High Blood Pressure
Understand and Prevent High Blood Pressure
(30) High Blood Pressure
Diagnosing and treating pre-eclampsia
Does a doctor deciding that you have pre-eclampsia depend only on high BP measurements or will I have to undergo other tests as well?
Your BP readings are important but yes, they do take other evidence into account. Pre-eclampsia will be suspected if your BP is 140/90 mmHg or more and is known to have been less than this before your pregnancy began, and/or if there is protein in your urine, and/or if you have some swelling of your whole body from increased fluid (oedema). Although most pregnant women will have some mild oedema (usually affecting their ankles and legs), protein in your urine and more severe oedema indicate that raised BP has caused some kidney damage. These are the earliest changes in the sequence of events that may, untreated, end with eclampsia. Occasionally pre-eclampsia is suspected for the first time because of poor growth of the baby when the midwife or doctor examines your abdomen. Babies in this circumstance are usually very quiet with the mother reporting a marked fall-off in the fetal movements.
You are considered to have mild pre-eclampsia if your diastolic pressure is between 90 and 99 mmHg, moderate if it is in the range 100–109 mmHg, and severe if it is 110 mmHg or more. If you have significant amounts of protein in your urine (most accurately measured on a 24-hour collection of urine), then pre-eclampsia is considered to be severe whatever the level of your BP. Blood tests may help in determining whether pre-clampsia has led to disturbance in your liver and kidneys or alteration in your ability to form clots.
Protein was found in my urine at my last visit. Does protein in the urine always mean that a woman has pre-eclampsia?
No. A bladder or kidney infection can also cause protein to appear in your urine, so the urine sample you provide should also be checked for infection. The urine tested needs to be a ‘clean catch’ or ‘midstream’ specimen, otherwise the germs thatnormally live in the vagina may be washed into the collecting tube and cause the sensitive urine testing strips (dipsticks) to give a false positive result. You provide a midstream (MSU) specimen by passing a little urine first before you collect your sample in the container provided. Sometimes you may be asked to collect all the urine you pass in 24 hours, to measure the total protein lost in your urine throughout the day. This should be less than 300 mg in 24 hours. Some people lose protein from their kidneys from time to time, without this signifying any damage.
Why does pre-eclampsia cause protein to collect in the urine?
Urine normally contains only water with a large variety of rather simple waste products (mainly urea and salt) dissolved in it. Proteins (which are large and complex chemical molecules) are normally filtered out and retained by your kidneys, and so do not appear in your urine. When BP rises for the first time in pregnancy, it rises much faster than ‘ordinary’ high BP in people who are not pregnant. Even though the actual level of raised BP may not be very high, because it has happened quickly, your kidneys have had less time to adapt to the new higher level and so are more easily damaged. The effect of even minor damage is that your kidneys begin to leak protein into your urine.
The amount of protein in your urine is roughly proportional to the severity of the damage to your kidneys. Your kidneys will recover to the pre-pregnancy state following pregnancy; however, occasionally, women are identified for the first time in pregnancy with pre-existing kidney damage. This will only become apparent if the kidneys have not returned to normal by 6 weeks following delivery.
If I already had high BP before my pregnancy, how can doctors recognize if I develop pre-eclampsia?
Blood pressure normally falls during pregnancy even in a woman whoalready high BP before she became pregnant (like you). Whatever your starting point, a rise above your pre-pregnancy BP level would be a cause for concern, and would alert your doctor or midwife to the possibility of pre-eclampsia. For those women for whom good pre-pregnancy BP measurements are not available, then BP measurements taken later in pregnancy can be compared with the readings taken early in pregnancy. Some research suggests that a diastolic pressure rising by more than 15 mmHg or a systolic pressure rising by more than 30 mmHg indicate a cause for concern. Urine tests, blood tests, and presence of oedema provide valuable additional information in these circumstances.
My legs became very swollen the last time I was pregnant, so my doctor was a bit concerned about pre-eclampsia, but stopped worrying when my BP and urine tests turned out to be OK. Please can you explain what was happening?
In severe pre-eclampsia, so much protein may be lost in the urine that the level of protein in blood falls. The blood cannot then retain all the water it contains; some leaks through the walls of the capillaries (the smallest blood vessels) to other parts of your body, making them swell. Because water tends to fall to the lowest point, this swelling first becomes obvious in your legs.
