health care provider. Take time to review your list and report any side effects you are having.
  • Communicate with your health care provider. Notify your health care provider immediately if you have any serious side effects. Let your health care provider know if you have any changes in your health that might affect your heart condition, such as weight gain or another medical condition.

SURGERY

There is no surgical treatment for primary (essential) high blood pressure. Treatment for the various secondary causes of high blood pressure, such as kidney disease or valvular heart disease, may include other drugs and/or surgery.

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HOME TREATMENT

How To Measure Your Blood Pressure Your blood pressure measurement actually tells you how much pressure it takes to stop the flow of blood through your arteries. This is assumed to be equivalent to the pressure at the pump end, the heart. Blood pressure is measured at two points in the heart's pumping rhythm: systolic pressure is taken at the moment the heart beats; diastolic pressure is taken when the heart is at rest between beats. To measure blood pressure, the soft, inflatable cuff of the sphygmomanometer is wrapped around the upper arm and inflated. Systolic pressure is measured when there is no longer a pulse in the arm beyond the cuff. Then the cuff is deflated and the diastolic pressure is taken when the blood flows freely once more. The combined pressure is usually expressed as a fraction - 120/90, for example. Ideally, blood pressure should be taken with the arm bare. A tight sleeve may constrict the arm or make it impossible to apply the blood pressure cuff properly. The cuff should be placed around the arm about one inch above the bend in the elbow. Before beginning to work with the sphygmomanometer, check the following four items: 1. Be sure that the sphygmomanometer reads 0 when there is no pressure in the system. 2. Check to be sure that the needle stays in place when the valve is closed. 3. Check the valve screw to make sure that it operates smoothly. 4. Inspect your stethoscope for cracks or leaks in the tubing, earpiece, bell, or diaphragm. Blood Pressure by Palpation: You should first feel for the blood pressure. Find the radial pulse, on the thumb side of the wrist. Then inflate the cuff 30 mm Hg beyond the point where the pulse is obliterated. Open the valve and release 2-3 mm Hg per second. When the pulsations of the radial pulse again become palpable, this is the systolic pressure. The diastolic pressure occurs when vibrations in the artery cease. Diastolic pressure is much more difficult to obtain. Taking systolic blood pressure (BP) by palpation. Blood Pressure by Auscultation: Next, use the stethoscope to take the blood pressure. Follow this procedure: 1. Position the disc of the stethoscope snugly against the skin where the elbow bends - a little to the left of the center on the right arm, and a little to the right of center on the left arm. There should be no gaps between the stethoscope and the skin, but you should not apply any undue pressure. Make sure that the stethoscope is not touching the cuff at any point. 2. Position the ear pieces of the stethoscope in your ears (with the ear pieces directed forward). 3. Hold the stethoscope disc snugly in position with one hand while you pump the cuff with the other hand. 4. Pump the cuff until the gauge registers about 30 mm Hg above the point where you felt the pulse disappear earlier, or about 200 mm Hg. 5. Loosen the valve slightly and permit the pressure to drop slowly. Listen carefully for the first sound of a beat - the number on the scale when you hear the first beat is the systolic pressure. (If you think that you missed the first bear or are unsure, tighten the valve again and pump the cuff up; repeat the process, listening carefully.) 6. Continue to deflate the cuff slowly until the last sound of blood pumping through the blood vessels is heard. When you hear no more blood flowing, the number on the scale is the diastolic pressure. Taking systolic blood pressure (BP) by auscultation. When taking your blood pressure, follow these general guidelines for best result: Avoid eating, smoking, or exercising for at least one half hour before measuring your blood pressure. Test yourself at about the same time each day. Plan ahead to give yourself time to get over any feelings of anger or anxiety. Sit quietly and eliminate extraneous noise. Follow the manufacturer's instructions carefully for the BP device used. Position your arm at heart level, palm up. If you are using a cuff device, wrap the cuff just above the elbow (make sure you are using the proper sized cuff for your arm) - with your sleeve rolled up above the cuff - and be sure it is not too tight. Make sure the hoses from the cuff are not tangled or pinched. Take care not to move the hoses during the reading. Wait at least five minutes in between readings, with the cuff fully deflated. Take the device along on medical visits once a year or more to check the accuracy against your health care provider's measurements.

Home treatment is important to help control high blood pressure, especially if you have other risk factors for heart disease and stroke. Even if your health care provider has prescribed medication for you, there are still many steps you can take to lower your blood pressure and reduce your risk of heart attack and stroke. Changes in lifestyle or behavior can help control high blood pressure and in some cases may allow you to reduce the amount of medication you need.

• Maintain a healthy weight. If you are overweight, take steps to lose the excess pounds. Being overweight increases your risk of developing high blood pressure. In fact, blood pressure rises as bodily weight increases. Losing even 10 pounds can lower blood pressure and it has the greatest effect for those who are overweight and already have hypertension. Being overweight is also a risk factor for heart disease. It increases your chance for developing high cholesterol and diabetes - two more major risk factors for heart disease. See Obesity for more information.
  
