© 2012 Dr. Dale Peterson & drdalepeterson.com

High blood pressure is one of the most common health challenges seen today. As I explained in my article High Blood Pressure:  The Silent Killer, some authorities suggest that nearly everyone will become hypertensive at some point in life. I believe that their definition of high blood pressure is too stringent and does not take into account the natural rise in blood pressure associated with normal aging. Nevertheless, many people are found to have blood pressures that place them at greater risk of suffering a stroke, heart attack, or other serious threat to their quality or length of life.

High blood pressure is an enigma. Try as I may, I can often find no logical reason for its presence. It is true that it is more likely to be present if someone is overweight, sedentary, and consumes a diet that is relatively high in sodium and low in potassium and magnesium. Underlying conditions such as the metabolic syndrome (prediabetes), sleep apnea, and high homocysteine levels may be responsible. The reality of blood pressure, however, is that it is often found to be high in people who are active, not excessively overweight, eat a reasonable diet, and who do not have any condition that can account for its elevation.

In those cases I believe it is advisable to use a medication to lower the pressure to an optimum level. Studies suggest that this is a diastolic (lower number) pressure in the 80 – 85 mm/Hg range. While I usually write about ways to eliminate the need for over-the-counter and prescription drugs, given the number of people who require medication to adequately control their blood pressure, I feel it is important to explain some of the advantages and disadvantages of antihypertensive medications.

When I entered medical school in 1969 blood pressure management was in its infancy. Diuretics, often referred to as “water pills”, had been introduced in the mid-1960s and were the primary drugs used for blood pressure control at that time. Centrally acting drugs such as Aldomet and reserpine were available, but a high incidence of adverse effects limited their use. Inderal (propranolol), the first agent in a new family called “beta blockers” arrived on the scene in 1973 and other agents followed in rapid succession. Today at least nine different classes of blood pressure medications are available.

Diuretics have been used in the management of blood pressure for close to fifty years. The first diuretics to be introduced were called thiazides. Hydrochlorothiazide (HCTZ) and chlorthalidone were used in doses up to 100 mg. daily. For a time chlorthalidone was promoted as superior to HCTZ because of its longer duration of action, but it ultimately fell into disfavor because its use could result in severe potassium deficiencies. Hydrochlorothiazide also causes loss of potassium and magnesium, but to a lesser degree.

Some diuretics such as spironolactone and triamterene cause the body to retain potassium. Triamterene is often used in combination with HCTZ to lessen the risk of body salt imbalances with diuretic use. The combination was first marketed under the brand name Dyazide. It is now available generically.

As more effective medications became available the use of diuretics declined. They are generally used today in combination with other agents and at much lower dosages. As little as 12.5 mg. of HCTZ can produce a significant drop in blood pressure with minimal adverse effects. Additional improvement in blood pressure falls off rapidly as the dosage is increased and doses above 25 mg. are rarely used today.

Because diuretics promote insulin resistance, one of the underlying causes of high blood pressure, I use them sparingly and only when needed to augment the effectiveness of another medication. Potassium and magnesium loss remains a concern at low dosages, but it is much easier to replace these electrolytes through diet and nutritional supplementation than when higher amounts are used.

For many years diuretics were considered the drugs of first choice for managing hypertension. When a diuretic alone failed to adequately control blood pressure a beta blocker was generally added. It is usually safe to assume that a generic drug with a name ending in “lol” is a beta blocker. Some examples are propranolol, metoprolol, atenolol, and labetalol.

Beta blockers can be quite effective in lowering blood pressure, but they are notorious for lowering the quality of life of individuals taking them. The loss of quality of life occurs gradually and can therefore be very insidious. I have observed that most people who are taking a beta blocker don’t realize how poorly they are feeling until they stop the drug.

Some adverse effects of beta blockers are slow or uneven heartbeats, a light-headed feeling, fainting, becoming short of breath with mild exertion, swelling of the ankles or feet, nausea, stomach pain, low grade fever, loss of appetite, coldness of the hands and feet, insomnia, anxiety or nervousness, and impairment of short-term memory. Sexual side effects are common and include loss of sex drive, erectile dysfunction, and loss of ability to achieve orgasm.