However, swollen legs are extremely common in pregnancy, and usually have nothing to do with pre-eclampsia. Anything that obstructs the flow of blood up your leg veins can cause raised BP in your veins (not your arteries, and arterial BP is what we are concerned with in pre-eclampsia). Fluid can then leak out of the veins into the skin, causing the same signs of oedema. The most obvious cause of such obstruction is the pregnant uterus (womb), and in late pregnancy some degree of oedema is almost inevitable in almost every pregnant woman. It can happen earlier in pregnancy in women who are overweight, or wear tight clothing, or stand for hours on end.
All these common causes of swollen legs can be distinguished from pre-eclampsia because they are not accompanied by protein in the urine. Finally, don’t forget that if only one leg swells, or one leg swells more than the other, the cause may be a deep vein blocked by a clot, a common and important complication of late pregnancy, which may need urgent treatment. See your doctor or midwife if you think this is happening.
If I do develop pre-eclampsia, is there a way for my doctors to treat it or even cure it?
There is no cure for pre-eclampsia other than delivery. Your obstetrician will need to consider the risks to you and your baby in determining the best timing and method of delivery. In late pregnancy it can be treated by starting labour early (induction) or by a planned or emergency caesarean section (an operation to deliver the baby through the abdomen) before labour starts. Although severe, rapidly progressing pre-eclampsia can occasionally begin at 24–26 weeks into the pregnancy, but this is very uncommon. Most women who get it develop a mild form of the disease at 34–36 weeks with small amounts of protein in the urine, and diastolic BP (the second of the two BP figures) in the 90-100 mmHg range. They usually do well if labour is induced a little early and deliver good sized babies, who can stay with their mothers on the ward. Babies who are very immature may need special care in a neonatal intensive care unit. Depending on how far you are on in your pregnancy, or whether this is your first or a later pregnancy, labour may be induced either by breaking your waters (called artificial rupture of membranes, or ARM) or by using prostaglandin (PG) pessaries or gel inserted into the vagina. Synthetic oxytocin (Syntocinon) may be used to make the uterus contract if labour does not start after the ARM or PG pessary. This has to be given by a drip into one of your veins. Sometimes this may be given immediately the ARM has been done. If your obstetrician decides that your pre-eclampsia needs drug treatment, then the most likely BP-lowering drugs to be used are either methyldopa, beta-blockers or a calcium-channel blocker (nifedipine). If these drugs are ineffective, then most obstetricians would use hydralazine (a vasodilator drug) orlabetalol (a beta-blocker by infusion - injection into a vein).
We used to be told that rest in bed was the most important treatment for pre-eclampsia, but obstetricians and midwives today don’t seem so concerned about this. Can you explain this?
Research studies have compared pregnant women with preeclampsia treated by traditional bed rest in hospital with similar women who simply took things easy at home - they have shown no difference at all in how well women (and their babies) got on.
Physical and mental rest is important, but many women get more rest if they are allowed up and about in their own homes than if they are compelled to lie in a hospital bed. However, women with pre-eclampsia who are being treated at home do need careful supervision, and should have their BP measured and their urine tested for protein at least once a day, and should be admitted to hospital immediately if they get abdominal pains or headaches.
(31) High Blood Pressure
Pre-eclampsia and future pregnancy
I had pre-eclampsia in my first pregnancy. Am I likely to get it again?
About 1 woman in 50 with mild pre-eclampsia in a first pregnancy and about 1 in 10 of those who had it severely go on to get severe pre-eclampsia in their second pregnancies. About one-third of all women who had pre-eclampsia in their first pregnancies (regardless of whether it was mild or severe) get mild preeclampsia in their second. Or, looking at it the other way, two thirds of those with severe and nearly three-quarters of those with mild pre-eclampsia have no problems with raised BP in their second pregnancies. I had eclampsia in my first pregnancy and was very ill. I would like to have another baby but I’m scared that it will happen again.
What are the chances that I will get eclampsia next time?
Eclampsia is rare. Of the 10 women who had it in the largest research study so far reported, none had eclampsia in their second pregnancy, eight had normal BP and two had mild preeclampsia.
If you developed kidney failure because of your eclampsia, then it would be worth asking your doctor to check your kidney function - this will involve doing a 24-hour urine collection test and having an ultrasound scan to check the size of your kidneys. There are also blood tests that check for a clotting disorder or disturbance in special antibodies (antiphospholipid antibody syndrome) that can influence your risk of recurrence of severe pre-eclampsia. If these tests are normal, your risk of getting eclampsia or severe pre-eclampsia are small. You will be advised to see a specialist obstetrician early in a future pregnancy and you may wish to ask for a pre-pregnancy visit to discuss the risks before embarking on a further pregnancy.