  
• Get regular light to moderate exercise. Take care not to overexert yourself, especially in hot or humid weather. Caution: Consult with your health care provider before beginning a new exercise program, particularly if you have been sedentary for some time. Here are some guidelines from the National Institute of Health:

Exercise (Physical Activity) For Prevention of or Treatment of Hypertension Phase 1: Getting Started Get started by doing 30 minutes of a moderate-level activity on most, and preferably all, days of the week. Brisk walking, bicycling, and gardening are examples. You can even divide the 30 minutes into shorter periods of at least 10 minutes each. For instance: Use stairs instead of an elevator. Get off a bus one or two stops early. Park your car at the far end of the lot at work. Note: Check with your health care provider before you start on any exercise program. This is especially true if you have heart trouble or have had a heart attack, if you are older and are not used to doing a moderate-level activity, if you have a family history of heart disease at an early age, or if you have any other serious health problem. Phase 2: Moderate-Level Physical Activities Engage in at least 30 minutes of moderate-level activity on most, and preferably all, days of the week. Examples of moderate-level activity are: Walking briskly (3-4 miles per hour) Conditioning or general calisthenics Home care and general cleaning Home repair, such as painting Mowing the lawn (with power mower) Gardening Dancing Racket sports, such as table tennis Golf (walking the course) Fishing (standing and casting, walking, or wading) Swimming (with moderate effort) Cycling (at a moderate speed of 10 miles per hour or less) Canoeing or rowing (at a speed of about 2-3.9 miles per hour) Tips to Stay Motivated with a Walking Plan Ask other people to walk with you. Find a partner or a group. When you know someone else is waiting for you, it keeps you going. Wear comfortable shoes and good socks to help cushion your feet. Wear clothes that are right for the season. Try using layers of clothing in the cold weather to keep you warm, and cotton clothes in the summer to keep you cool. Drink plenty of water. It doesn't have to be that fancy bottled stuff get your own container and keep it filled with plenty of regular water. Carry it with you if you can. Don't forget to stretch before you walk. Try to start off slowly. Be safe - pay attention to your surroundings. Walk in a safe place that has plenty of lights in the evening. Try walking around a local school's parking lot, or going to the mall. Try to walk at least three times a week. It may seem like a lot at first, but you will gradually build up. Try to think of your walk in three parts. Imagine a warm-up period at the beginning, challenge yourself with a brisk pace in the middle, and finally picture a cool-down. You can feel success when you finish each part. Source: Adapted from Pate, et al., Journal of the American Medical Association, 1995, Vol. 273, page 404.

• Limit or eliminate alcohol use. Drinking too much alcohol can raise blood pressure. It also can harm the liver, brain, and heart. Alcoholic drinks also contain calories, which matter if you are trying to lose weight. If you have to drink alcoholic beverages, have only a moderate amount - one drink a day for women; two drinks a day for men.

What counts as a drink? 12 ounces of beer (regular or light, 150 calories) 5 ounces of wine (100 calories) 1 ounces of 80-proof whiskey (100 calories).

• Stop smoking. Smoking injures blood vessel walls and speeds up the process of hardening of the arteries. So even though it does not directly cause high blood pressure, smoking is bad for anyone, especially those with high blood pressure. If you smoke, quit. If you don't smoke, don't start.
  
  
• Use anti-inflammatory medications wisely. Do not take antihistamines except under a health care provider's direction.
  
  
• Learn to check your blood pressure at home. Have your blood pressure checked at least every four to six months. Because hypertension often shows no signs, regular blood pressure checks by a professional are important; especially if you are in a high risk category.
  
  
• Follow the nutrition guidelines for hypertension (including the Dietary Approaches to Stop Hypertension, or DASH, diet). See DASH dietary outline below.
  
  
• Reduce stress. As much as possible, avoid stress. Take a stress management course and find ways to reduce the stress in your life. A recent survey showed that 70-90 percent of us feel stressed at work and outside. Today's fast paced lifestyle is putting a toll on us. Unless we learn to manage stress, we will get sick. Learn steps to manage daily stress and how to detect symptoms of stress. Recognize diseases that are often mistaken for stress, and learn common sense ways to manage and prevent stress. Prevention and cure are the two limbs of stress management. See Stress for more information.
  
  
• Be sure to get sufficient sleep. People with hypertension often suffer from sleep apnea, in which they stop breathing for 10 seconds or more throughout the night. Apnea is associated with loud snoring and restless sleep, and can cause the individual to feel excessively sleepy during the day. Evaluation and treatment of apnea may help reduce high blood pressure. Heavy snorers are more likely to have high blood pressure or angina than silent sleepers. Research suggests that snorers may suffer from a malfunctioning of the part of the brain responsible for fluent breathing; this can put an unnatural strain on the heart and lungs due to oxygen shortage.
  
  
• if you are pregnant, have your blood pressure monitored frequently by your midwife or health care provider. Untreated hypertension in pregnancy can progress suddenly and pose a serious ' threat to both mother and child.

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NUTRITION, HOLISTIC RECOMMENDATIONS, HERBS & SUPPLEMENTS

In addition to lifestyle changes, several other non-drug methods of reducing blood pressure can be tried.

Eat plenty of fruits and vegetables, such as apples, asparagus, bananas, broccoli, cabbage, cantaloupe, eggplant, garlic, grapefruit, green leafy vegetables, melons, peas, prunes, raisins, squash, and sweet potatoes.