Beta blockers can mask the symptoms of hypoglycemia (low blood sugar), so they should be used with caution when diabetes is present, especially if a person is taking insulin. They also prevent airways from opening and can trigger or significantly worsen an asthma attack. In addition, they weaken the pumping ability of the heart muscle. When they were first introduced they were not to be prescribed to someone with a history of congestive heart failure. Ironically, they are considered drugs of choice in the management of congestive heart failure today. This is because a number of studies have reported that beta blockers increase the life expectancy for individuals with heart disease. The life extension may be due in part to the drugs’ ability to block the increase in heart rate that normally occurs in response to activity. Unfortunately, this also means that people taking beta blockers are no longer able to obtain the benefits of exercise in lowering blood pressure and improving heart function.

The effect of beta blockers that concerns me the most is a loss of the zest for living. When I question people who are taking beta blockers many admit that they feel tired, lack enthusiasm, and find that they are no longer enjoying life. Many admit that they are simply going through the motions of living. Some have developed a full scale depression. Because the joy of living disappeared so gradually, many people have forgotten what life was like before they began taking a beta blocker. Few of those who have recognized the loss of joy in their lives have made a connection between the blandness they feel and the drug they are taking.

Many primary physicians today prescribe antihypertensive drugs with more favorable side effect profiles, but beta blockers remain intensely popular in the specialty of cardiology. I rarely see someone who is not on a beta blocker if they have seen a cardiologist. While cardiologists decry the failure of primary physicians to prescribe beta blockers routinely in heart failure patients I believe it is because physicians who look at the big picture are more likely to recognize the harm being done by the drugs than those who are concerned only with their own narrow area of practice.

When considering the use of beta blockers in congestive heart failure (CHF) it important to understand that the condition has a worse prognosis than all but the very worst cancers. Twenty percent of people hospitalized for congestive heart failure will die within the first year and another ten percent will die each year thereafter.

A number of medical studies have reported dramatic improvement in CHF with the use of nutritional supplements such as coenzyme Q10 and L-carnitine, but none of the studies used to support the use of beta blockers in CHF have compared the outcome of people on beta blockers with that of others nutritionally supporting their heart function. I have recommended nutritional supports to individuals struggling with heart failure for decades and I have consistently seen excellent results. In some instances the outcomes have been nothing short of amazing.

In 1998 I stood at the bedside of a man who had been hospitalized for management of congestive heart failure while a cardiologist and pulmonologist told him that he would be dead within three months if he could not obtain a heart transplant. He elected to take a nutritional rather than a surgical approach to his health challenge and lived for more than a decade before dying of an unrelated cancer.

I saw a woman who had been placed on hospice because of what was considered end-stage heart failure recover and spend the next two winters walking the beaches of Hawaii with her friends before she died of causes unrelated to her heart. A year ago I was told that I should apply for disability because my heart was damaged beyond repair. By applying the same principles I had seen work repeatedly in others I recovered quickly and found myself performing up to my usual level within two months.

When I am confronted with a situation in which blood pressure remains dangerously high despite the institution of the measures I addressed in last month’s issue I turn first to a medication in one of three classes: angiotensin converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), or calcium channel blockers. While no drug is free of risks or adverse effects, medications in these classes tend to produce fewer undesirable effects than others.

The generic names of ACE inhibitors generally end in “pril.” Some commonly prescribed ACE drugs are lisinopril and enalopril. In addition to lowering blood pressure these drugs can improve congestive heart failure by reducing resistance to blood flow in arteries. They are also approved for use in preserving kidney function in diabetes. The most common adverse effect of ACE inhibitors is an annoying cough that refuses to go away. The cough is non-productive and at times is mild enough that an individual is unaware of its presence until a family member draws attention to it. The most serious adverse reaction to ACE inhibitors is an allergic reaction that causes dangerous swelling called angioedema. Individuals taking an ACE inhibitor should be aware of this possibility and seek medical attention if it occurs.