I’ve heard that taking aspirin can prevent pre-eclampsia. I had pre-eclampsia in my first pregnancy, so should I start taking aspirin now that I’m pregnant again?
No, for two reasons. The first (and more obvious) is that self-medication can be dangerous. The second is that a number of clinical trials addressing this question have shown conflicting results. A large review of all of the studies testing the value of aspirin in preventing pre-eclampsia has suggested that the risk of developing pre-eclampsia is reduced by 15% as is the risk of death of a baby (this is a much smaller benefit than was initially anticipated). These potential benefits may be important, but aspirin was only started at around 12 weeks of pregnancy in these studies and the safety of aspirin at earlier stages of pregnancy has not been demonstrated. It is important, therefore, that you wait until the stage of your pregnancy is confirmed and that you take aspirin only under medical supervision. New information becomes available all the time and you may want to discuss it further with your doctor. There are newer studies suggesting that additional supplements of vitamin C and E may reduce the risk of pre-eclampsia, but again there are concerns about fetal safety as the doses used were quite high. Further evaluation is required and you should not take any medication in pregnancy, even over-the-counter drugs (from a pharmacy or supermarket), without discussing it first with a well informed GP or obstetrician.
Blood pressure after pregnancy
I was put on BP-lowering drugs in pregnancy for the first time. How long will I need to continue with treatment?
This will vary according to how high your BP was in pregnancy and how much BP-lowering medication you needed. Some women will see a rapid fall in their BP over several days following delivery. This may allow you to stop all drugs before discharge from hospital. In other women it is more gradual and you may require ongoing medication for up to 6 weeks following delivery, although the amount is usually reduced over time as your BP comes down. If you had been started on methyldopa during pregnancy, this will be changed to a different drug immediately after delivery, as it can lead to a lowering of mood and symptoms of depression. Occasionally with pre-eclampsia, you may need to start BP-lowering drugs for the first time following delivery or require further increases in your medication, as some women show signs of deterioration immediately after delivery before they start getting better.
Will I still need to visit my obstetrician for BP checking after I have had my baby?
Your obstetrician and the midwives will monitor your BP while you are still in hospital. They will hand over your care on discharge usually to your GP and community midwife. You will need to have ongoing BP measurements at regular intervals until your BP has returned to normal off all medication. If your BP continues to be high after 6 weeks, you are probably demonstrating a natural tendency to high BP and will receive ongoing care from your GP. Your GP will also take your BP into account when advising you on contraception. If you had very severe pre-eclampsia you may be asked back to the hospital for a postnatal visit at 6 weeks to discuss the events in your pregnancy, to evaluate the risk of problems in future pregnancies and to arrange further tests if you are found to have a kidney disorder or clotting problem.
My doctor thinks I will need to continue BP-lowering drugs after pregnancy. I would like to breastfeed for as long as possible - will this be safe for my baby?
The same issues arise for breastfeeding as were discussed for drug treatment in pregnancy (see the section on High BP and planning a pregnancy). Very few drugs have ever been evaluated by trials that included breastfeeding women, and most of the information available is from indirect studies and reporting of bad outcomes (adverse event reporting). In general terms, most drugs pass into breast milk in small amounts (the same is true for passage of drugs across the placenta to the unborn baby).
The safest approach is to take BP-lowering drugs that are considered suitable for pregnancy. The exception is methyldopa, which can be associated with symptoms of depression and is usually discontinued after delivery. If your BP has been well controlled with a beta-blocker or a calcium-channel blocker (usually nifedipine), you can be reassured that this can be continued after pregnancy with a very low risk of any untoward
consequences for your breastfed baby. For other drugs you will need to weigh up the benefits of breastfeeding with the risks to your baby of receiving small amounts of the drug in your breast milk. You will be offered expert advice in this situation.
I have been on a combined form of the contraceptive pill for several years. Will this increase or decrease my BP?
Combined oral contraceptives (COCs), are the form of the pill that contain two different hormone preparations - oestrogen and progesterone. There is consistent evidence that shows use of COCs increase BP by about 5/3 mmHg on average. In a small proportion (less than 1%) of women taking COCs, much higher BP may be triggered. Unfortunately this response is difficult to predict. It is not possible to tell which women are susceptible to high rises in BP, and these sharp rises can occur many months or years after initial treatment with COCs.