Beneficial Vegetables and Spices for Hypertension A number of common vegetables and spices have beneficial effects in controlling hypertension. Incorporate these into your cooking. Alternately, you can make a tea or a vegetable soup. Celery (Apium graveolens). Oriental Medicine practitioners have long used celery for lowering high blood pressure. There are some experimental evidence that shows that celery is useful for this. In one animal study, laboratory animals injected with celery extract showed lowered blood pressure. Eating as few as four celery stalks was found to be beneficial in lowering blood pressure in human beings. Garlic (Allium sativum). Garlic is a wonder drug for heart. It has beneficial effects in all cardiovascular system including blood pressure. In a study, when people with high blood pressure were given one clove of garlic a day for 12 weeks, their diastolic blood pressure and cholesterol levels were significantly reduced. Eating quantities as small as one clove of garlic a day was found to have beneficial effects on managing hypertension. Use garlic in your cooking, salad, soup, pickles, etc. It is very versatile. Onion (Allium cepa). Onions are useful in hypertension. What is best is the onion essential oil. Two to three tablespoons of onion essential oil a day was found to lower the systolic levels by an average of 25 points and the diastolic levels by 15 points in hypertension subjects. This should not be surprising because onion is a cousin of garlic. Tomato (Lycopersicon lycopersicum). Tomatoes are high in gamma-amino butyric acid (GABA), a compound that can help bring down blood pressure. Broccoli (Brassica oleracea). This vegetable contains several active ingredients that reduce blood pressure. Carrot (Daucus carota). Carrots also contain several compounds that lower blood pressure. Saffron (Crocus sativus). Saffron contains a chemical called crocetin that lowers the blood pressure. You can use saffron in your cooking. (It is a very popular spice in Arabic cooking.) You can also make a tea with it. Many Indians add a pinch of saffron in the brewed tea to give a heavenly flavor. Unfortunately, it is very expensive. Assorted spices. Spices such as fennel, oregano, black pepper, basil and tarragon have active ingredients that is beneficial in hypertension. Use them in your cooking.

Include fresh "live" juices in the diet. The following juices are healthful: beet, carrot and celery, currant, cranberry, citrus fruit, parsley, spinach, and watermelon. See Juicing for more information about preparing fresh juices.

Eat grains like brown rice, buckwheat, millet, and oats.

Drink steam-distilled or quality water (without added sodium).

Take 2 tablespoons of flaxseed oil daily.

Apple pectin aids in reducing blood pressure.

Fast for 3 to 5 days each month. Periodic cleansing fasts help to detoxify the body. See Fasting for more information.

A diet low in calcium, potassium, and magnesium and high in sodium may cause high blood pressure. Avoid using too much sodium. Make sure you eat a low/no sodium diet with foods rich in calcium, potassium, magnesium, and fiber.

SODIUM (SALT) & HYPERTENSION

Approximately 80 million Americans have increased sensitivity to dietary sodium. African-Americans in particular are prone to salt-sensitive hypertension.

Research has revealed that people with variations in two specific genes are twice as likely to develop high blood pressure from salt consumption. This discovery may make it possible to identify children prone to high blood pressure; if such people can be identified in early childhood, it may be possible to modify their diets so that they can avoid developing high blood pressure later in life.

Follow a strict salt-free diet. This is essential for lowering blood pressure. Lowering your salt intake is not enough. You should try to eliminate all dietary salt. Read labels carefully and avoid those food products that have "salt," "soda," "sodium," or the symbol "Na" on the label. Some foods and food additives that should be avoided on this diet include monosodium glutamate (Accent, MSG); baking soda; canned vegetables (unless marked sodium- or salt-free); commercially prepared foods; toothpastes containing saccharin or baking soda; over-the-counter medications that contain ibuprofen (such as Advil or Nuprin); diet soft drinks; foods with mold inhibitors, preservatives, and sugar substitutes; meat tenderizers; softened water; and soy sauce.

POTASSIUM

Potassium helps to prevent and control blood pressure. Be sure to get enough potassium in the foods you eat. Some good sources are various fruits, vegetables, dairy foods, and fish. Foods high in potassium are apricots, lean pork, prunes and prune juice, bananas, lean veal, pumpkin, catfish, lima beans, spinach, cod, milk, stewed tomatoes, dry peas and beans, orange juice, sweet potatoes, flounder, peaches, trout, green beans, plantain, winter squash, potatoes, and yogurt.

MAGNESIUM

Researchers at the State University of New York found that the lower the level of magnesium in the body, the higher the blood pressure. This double-blind, placebo-controlled trial showed that taking supplemental magnesium can result in a significant, dose-dependent reduction in both systolic and diastolic blood pressure.

Because of the use of diuretic drugs causes increased urinary excretion of magnesium, it can cause hypomagnesemia in elderly people. Magnesium is needed in conjunction with calcium to prevent bone deterioration, as well as to maintain normal heart rhythm and muscular contraction. Losses of potassium due to diuretics may be dangerous, causing heart malfunction. Herbal diuretics are far safer. Consult your health care provider before using diuretics.

Magnesium deficiency has been implicated in high blood pressure. Magnesium levels are shown to be consistently low in people suffering from hypertension. Leafy greens, legumes, whole grains, purslane, poppy seeds and string beans are good dietary sources for magnesium. Other foods high in magnesium are beans, okra, soy milk, broccoli, oysters, spinach, chard, plantain, tofu, croaker, scallops, whole grain ready-to-eat and cooked cereals, mackerel, sea bass, whole wheat bread, nuts and seeds. Or you can take a daily supplement of 400 mg magnesium.

CALCIUM

Calcium is an important nutrient for overall good health. Population studies indicate that hypertensive individuals consume less daily calcium. They may benefit from calcium supplementation. Several clinical studies have demonstrated the blood pressure lowering effect of calcium supplementation. Take 1 gram of elemental calcium daily. Good sources of calcium are dairy foods such as milk, yogurt, and cheese. Be sure to choose skim or low fat varieties. Low fat and nonfat dairy products have more calcium than the high fat versions. Foods high in calcium are broccoli, perch, turnip greens, cheese, salmon, tofu (made with calcium sulfate), mackerel, spinach, yogurt, and milk.

