The Mystery of High Blood Pressure (June 30, 2015)

Occasionally one of you all suggests to me a topic for a newsletter. The most recent idea I received was a text message from someone who thought I should write about high blood pressure “in angry red-faced middle-aged white males who think that their anger is giving them high blood pressure when actually the high blood pressure is causing the anger”. Woa. That sounds like it was a tough day all around.

Interestingly, this alert texter had hit on a very common pattern found in Chinese medicine for hypertension, which can be effectively treated with an herbal formula commonly used in the biz. But I thought that first I should look a little bit more into what western medicine has to say about hypertension. Here’s the first fact I ran into, and it knocked me completely off course from my original intention of discussing "wind resulting from liver yang rising".

Ready? Here goes:

95% of all cases of hypertension are OF UNKNOWN ORIGIN.

And here you thought that you have all those prescriptions because your doctor was totally on top of it! When really it's more like s/he is just scrabbling desperately to get a handle on the situation.  

For a long time, high blood pressure was thought by the medical profession to be an adaptation of the cardiovascular system to normal age-related changes in the body, and thus that it shouldn’t be interfered with. They called it “essential" hypertension for that reason. (The term is still used.) Here is a wonderful quote from that period: “In this group of cases (high blood pressure due to atherosclerosis) it is well to recognize that the extra pressure is a necessity–as purely a mechanical affair as in any great irrigation system with old encrusted mains and weedy channels. Get it out of your heads, if possible, that the high pressure is the primary feature, and particularly the feature to treat.” What charming metaphors! They don't write papers like that any more.

Bizarrely enough, life insurance companies were way ahead of doctors on this. For decades they increased premiums on life insurance policies for people with hypertension, often even refusing to issue policies at all, despite the supposed good health of their prospective clients. Of course insurance companies, unlike doctors, only make money when they are right, so maybe that had something to do with it. 

Anyway, we’ve all seen the light since then, and medicine has manfully done its best to make up for its earlier crime of ignoring evidence for decades that... ok, I'm sorry. Here is what we DO know. We know that people with normal blood pressure are a lot healthier than people with hypertension (which is usually defined as 140/90 or more). We also know that if you lower blood pressure in people with hypertension, whether it's with drugs or with appropriate changes in lifestyle, that they have many fewer of what Wikipedia delicately refers to as “cerebral, cardiac and renal events”. (Yes, I read Wikipedia, and you'd better hope that your doctor does, too. Half of all doctors do, but the ones who don't are the ones who think they know it all already.)

We know a lot about the many different mechanisms that control blood pressure, how and why they do so, and often how we can effectively intervene. But we don’t know the basic reason(s) why 95% of the Jane and Joe Schmoes out there with this disorder actually have it, this condition that is the second most common reason for doctor visits. So it is treated effectively only by trial and error. And sometimes even that can't be managed.

There are a number of known factors that increase blood pressure. These are probably involved in greater or lesser degrees from person to person, and this list is by no means exhaustive: (1) stress, (2) inadequate calcium and/or (3) inadequate potassium intake, (4) obesity, (5) high alcohol consumption, (6) insulin resistance, (7) high salt consumption (at least it is in salt-sensitive people, who make up at least 25% of the population), (8) aging and maybe (9) sedentary lifestyle. Most of these are additive as well - the more of them you have, the more likely you are to have hypertension and the worse it is likely to be. When you then take into account the genetic component (many genes with many variations between individuals are involved) and environmental factors, you get what might be referred to euphemistically as a complex situation or less tactfully as a dog's breakfast. 

But I’d like to talk about stress, partly because I think that stress is generally very overlooked by the medical profession, and particularly so in the area of high blood pressure. It didn't used to be. But now, except for a nod or two given to "white coat hypertension" and an admonition to meditate, we don't really hear the medical community discuss stress and hypertension anymore. Maybe it’s because there are no medications for stress (not until you start flat-out losing beers from your emotional six-pack, anyway). But whereas there are umpteen federal guidelines on diet and exercise, salt intake, and every other modifiable factor I listed earlier, there are no similar guidelines for stress. 

The other reason that I want to mention stress is that my personal opinion is that it is pivotal in the development and maintenance of high blood pressure. And this is why. Essential hypertension tends to always follow the same pattern of development. The first sign you see is an increase in cardiac output (heart beating faster and/or more strongly). The second thing that happens is a return of that cardiac output to normal with a simultaneous increase in the peripheral resistance of the blood vessels (making it harder to get blood through them). Now when I look at that list of risk factors above, the one that leaps out at me as being most likely to be the causative factor for those first steps is stress. Because cortisol is the main stress hormone and it does BOTH of those things. (Incidentally, cortisol is also involved in adjusting calcium and potassium levels,controlling insulin and blood sugar levels, and salt balance. Circumstantial evidence. But a lot of it.)

I wouldn’t go so far as to say that if you had no stress, you would have no high blood pressure. Although the few populations you can find without high blood pressure do lead very low-stress lives (at least they were low-stress until we began harassing them by measuring their blood pressures all the time). But if just being in a doctor’s office is stressful enough to send someone’s normal blood pressure into the abnormal range, what does that say about the hundred other things that happened that day – and every other day -- that are similarly stressful? No wonder moderate use of alcohol is good for your heart. 

Stress isn’t just an uncomfortable feeling. It’s a different physiological gear that your body goes into that makes many changes to normal metabolism in order to prepare you for either battle or running away. And many of those changes, when they become a way of life instead of a momentary adjustment, are risk factors for disorders that are very, very common. Hypertension being among them.

So we should not make the mistake of pushing stress reduction to the end of the list of helpful life changes. In fact, unless you are smoking more than half a pack a day of cigarettes (even American Spirits) or bungee-jumping with cords you bought at a yard sale, I’d put it first on the list.  And if you are one of those red-faced middle-aged persons mentioned at the start of this email today -- for your own sake and for the sake of the people you deal with every day, I wouldn’t wait another second to do so.

--dr. diane holmes
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