The small rise in BP is seldom recognized in practice, because the COC is mainly used by young women with systolic and diastolic pressures so low, often around 100 mmHg systolic, that even a rise of 10 or 20 mmHg of systolic pressure remains well below levels that will attract attention from most doctors or nurses.
There are many different contraceptive pills available. Are there any differences in terms of their effects on BP?
There is no difference in terms of different formulations of the COC and high BP. The ‘pill scare’ a few years ago relates to the risk of venous thromboembolism (blood clots in the leg that can travel to the lung) when different progestogen formulations in second- and third-generation COCs were compared. Some studies have shown that newer, third-generation pills, containing the progestogens either desogestrel or gestodene, are associated with a slight increase in the blood clots when compared with older, second-generation pills containing levonorgestrel. These differences in absolute terms are very small, being 15 per 100,000 women per year of use in second-generation COCs compared to about 25 per 100,000 per year of use in third-generation COCs.
When the risk of stroke and heart attacks were comparedbetween second-and third-generation pills, no differences could be found.
I have heard that there is a risk of heart attack or stroke with the contraceptive pill. Is this risk increased if I take the combined oral contraceptive?
There is a small increase in risk of heart attack or stroke associated with COC use. It is for this reason that a regular check of your BP - usually every 6 or 12 months - should be made. In women with pre-existing cardiovascular disease, the COC is not recommended because of the overall increase in such disease.
I have been put on the mini-pill. Does this increase BP?
The progestogen-only pill (POP), otherwise known as the mini pill, is not associated with an increase in BP. The POP is most commonly used in two situations: firstly, in those women who have taken the COC and who have developed high BP; secondly, in women who already have high BP and who do not want to use non-hormonal methods of contraception. I already have high BP.
Will I be allowed to use an oral contraceptive pill?
If your BP has ever been high enough to cause concern, you should not use COCs. Although the COC is not absolutely forbidden, other choices, such as non-hormonal forms of contraception, should be tried, particularly if you have other risk factors for coronary heart disease – smoking, obesity, high cholesterol, or family history of disease.
In women for whom other forms of contraception are not acceptable, changing to a POP with careful monitoring of BP is recommended. It should be remembered that the POP is a less effective contraceptive than the COC. In younger women (aged under 35 years), who are more fertile and in whom the risk of pregnancy-associated heart attack or stroke is greater than COC-related risk, then the issue of continuing with a COC or changing to a POP is more finely balanced.
I should still like to go on to the pill. How can I minimize my risk of having a stroke or heart attack?
Nobody should consider starting the pill without a BP check. You should also have a clinical history and examination performed, focusing particularly on family history of stroke and heart disease, BP recording and examination of your heart. In women with no personal history of breast and gynecological conditions, pelvic and breast examination is not necessary. Secondly, you should make sure that your other cardiovascular risk factors are minimized – most often this means stopping smoking. Lastly, most women begin to consider other methods of contraception by about 35 years of age, usually either in the form of the POP or non-hormonal methods of contraception.
How often should BP be checked in women on the contraceptive pill?
Recommended practice is once every 6 months, although many women who have normal readings have a BP check only every 12 months. The best arrangement is to have BP checked each time a repeat prescription is collected.
(32) High Blood Pressure
Menopause and HRT
I am 51 years old and have just discovered that I have high BP. Is the menopause a cause of high BP?
No. Most women have their last menstrual period between 45 and 55 years. Blood pressure rises with age, and many women consult around this time for menopausal symptoms such as flushes and palpitations, so discovery of high BP can coincide with the menopause, but is not caused by the menopause. My doctor has put me on HRT patches.
Does HRT have any effect on BP?
The use of hormone replacement therapy (HRT) is not associated with an increase in BP. The benefits of HRT relate to reducing the symptoms of the menopause, such as hot flushes, palpitations, mood swings, and sleep disturbance. HRT is also helpful in reducing the risk of osteoporosis (thinning of bone density) and subsequent fractures, and has been shown to reduce the risk of colon cancer.
These benefits of HRT have to be balanced against the small increase in the risk of venous thromboembolism, breast cancer, and endometrial (womb) cancer in HRT users.