Eat a diet rich in essential fatty acids, vitamin C, Coenzyme Q10, Zinc and other valuable nutrients.

ESSENTIAL FATTY ACIDS

Increasing dietary linoleic acid decreases the blood pressure. Hypertensive patients are deficient in E series prostaglandins. Linoleic acid was found to normalize prostaglandins. Fish oil (omega-3 fatty acids) also may have some effect on lowering blood pressure.

COENZYME Q10

Coenzyme Q10 (CoQ10) is an essential component of the metabolic processes involved in energy production. Individuals with cardiovascular disease (including hypertension, angina and congestive heart failure) often are deficient in CoQ10 and require increased tissue levels of CoQ10. Clinical studies have indicated that CoQ10 is of considerable benefit in the treatment of hypertension and other cardiovascular disease.

VITAMIN C

The lower the serum vitamin C level, the higher the blood pressure in persons suffering from hypertension. Whether this is due to dietary habits or a blood pressure lowering effect of vitamin C has yet to be determined.

ZINC

Zinc has been shown to reverse cadmium induced hypertension effectively in rats. Do not exceed 100 mg of zinc from all nutritional sources.

BOVINE RENAL EXTRACT

Bovine renal extract has shown to possess blood pressure lowering effects in animals and hypertensive human subjects.

BASIC VITAMIN/MINERAL FORMULA

Use a multivitamin and mineral complex for all nutrients needed to maintain nutritional balance. Recommended levels of nutrients are:
500 IU Vitamin A
4000 mg Vitamin C
400 IU Vitamin D
600 IU Vitamin E
100 mg Vitamin B15
50 mg niacinamide
50 mg Vitamin B1
1000 mg pantothenic acid
50 mg Vitamin B2
300 mcg folic acid
100 mg vitamin B6
100 mcg biotin
500 mcg vitamin B12

TYROSINE, TYRAMINE & AMINO ACIDS

If you are taking an MAO inhibitor (one of a class of drugs prescribed to counter depression, lower blood pressure, and treat infections and cancer), avoid the chemical tyramine and its precursor, tyrosine. Combining MAO inhibitors with tyramine causes the blood pressure to soar and could cause a stroke. Tyramine-containing foods include almonds, avocados, bananas, beef or chicken liver, beer, cheese (including cottage cheese), chocolate, coffee, fava beans, herring, meat tenderizer, peanuts, pickles, pineapple, pumpkin seeds, raisins, sausage, sesame seeds, sour cream, soy sauce, wine, yeast extracts (including brewer's yeast), yogurt, and other foods. In general, any high-protein food that has undergone aging, pickling, fermentation, or similar processes should be avoided. Over-the-counter cold and allergy remedies should also be avoided. See Tyramine-Restricted Diet for more in depth information.

Do not take supplements containing the amino acids phenylalanine or tyrosine. Also avoid the artificial sweetener asparatame (Equal, NutraSweet), which contains phenylalanine.

Avoid all animal fats. Bacon, beef, boullions, chicken liver, corned beef, dairy products, gravies, pork, sausage, and smoked or processed meats are prohibited. The only acceptable animal foods are broiled white fish and skinless turkey or chicken, and these should be consumed in moderation only. Get protein from vegetable sources, grains, and legumes.

Avoid foods such as aged cheese, aged meats, anchovies, avocados, chocolate, fava beans, pickled herring, sour cream, wine, and yogurt.

Eat a high fiber diet and take supplemental fiber. Oat bran is a good source of fiber. Note: Always take supplemental fiber separately from other supplements and medications.

ALTERNATIVE OR COMPLEMENTARY MEDICINE THERAPIES

Alternative or complementary medicine therapies that help reduce stress and improve quality of life may have some effect on blood pressure. These therapies include:

• Acupressure. See Acupressure for Hypertension.
• Acupuncture. See Acupuncture for Hypertension.
• Aromatherapy. See Aromatherapy for Hypertension.
• Ayruveda. See Ayurvedic Treatment for Hypertension.
• Bach Flower Remedies. See Bach Flower Remedies for Hypertension.
• Biofeedback. See Biofeedback for Hypertension.
• Color Therapy. See Color Therapy for Hypertension.
• Homeopathy. See Homeopathy for Hypertension.
• Reflexology. See Reflexology for Hypertension.
• Shiatsu. See Shiatsu for Hypertension.
• Guided imagery. See Guided Imagery for more information.
• Yoga. See Yoga Information.
• Meditation. See Meditation for Hypertension and Meditation for more information.
• Music Therapy. See Music Therapy for more information.
• Hypnosis. See Hypnotherapy for more information.
• Humor Therapy. See Humor Therapy for more information.

A vegetarian diet has been shown to be prophylactic against hypertension. Most vegetarians enjoy lower blood pressure readings than meat eaters. The reason is that the components of a vegetarian diet--more fiber, vitamin C, vitamin E, magnesium, calcium, potassium, and significantly less salt and less total fat, saturated fat, and cholesterol--help to fight hypertension. Some people don't do well as vegetarians; they feel tired and run-down on a vegetarian diet, especially if they have been eating sugars and have low blood sugar. And for many people it's impractical to go a strictly vegetarian diet. But some of people are vegetarians and are quite robust and healthy. While strict vegetarianism may not be sensible for many people, it is advisable for them to adopt as many of the aspects of a vegetarian diet as possible, particularly the reduction of saturated fat and cholesterol. Studies have been done with Finns, who eat more saturated and less polyunsaturated fats compared with Americans, and who have a higher incidence of hypertension. When their saturated fat intake was decreased, despite the fact that their sodium intake was unchanged, they experienced an average pressure drop of 7.5 mmHg systolic and 2.8 mmHg diastolic. When their previous, high saturated fat intake levels were resumed, their pressure once again went up.