ARBs are closely related to ACE inhibitors. Because generic versions are not yet available they are priced much higher than ACE drugs. I do not prescribe an ARB initially, but since the drugs do not cause a cough they offer an alternative for those who experience that ACE side effect. The generic names of ARBs typically end in “sartan.”

Calcium channel blockers are also fairly low in adverse effects. Commonly prescribed medications in this family are amlodipine, diltiazem, verapamil, and nifedipine. Ankle swelling can occur, particularly with use of amlodipine. Constipation tends to be a challenge when verapamil is used. The calcium channel blockers work well in combination with ACE and ARB medications and are useful in bringing blood pressure under control when a second drug is required.

Some people I see express a concern that these drugs are blocking the absorption or use of calcium in the body, but this is not the case. The drugs are technically calcium channel blockers, not calcium blockers. The calcium channel refers to the means of transporting calcium into muscle cells in the heart and arteries. The decrease in cellular calcium results in a drop in the heart’s pumping force and a relaxation of arteries. These changes lead to a drop in blood pressure. The relaxing effect in arteries can be beneficial when arteries have stiffened due to aging, but reducing the forcefulness of heart muscle contraction can potentially worsen congestive heart failure.

Alpha blockers are another class of antihypertensive medications. Their generic names typically end in “osin.” They work by blocking the action of the nervous system that signals muscles in arteries to contract. Because they also relax the muscle at the outlet of the bladder they are often prescribed to improve urine flow in men with enlarged prostate glands. The drugs can cause blood pressure to drop when getting up from a sitting or lying position. This effect is most pronounced with the first dose. For this reason the drugs are usually started at bedtime and the doses gradually increased as the body adapts to their effects.

Several drugs work within the brain to diminish the activity of the nervous system that responds in a “fight or flight” manner to stress. These are clonidine, guanfacine, and methyldopa. Because they act within the brain these drugs tend to be sedating. They can also cause dry mouth, blurred visión, and constipation. Depression can occur. I have seen this happen more often with methyldopa than with the other agents. Methyldopa was one of the first non-diuretic blood pressure medications introduced. It is rarely used today because it must be taken three or four times daily to obtain the best results.

Centrally acting drugs can improve hot flashes. Therefore, clonidine may be used to obtain a dual benefit in a woman experiencing menopausal symptoms in addition to having high blood pressure.

Aliskiren (Tekturna) is a relatively new medication that is in a class of its own. It works by inhibiting the action of renin, a substance that plays a major role in blood pressure regulation. Since the drug is not superior to medications that are available generically its high cost is unjustifiable in most instances. The drug can cause flu-like symptoms including headache, backache, muscle aches, and cough.

Vasodilators are drugs that work by relaxing muscles in arteries. The exact way in which this is accomplished is not fully understood, but it is known that the drugs act directly upon the muscles and not by affecting the brain or the nervous system. Hydralazine is a vasodilator that has been available for decades. It is used only as a drug of last resort because it can have serious consequences. One is the development of systemic lupus erythematosis (“lupus”) or a condition that is very much like lupus. Lupus is an autoimmune condition that can damage nearly all organs within the body. Hydralazine can also cause a serious drop in production of red blood cells, white blood cells, and platelets.

The other vasodilator is minoxadil. It is prescribed only when blood pressure remains dangerously high despite the use of other medications. This is because the drug can damage the heart muscle. It can also trigger salt and water retention leading to congestive heart failure. Because increased hair growth was noted in people taking the drug, a topical form was introduced for treatment of baldness. The topical form has not been associated with the serious adverse effects seen when the drug is taken orally.

The goal in treating hypertension is to control blood pressure by addressing the underlying causes I discussed in High Blood Pressure:  The Silent Killer. Unfortunately, I have found that many people continue to have unsafe blood pressure levels even after they have taken appropriate steps to lower them. Hopefully knowing what options are available will help you avoid or minimize adverse reactions if you should require an antihypertensive drug.

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