Cardiovascular disease, most particularly coronary artery disease, was initially thought to be reduced by the use of HRT.
Unfortunately, recent clinical trials have not confirmed these benefits and suggest that HRT increases the risk of such disease in women who have previously suffered coronary artery disease.
The association with coronary heart disease and HRT relates primarily to ‘opposed’ HRT (containing both oestrogen and progestogen components). ‘Unopposed’ (oestrogen-only preparation) has not been shown to be harmful or protective in terms of risk of coronary artery disease.
If I already have high BP, is this a reason not to take HRT?
HRT can be used by women with high BP. The main issue is to make sure that BP levels are controlled by means of BP-lowering medication. Because of the potentially harmful effects of HRT on coronary heart disease, you should have your BP checked two to three times in the first 6 months and then at regular 6-monthly intervals.
Living with high BP
Having high BP can influence many different aspects of your life.
Are there any kinds of work that people with high BP are not allowed to do?
Providing high BP is well controlled by medication, the only kinds of work you cannot do are those excluded by employing authorities, for example flying a plane, scuba or aqualung diving, or other work under raised atmospheric pressure (as in diving bells). These jobs are dangerous for anyone with treated high BP, because all BP-lowering drugs impair the usual responses to the extreme conditions of atmospheric pressure or gravitational force normally experienced in these activities. Anyone with an untreated BP at or over about 140/90 mmHg will be excluded from such employment.
Driving trains or lorries, or operating machinery, might also be barred if you are on BP-lowering drugs that make you drowsy. Discuss this with your doctor so that drugs with this side effect can be avoided.
What kinds of work might be bad or dangerous for people making their BP rise? I work in the chemicals industry. Could my high BP have been caused by my work?
This question is difficult to answer, because we still know relatively little about what the environmental causes of high BP are. Some research suggests that sustained industrial noise, at levels that make it necessary for workers to shout in order to be heard over a distance of under a meter (1 or 2 feet), may cause a sustained rise in BP. There is no convincing evidence of any effect from shift work.
Several metals, their soluble salts, or their welding fumes can cause high BP either directly, or by damaging the kidneys. These chemicals include cadmium and lead. The many workers who handle unknown chemicals of all kinds need to be aware of the possibility that these may cause many different sorts of damage, usually to the liver and/or kidney, and this in turn may be expressed as high BP. Carbon disulphide, once used in a now obsolete process for making viscose rayon, was correctly suspected of being a hitherto unknown cause of coronary heart attacks by a vigilant family doctor in North Wales. Other discoveries of this sort may be made in the future; it is sometimes important to keep an open mind. In studies of Norwegian present and past shipbuilders, both unemployment itself, and fear of impending unemployment, were shown to raise both BP and blood cholesterol. There is good evidence from
Travel and holidays
Does flying in a pressurized aircraft have any effect on BP?
No, but middle-aged and elderly people with problems of overweight or heart failure should make sure that they have room for their legs without pressure from luggage, that they do frequent static leg exercises by alternately tightening and relaxing their calf muscles every half hour, and get up and walk and stretch regularly on long journeys. Drink plenty of water and avoid alcohol on long-haul flights. There are high risks of developing deep vein thrombosis (blood clots in the veins) in the legs if this advice is not followed.
I am going to
People living long enough at very high altitude to become fully acclimatized develop thicker blood because they need more red blood cells to carry the smaller available load of oxygen. As blood viscosity increases, so does BP and stroke risk. People whose high BP has not yet been fully controlled by medication might be wise to postpone travel to such areas until their BP has been brought down to normal.
Is it difficult to get the same BP medication abroad if I run out?
All the commonly prescribed BP-lowering drugs are available in other economically developed countries, but often at very high prices. Brand names are often entirely different, so you should make sure that you know the generic names of your medication before you go.
Unless you are going away for more than 3 months or so, your family doctor will prescribe enough of your medication to cover the whole period of your absence. If you have to take more than 100 of any tablets for your personal use, it is wise to ask your doctor to write a note confirming what has been prescribed, how much, and that this is necessary for your personal care. Customs officials can be very difficult about bringing large quantities of drugs into countries.
If I need to see a doctor while I am abroad, what should I do?
If you are getting good regular supervision from your own family doctor in the
Make sure before you go that you know exactly what medication you are taking, generic names as well as brand names, and roughly what your BP was before you started treatment. It may help to have this written down.