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Dietary Approaches to Stop Hypertension (DASH) Diet

Introduction: Following the DASH diet which is an eating plan that is low in cholesterol, saturated fat, and total fat, but rich in low-fat dairy foods, fruits, and vegetables, has been proven to lower blood pressure. DASH also recommends eating whole grains, fish, poultry and nuts as part of a balanced diet.

DASH is one of several lifestyle changes your health care provider will use to lower your high blood pressure. Your health care provider may also want you to decrease the amount of sodium and sodium-rich prepared foods in your diet. Lowering sodium while following DASH has been proven to lower blood pressure even further than just DASH alone.

Key points: To increase the potassium in your diet, fruits and vegetables are excellent sources of this nutrient. Dairy products are high in calcium and magnesium. DASH recommends that you eat 8 to 10 servings of fruits and vegetables, and 3 servings of low-fat dairy products per day.

Eating a diet low in both saturated fats and total fat will also help lower your blood pressure. Only 30% of your total calories should be from fats, with only 7% to 10% of your fat calories from saturated fats. Saturated fats are found in meats, cheese, butter, poultry, snack foods, and other foods.

In general, vegetarian diets reduce blood pressure. The DASH diet could easily be a vegetarian diet if legumes were substituted for meat. Vegetarian diets tend to be higher in potassium, magnesium, and calcium, as does the DASH diet. Vegetarian diets also are higher in fiber and unsaturated fats than other diets.

Make small changes first by changing only your fruit and vegetable intake. Keep track of the fruits and vegetables you eat, and slowly add more to your diet. Your goal is 8 to 10 servings per day. Check what counts as a serving in the food guide pyramid.

Reduce the amount of saturated fat you eat. Substitute monounsaturated and polyunsaturated oils instead.

If you also need to reduce the amount of sodium in your diet, cut down on the amount of processed foods you eat, such as snack items, luncheon meats, and canned soups.

The DASH plan shown below is based on 2,000 calories a day. The number of daily servings in a food group may vary from those listed depending on your caloric needs.

Food Group	Daily Servings (except as noted)	Serving Sizes
Grains & grain products	7-8	1 slice bread 1 cup ready-to-eat cereal* 1/2 cup cooked rice, pasta, or cereal
Vegetables	4-5	1 cup raw leafy vegetable 1/2 cup cooked vegetable 6 ounces vegetable juice
Fruits	4-5	1 medium fruit 1/4 cup dried fruit 1/2 cup fresh, frozen, or canned fruit 6 ounces fruit juice
Lowfat or fat free dairy foods	2-3	8 ounces milk 1 cup yogurt 1.5 ounces cheese
Lean meats, poultry, and fish	2 or less	3 ounces cooked lean meats, skinless poultry, or fish
Nuts, seeds, and dry beans	4-5 per week	1/3 cup or 1.5 ounces nuts 1 tablespoon or 1/2 ounce seeds 1/2 cup cooked dry beans
Fats & oils**	2-3	1 teaspoon soft margarine 1 tablespoon lowfat mayonnaise 2 tablespoons light salad dressing 1 teaspoon vegetable oil
Sweets	5 per week	1 tablespoon sugar 1 tablespoon jelly or jam 1/2 ounce jelly beans 8 ounces lemonade

* Serving sizes vary between 1/2 to 1-1/4 cups. Check the product's nutrition label.

** Fat content changes serving counts for fats and oils: For example, 1 tablespoon of regular salad dressing equals 1 serving; 1 tablespoon of a lowfat dressing equals 1/2 serving; 1 tablespoon of a fat free dressing equals 0 servings.

Source: National Institutes of Health

Think about including fruits and/or vegetables in every meal. Take fruit to work or school as a snack. Drink nonfat milk. A glass of skim milk has only 80 calories and no fat and is packed with blood pressure–lowering nutrients. Have a "skinny" lattè (caffè lattè made with skim milk) as a way to add milk to your diet. If you don't drink coffee, try a skinny almond milk. Make a baked potato bar. Serve baked potatoes with a variety of toppings, including chili, broccoli, ratatouille, salsa, refried beans, and shredded low-fat cheese. Be creative. You could end up with 4 or 5 servings of vegetables at one meal. Use a variety of cut-up vegetables with a low-fat dip as an appetizer, instead of high-fat chips and dips. Try some new vegetables. Make a stir-fry containing lots of different vegetables. Try some vegetarian meals featuring legumes (cooked dried beans and peas). Add garbanzo beans to a salad; use fat-free refried beans; have some split pea or black bean soup. Buy a vegetarian cookbook and try one recipe per month or per week. Combine a ready-made pizza crust with low-fat mozzarella cheese, and lots of vegetable toppings. Use tomatoes, zucchini, spinach, carrots, cauliflower, and onions. For breakfast, have whole grain cereal, fruit, and milk. For a snack, have a smoothie made with low-fat milk and frozen fruit chunks. Make a dip for fruit from low-fat vanilla yogurt and cinnamon.

Here is a sample menu for the Dietary Approaches to Stop Hypertension (DASH) diet. It is based on a 2,000-calorie diet.