Think carefully before adding any new medication. South and Central European countries have strong traditions of prescribing lots of drugs for everything, which you should avoid. Local doctors occasionally imagine that no tourist can be satisfied with a visit that does not end with a new prescription. Just ask what exactly it is for, and if in doubt, don’t collect it. You are more likely to suffer from overtreatment than under treatment. Lastly, be careful if you take over-the-counter medications for colds or ’flu. Many of these drugs contain ephedrine and caffeine, which raise your BP. It is usually better to take a supply of paracetamol tablets with you.
What should I do about medication if I get diarrhea or vomiting while travelling?
Travellers’ diarrhoea and/or vomiting is rarely severe, and usually self-limiting, getting better after 3 or 4 days without antibiotics or any treatment other than increased fluid intake. Whatever the cause, you should continue your medication unless you have to be admitted to hospital for intravenous fluid replacement, which is extremely unlikely.
Infection with protozoa (‘giardiasis’) is common in Eastern Europe and the Middle East, and often causes more prolonged diarrhoea and nausea, sometimes dragging on for months unless it is actively treated with the antibiotic metronidazole. This interacts in the blood with alcohol to produce severe headache, but it does not interact harmfully with any of the drugs used to treat high BP.
Diarrhoea is caused by rapid movement in the stomach (gut). Gut movement can be slowed by drugs such as co-phenotrope (Lomotil) and loperamide (Imodium). Either of these drugs is safe to use with BP-lowering drugs.
The main risk from diarrhoea and vomiting is dehydration and depletion of sodium and potassium. Rational treatment mainly depends on correcting these losses by drinking water (drink half a litre – about a pint – after each passage of diarrhoea or vomit).
Glucose helps a sick gut to absorb the extra water. You can do this yourself by drinking orange juice or Coca-Cola (for glucose and potassium), adding 1 level teaspoon of table salt to each litre (just under 2 pints); or you can get Oral Rehydration Salts (Dioralyte) from a chemist and dissolve these in water strictly according to the instructions. Make sure that the water you are drinking is pure.
For people on an ACE inhibitor, the normal kidney mechanisms for correcting sudden fluid and salt loss cannot operate. They therefore have much higher risks of collapse, with dehydration and salt loss. For people on ACE inhibitors, rehydration and correction of salt levels must be taken more seriously and medical advice sought.
(33) High Blood Pressure
I have always done a lot of sports. Now that I have been diagnosed with high BP, are there any sports that are particularly good or bad for me?
Scuba diving may be dangerous for anyone either with uncontrolled high BP, or on BP-lowering drugs. They will have to be satisfied with snorkeling, diving not more than 2 or 3 meters (6–10 feet).
Squash and other similar extremely active and exhausting competitive sports are unwise, and so are all kinds of static exercise such as weight-lifting, press-ups and body-building.
Apart from these, there is virtually no sport that people with treated and controlled high BP cannot do, providing they get themselves sensibly into training, and do not rush into very demanding activities for the first time in middle-age. People who maintain regular exercise tend to have lower BPs. Swimming is probably the best form of exercise, as it remains possible even for older people with joint and back pain. Cycling is a good alternative for people without back pain.
I am worried that I won’t be able to make love to my partner as often as usual. Does high BP affect sexual appetite or performance?
Roughly 5% of middle-aged men, and an unknown proportion of women, have problems of diminished desire and/or performance. There is no evidence whatever that high BP itself affects either of these, but, in any large group of men with high BP, this figure for failure of erection is likely to be nearer 10% or more. This is not because of high BP itself, but because of other factors, such as:
• Health changes commonly associated with erection failure, for example diabetes;
• Causes of high BP, such as obstruction, for example, of the aorta or of arteries in the pelvis; • blood-pressure lowering medication, most commonly high dosage of diuretics;
• Worry and loss of confidence associated with the diagnosis of high BP.
Sex starts in the mind. If the mind is disturbed or preoccupied with other worries, such as ‘Will I (or my partner) have a brain haemorrhage from high BP while we make love?’, the sequence of first emotional changes then physical changes, which must occur before successful lovemaking can take place, may not even begin; or, having begun, may at any point be interrupted.
Depending on where this interruption occurs, the consequences may be:
• Loss of desire or failure to obtain an erection;
• Having obtained it, failure to maintain it until both partners achieve orgasm; or
• Premature ejaculation.
Although all these failures refer to men, in whom they are more obvious, there is no reason to doubt that they happen also in women, for whom erection of the clitoris is just as necessary as penile erection in men.
Men who usually have good erections when they wake in the morning can be sure that there is unlikely to be a physical problem. Whatever problems they have are probably connected in some way with their own mind, or the interaction between minds necessary for a successful relationship. Problems of this sort can often be solved simply by discussing them frankly with your partner, a simple step many find very difficult to take. If problems can’t be sorted out in this way, you should look for help from an experienced and sympathetic counsellor. Local Family Planning clinics and marriage counselling units can usually organize this for you.
Men who rarely or never have good morning erections nearly always have an underlying physical cause, because of problems either with their blood supply or nervous control of the penis. Both these impairments are very common in people with diabetes, often at an early stage in the disease. As diabetes is much commoner in people with high BP than it is in the general population, failure of erection is also commoner among people with high BP.
Erectile failure from a physical cause (‘organic impotence’) can be treated in several ways. Drug treatment with sildenafil (Viagra) or one of the newer ones (tadalafil [Cialis], vardenafil [Levitra]) enables many men to achieve a satisfactory erection. Viagra should be taken about an hour prior to sexual activity. Adjustment of the dosage may be necessary and you should not take it if you are already taking certain antianginal medication (nitrates). If in doubt, consult your GP.
In men in whom Viagra doesn’t work, there are alprostadil injections. This drug is injected into the skin at the base of the penis with a very fine needle. This will last for 10–20 minutes, and can be repeated. This sounds awful, but usually works very well, particularly if the main problem is impaired nervous control rather than impaired blood supply, as it usually is in diabetics. Another choice is the vacuum therapy device (VTD), consisting of a vacuum chamber with a constriction ring, and a hand- or battery-operated pump. It creates a negative pressure around your penis, increasing the blood flow, thus inducing an erection. The constriction ring maintains it.
Finally, you can consider having a surgical operation to implant either a fixed or variable internal splint into the penis, so that you can make an erection. This also generally works very well. The latter two options require referral to a specialist clinic.
Erectile failure caused by BP-lowering medication is relatively common, mainly from diuretics (often in excessive doses), beta-blockers and methyldopa, but occasionally with all such drugs. Impotence from this cause is always reversible; it stops soon after stopping the drug. If it doesn’t, the drug is not the cause.
Will having sex raise my BP?
Yes, but transiently. As in any other vigorous physical activity, BP rises moderately in anticipation, and steeply during performance. It falls quickly afterwards, and there is some evidence that regular sexual activity may reduce rather than increase average BP at other times.
I already have a high BP. Can sexual activity be dangerous for people with high BP?
Activities that cause very high peaks in BP, such as weight-lifting, push-ups, or pushing a car out of a ditch, are dangerous for people known to have uncontrolled high BP, and unwise even if high BP has been controlled by medication. The risks are of acute coronary insufficiency leading to interruption of normal heart rhythm, and bleeding from a brain artery leading to stroke. Even if sexual activity were to raise BP to the same extent and for similar lengths of time, this might not carry the same risk. The whole body is in a transiently exalted state during sexual activity, in which perception of pain, for example, virtually disappears; many other changes occur other than raised BP, probably including changes in blood coagulability, which are more likely to prevent than to cause a heart attack or stroke. Coronary thrombosis and heart attack can occur occasionally during intercourse, and stroke is not impossible. However, even these rare events seem to happen far less often during sexual activity than in common and equally physically demanding sports.
I have high BP for which I am taking tablets. I am having problems with getting an erection. What advice can you give me?
There are several aspects to this question. Firstly, taking any medication for high BP does not stop a man using treatments for erectile failure.
The second issue is that some people think that their drug given for high BP has caused the failure. You might have noticed this only when the BP-lowering treatment was started. The real problem, however, lies in the underlying disease, which has narrowed your blood vessels and hence caused your BP to rise, and stop the blood flowing to the penis. It is very important, if your doctor has put you onto a BP-lowering drug, not to stop it if erection failure follows, but to return to your doctor and discuss this issue with him. Your doctor should easily be able to prescribe another drug to control your BP and this could help your problem. It is, however, true that some of the older drugs treating high BP do cause more problems than some of the newer drugs. So your doctor may decide to change your treatment for high BP to see if one drug can control both your BP and erection problems.
(34) High Blood Pressure
Can I carry heavy shopping?