Breakfast

1 cup corn flakes with 1 teaspoon of sugar
8 ounces low-fat milk
1 banana
1 slice whole-wheat toast
1 tablespoon jelly
1/2 grapefruit

Lunch

2 ounces sliced turkey
1 pita bread
1 tablespoon low-fat mayonnaise
Raw vegetables: 3–4 carrot sticks, celery sticks, radishes, 2 loose lettuce leaves
1/2 cup fruit cocktail

Snack

1/4 cup dried apricots
3/4 cup mini pretzels
1/3 cup mixed nuts
1 cup flavored low-fat yogurt

Dinner

3 ounces grilled lean beef
1 cup scallion rice
1 cup steamed broccoli
Spinach salad with 1/2 cup raw spinach, 2 cherry tomatoes, 2 cucumber slices
1 tablespoon light Italian dressing
8 ounces low-fat chocolate milk

For more sample menus and recipes, contact the National Heart Lung and Blood Institute: NHLBI Health Information Center, P.O. Box 30105, Bethesda, MD, 20824-0105; or go to http://www.nhlbi.nih.gov, and click on the high blood pressure information.

People who do not eat a balanced diet or one that includes mainly processed foods usually do not get enough and potassium, calcium, and magnesium in their diets. Not getting enough of these nutrients, which come from fruits, vegetable and dairy products, may contribute to high blood pressure.

Researchers believe that it is the combination of 8 to 10 servings a day of fruits and vegetables, and 3 servings of low-fat dairy products that causes the DASH diet to lower blood pressure. Simply adding calcium, potassium, and magnesium supplements to the diet does not lower blood pressure.

Good sources of potassium: Bananas, cantaloupe, oranges, and orange juice, Raw or cooked spinach, lima beans, zucchini, broccoli, carrots, cauliflower, and artichokes Potatoes Legumes (cooked dried beans and peas) such as pinto beans, chickpeas, and lentils

A serving size of fruits and vegetables includes:

3/4 cup fruit or vegetable juice.
1/2 cup raw, canned, or cooked fruits or vegetables.
1 medium apple or banana.
1 cup raw, leafy vegetables

Good sources of calcium: Low-fat dairy products (yogurt, skim milk, cheese)

A serving size includes:

1 cup milk or yogurt.
1.5 oz (42.52 g) to 2 oz (56.7 g) low-fat cheese.
1/2 cup cottage cheese.

Good sources of magnesium: Legumes (cooked dried beans and peas), Rice and potatoes, Bananas.

A serving size includes:

1/2 cup cooked dry beans.
1/2 cup pasta or rice.

Ask your health care provider to recommend a dietitian who can work with you to change your eating habits and help you plan menus that follow the DASH eating style. See a sample DASH menu. Use a form to track your eating habits. Record everything you eat before you start DASH, charting the number of servings you eat in the following food groups: grains, vegetables, fruits, dairy, meats (including poultry and fish) nuts, seeds and beans, fats and oils, and sweets. As well as you can, record the amount of sodium in everything you eat. After you begin the DASH eating plan, keep the same charts, and compare your lists.

Use the following as a guide for the DASH eating plan:

Milk and dairy: 2–3 servings per day. One serving equals: 8 ounces of nonfat milk; 1 cup of low-fat yogurt; or 1-1/2 ounces of low-fat cheese.

Fruits: 4–5 servings per day. One serving equals: 1 medium fruit; ¼ cup dried fruit; 1/2 cup frozen or canned fruit; or 6 ounces of fruit juice.

Vegetables: 4–5 servings. One serving equals: 1 cup raw leafy vegetables; 1/2 cup cooked vegetables; or 6 ounces vegetable juice.

Grains: 7–8 servings per day. One serving equals: 1 slice whole-wheat bread; 1/2 cup dry or hot cereal; 1/2 cup cooked rice or pasta.

Meat, fish, poultry: 2 or fewer servings per day. One serving equals: 3 ounces cooked meat, poultry, or fish (about the size of a deck of cards).

Nuts, seeds, dried beans: 4–5 servings per week. One serving equals: 1/3 cup nuts; 2 tablespoon seeds; or 1/2 cup cooked dried beans.

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HERBS

Cayenne (capsicum), chamomile, fennel, hawthorn berries, parsley, and rosemary are used for high blood pressure. Caution: Do not use chamomile on an ongoing basis, as ragweed allergy may result. Avoid it completely if you are allergic to ragweed.

Drink 3 cups of Suma tea daily.

Hops are good for calming the nerves.

Avoid the herbs ephedra (ma huang) and licorice, as these herbs can elevate blood pressure.

Other Herbs:

Lime blossom (Tilia europea). For treating hypertension associated with arteriosclerosis and anxiety, take an infusion. Pour one cup of boiling water onto one teaspoonful of the dried flowers; leave to infuse ten minutes, filter, and drink.

Hawthorn (Crataegus, various species). Hawthorn has been used as a heart tonic for centuries. Make a tea by adding one teaspoon of dried hawthorn herb to cup of boiling water. Drink up to two cups a day.

Kudzu (Pueraria lobata). Chinese studies suggest that kudzu helps normalize blood pressure. When a tea containing about eight teaspoons of kudzu root was given daily to 52 people for two to eight weeks, 17 people experienced marked decline in their blood pressure. Kudzu is a powerful antioxidant. It has 100 times the antioxidant activity of vitamin E. Hence it also helps prevent heart disease and cancer.

Garlic (Allium sativum). Garlic is a wonder drug for heart. It has beneficial effects in all cardiovascular system including blood pressure. In clinical studies, garlic has been shown to decrease the systolic pressure by 20-30 mm Hg and the diastolic by 10-20 mm Hg. When people with high blood pressure were given one clove of garlic a day for 12 weeks, their diastolic blood pressure and cholesterol levels were significantly reduced. Eating quantities as small as one clove of garlic a day was found to have beneficial effects in managing hypertension. The pharmaceutical mechanism of garlic's effect on blood pressure is believed to be related to its effect on the autonomic nervous system, lipid-lowering properties and perhaps its high content of sulphur-containing compounds. People with high blood pressure were found to have decreased levels of sulphur-containing amino acids in their plasma. Use garlic in your cooking, salad, soup, pickles, etc. It is very versatile.

Saffron (Crocus sativus). Saffron contains a chemical called crocetin that lowers the blood pressure. You can use saffron in your cooking. (It is a very popular spice in Arabic cooking.) You can also make a tea with it. Many Indians add a pinch of saffron in the brewed tea to give a heavenly flavor. Unfortunately, it is very expensive.

Valerian (Valeriana officinalis). Valerian is good for hypertension and calming the nerves. It contains a chemical called valerenic acid that inhibits an enzyme that breaks down GABA. GABA (Gamma-amino butyric acid) is known to control blood pressure. Its effect on blood pressure may also be from its sedative action.

Mistletoe (Viscum album). Mistletoe is believed to function as a regulator of blood pressure, exerting a healing effect in both hypertension and hypotension. In Europe, mistletoe has often been combined with hawthorn (crataegus) in treating hypertension.

Hawthorn Combination
Ingredients:

Hawthorn berries (Crataegus) - 1 part
lime blossom (Tilia europea) - 1 part
Yarrow (achillea) - 1 part

Oriental/Chinese Herbs
Siler and Platycodon Formula (Sang-Feng-Tung-Shen-San): For hypertension accompanied by obesity and constipation.

Ingredients:

Siler root 3.0 g
Talc 3.0 g
Skullcap root 2.0 g
Licorice root 2.0 g
Gypsum 2.0 g
Platycodon (balloon flower root) 2.0 g
Paichu (White atractylodes rhizome) 2.0 g
Chinese angelica root 1.2 g
Ma-Huang (Ephedera) 1.2 g
Cnidium 1.2 g
Peony root 1.2 g
Gardenia fruit 1.2 g
Rhubarb rhizome 1.5 g
Ginger 1.2 g
Field mint 1.2 g
Forsythia fruit 1.2 g
Chinchieh herb (Schizonepeta) 1.2 g
Nitrous sulfate 1.5 g

Rehmannia Eight Formula: For older people with hypertension, fatigue, frequent kidney atrophy or nephritis.
Ingredients:

Chinese foxglove (rehmmania) 8.0 g
Yam (dioscorea) 4.0 g
Cornus 4.0 g
Hoelen 3.0 g
Tree peony bark 3.0 g
Aconite root 1.0 g
Cinnamon twigs 1.0 g

NUTRIENTS
Supplement	Suggested Dosage	Comments
Essential
Calcium And Magnesium	1,500-3,000 mg daily. 750-1,000 mg daily.	Deficiencies have been linked to high blood pressure.
Garlic (Kyolic)	2 capsules 3 times daily.	Effective in lowering blood pressure.
L-Carnitine	500 mg twice daily, on an empty stomach.	Transports long fatty acid chains. Together with L-Glutamic acid and L-Glutamine, aids in preventing heart disease.
Plus L-Glutamic Acid And L-Glutamine	500 mg each daily, on an empty stomach. Take with water or juice. Do not take with milk. Take with 50 mg vitamin B6 and 100 mg vitamin C for better absorption.	To detoxify ammonia and aid in preventing heart disease. See Amino Acids for more information.
Selenium	200 mcg daily.	Deficiency has been linked to heart disease.
Very Important
Coenzyme Q10	100 mg daily.	Improves heart function and lowers blood pressure.
Essential Fatty Acids (Black currant seed oil, flaxseed oil, olive oil, and primrose oil are good sources)	As directed on label. Take before meals.	Important for circulation and for lowering blood pressure.
Vitamin C	3,000-6,000 mg daily, in divided doses.	Improves adrenal function; reduces blood-clotting tendencies.
Important
Lecithin granules Or Capsules Or Lipotropic factors	1 tablespoon 3 times daily, before meals 1,200 mg 3 times daily, before meals As directed on label.	To emulsify fat, improving function and lowering blood pressure.
Vitamin E Plus And/Or Octacosonol	Start with 100 IU daily and add 100 IU daily each month, until you reach 400 IU. As directed on label.	Improves heart function. Use emulsion form for easier assimilation and greater safety at high doses.
Helpful
Bromelain	As directed on label.	An enzyme that aids in the digestion of fats.
Kelp	1,000-1,500 mg daily.	A good source of minerals and natural iodine.
Kyo-Green from Wakunaga	As directed on label twice daily.	This concentrated barley and wheatgrass juice contains important nutrients.
Maitake Or Shiitake Or Reishi	As directed on label. As directed on label. As directed on label.	To help reduce high blood pressure and prevent heart disease.
Multivitamin and mineral complex With Vitamin A And Zinc	As directed on label. 15,000 IU daily. If you are pregnant, do not exceed 10,000 IU daily. 50 mg daily.	All nutrients are needed for balance.
Plus extra Potassium	99 mg daily.	If taking cortisone or high blood pressure medication, take extra potassium to counteract depletion of this mineral.
Proteolytic enzymes	As directed on label. Take with meals and between meals.	Aids in cleansing the circulatory system. Completes protein digestion.
Raw Heart glandular Plus Bio-Cardiozyme Forte from Biotics Research Or Heart Science from Source Naturals	As directed on label. As directed on label. As directed on label.	Strengthens the heart. A complex that strengthens the heart muscle Contains antioxidants, cholesterol fighters, herbs, and vitamins that work together to promote cardiovascular function.
Vitamin B complex Plus extra Vitamin B3 (niacin) And Choline And Inositol	100 mg twice daily, with meals. 50 mg twice daily. 50 mg twice daily. 50 mg twice daily.	Important for circulatory function and for lowering blood pressure. Take niacin only under the supervision of a health care provider.
Vitamin B6	50 mg daily 3 times daily.	Reduces water content in tissues to relieve pressure on the cardiovascular system.

Mountain Rose Herbs, Bulk Herbs A-B
Mountain Rose Herbs, Bulk Herbs C-D
Mountain Rose Herbs, Bulk Herbs E-J
Mountain Rose Herbs, Bulk Herbs K-O
Mountain Rose Herbs, Bulk Herbs P-R
Mountain Rose Herbs, Bulk Herbs S-Z

Click Here To Visit Herbal Remedies Product Page

FOR FURTHER INFORMATION

National Heart, Lung, and Blood Institute (NHLBI)
P.O. Box 30105
Bethesda, MD 20824-0105
Phone: (301) 592-8573
Fax: (301) 592-8563
E-mail: NHLBIinfo@rover.nhlbi.nih.gov
Web Address: http://www.nhlbi.nih.gov

The National Heart, Lung, and Blood Institute (NHLBI) information center is available Monday through Friday, 9 a.m. to 5 p.m. (EST), to accept orders for publications and inquiries on the prevention and treatment of heart, lung, and blood diseases.

American Heart Association (AHA)
7272 Greenville Avenue
Dallas, TX 75231
Phone: 1-800-AHA-USA1 (1-800-242-8721)
Web Address: http://www.americanheart.org
Call the American Heart Association (AHA) to find your nearest local or state AHA group. The AHA can provide brochures and information on support groups and community programs, including Mended Hearts, a nationwide organization whose members visit heart patients and provide information and support.

NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...

You have high blood pressure and:

• Your blood pressure is usually normal or well controlled but it suddenly goes well above the normal range on more than one occasion.
  
  
• Your blood pressure is 180/110 mm Hg or higher.
  
  
• A sudden, severe headache.
  
  
• Chest pain (angina).
  
  
• Other symptoms of a heart attack.
  
  
• Symptoms of a stroke or transient ischemic attack (TIA).

Call health care provider if...

• Your blood pressure is 140/90 mm Hg or higher on two or more occasions (taken at home or in a community screening program). If one blood pressure measurement is high, have another reading taken by a health professional to verify the first reading. Many health care offices or clinics will take blood pressure measurements without charge or an appointment.
  
  
• You develop significant side effects from any medication you take for high blood pressure.

Adults are encouraged to have their blood pressure checked regularly. See schedule below:

This schedule shows how often you need to have your blood pressure checked, based on your initial blood pressure readings.

The Sixth Joint National Committee (JNC 6) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended regular blood pressure checks by a health professional based on a person's initial blood pressure reading. The JNC 7 currently is reviewing these guidelines, which will be released in the fall of 2003.

If your initial blood pressure reading is:

Systolic (mm Hg)	Diastolic (mm Hg)	Then you should:
Below 130	Below 85	Recheck in 2 years.
130 to 139	85 to 89	Recheck in 1 year.
140 to 159	90 to 99	Recheck within 2 months.
160 to 179	100 to 109	Evaluate within 1 month.
Over 180	Over 110	See a health professional immediately.

If you have high blood pressure, see your health care provider regularly to evaluate whether your treatment is working and to discuss any adjustments or side effects.

A diagnosis of hypertension is based on the average of two or more blood pressure readings taken at each of two or more visits after an initial screening.

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Prescription for Nutritional Healing: The A-To-Z Guide To Supplements

-- by Phyllis A. Balch, James F. Balch

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Helpful Links

HeartCenterOnline: The Blood Pressure Center

American Society of Hypertension, Inc.

Journal of Hypertension

Life Clinic Home Page

Pulmonary Hypertension Association

World Hypertension League Home Page

The 7th Report of the Joint National Committee on High Blood Pressure

Hypertension Online

Canadian Hypertension Society Website

Pregnancy-Induced Hypertension (PIH)

BOOKS

High Blood Pressure: Natural Self-Help for Hypertension

-- By Sarah Brewer, Michelle Berridale-Johnson

High Blood Pressure at Your Fingertips

-- By Julian Tudor Hart, Tom Fahey, Wendy Savage, Ian Baird

Mayo Clinic on High Blood Pressure

-- By Sheldon G. Sheps MD

High Blood Pressure for Dummies

-- By Alan L. Rubin MD

Reversing Hypertension: A Vital New Program to Prevent, Treat and Reduce High Blood Pressure

-- By Julian Whitaker MD

Controlling High Blood Pressure the Natural Way

-- By David Carroll

What Your Doctor May Not Tell You About Hypertension: Revolutionary Nutrition

-- By Mark C. Houston, Barry Fox, Nadine Taylor

Lower Your Blood Pressure in 8 Weeks: A Revolutionary Program for a Longer, Healthier Life

-- By Stephen T. Sinatra

High Blood Pressure Lowered Naturally: Your Arteries Can Clean Themselves

-- By Fireside Books, FC&A Publishing

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