When you are carrying shopping, most of the hard work is done by your legs, and its good exercise but tiring. It should not affect your BP. Why not use a wheeled shopping trolley and get your exercise in some other way? Can I drive safely on BP-lowering drugs?
Some drugs used to lower BP can make you drowsy and this may cause problems for some drivers. Methyldopa and some beta-blockers are known particularly to cause drowsiness. All the drugs that do make people drowsy will do so much more if they’re combined with alcohol.
The answer is that, if you feel drowsy on medication, you should discuss with your doctor whether you should drive. It is worth mentioning that beta-blockers have been effectively prescribed for people who are nervous and are taking their driving test. They can have a calming effect particularly in people with a tremor.
Are there any support groups or self-help organizations for people with high BP?
Not specifically. There are some organizations such as the Stroke Association and the Blood Pressure Association who provide self-help leaflets and informal support. It is also worth looking at the patient information leaflets produced by the British Hypertension
Monitoring and follow-up
Systematic registration, review and recall is the cornerstone to organized care for people with high BP. Achieving target BP ensures that the benefits of BP-lowering are realized. To achieve this aim you need to be prepared to take part in an organized system of monitoring and care.
What kind of follow-up should I expect from my general practice? What are the main reasons behind continued follow-up?
It is important that you maintain continuity with your general practitioner so that your BP is properly managed. The aims for follow-up of BP are:
• To make sure that BP is reduced sufficiently to an agreed target level;
• To assess complications of hypertension (target organ damage);
• To continue to assess and treat cardiovascular risk factors, particularly high cholesterol levels;
• To assess possible other illnesses, such as newly diagnosed angina, and consequent tailoring of treatment;
• To continue monitoring any adverse effects from
BP-lowering drugs, which may require regular monitoring of your kidney or liver function by means of blood tests.
Your doctor may also ask you about how well you are taking your medication and whether you are maintaining your lifestyle changes, such as stopping smoking and losing weight.
If I have side effects with the medication that I am on, will I be able to change?
Your doctor should be willing to change your drug treatment when necessary. Your doctor will want to discuss with you why you want to change and the choices that are open to you.
Can BP be reduced to too low a level?
BP has a continuous graded and direct relationship with death or illness from a heart attack or stroke. In other words there is no BP level that is too low or unsafe in terms of your overall health. Several years ago there were concerns that lowering of BP might increase risk of death from other causes. However, when large numbers of people have been followed up over time, the association between low BP and subsequent death was found to be due to the fact that low BP may be caused by other life threatening coexisting conditions such as cancer. You should not be worried about lowering your BP too much. The problem most people are faced with is not being able to get their BP down to target treatment levels.
I have trouble taking my medicines and frequently miss a dose. Is this a common problem and how can I be helped?
It is well recognized that for symptomless conditions like high BP, people often forget to take their medication. Studies have shown that certain things, such as telephone reminders, more information and better motivation, can help people remember to take their medicines. Adjustment to the dosage of medication that people take can also help – once-daily dosages are associated with better levels of compliance than medications that have to be taken twice or three times daily. Education systems that help people remember and also help people understand reasons why they are taking BP-lowering drugs can also be effective. There are also special containers available from pharmacies to remind you when to take your tablets and to show you if you have forgotten to take your day’s dose.
If you are finding it difficult to take your medicines or are forgetting to take them, recognize that this is an important issue that should be discussed with your doctor or practice nurse. Often people fail to take their treatment because they suffer side effects. There are alternative treatments available and, if you feel you can’t tolerate a particular type of BP-lowering drug, you should discuss the alternatives.
When I am attending my general practice for follow-up care for my high BP what should I expect?
Suggested guidelines for doctors for follow-up and control of high BP follow a graded approach in terms of the frequency of visits until your BP is fully controlled. Initially you should expect to be asked to attend monthly visits for any adjustment of drug treatment until two or more BP readings are below the target treatment level. If you’ve been recently diagnosed, you may be asked to return once a month until your BP readings are stabilized, you are tolerating your BP-lowering drugs and you have no outstanding worries. For people with very high initial BP readings, or with a history of intolerance to drugs, or with other cardiovascular risk factors or target organ damage, a 3-monthly review interval is recommended. For those people who are well controlled on stable BP medication and with a stable BP reading, 6-monthly visits are usually recommended.
Will I have to undergo any more tests at follow-up other than BP measurements?
Generally speaking two-thirds of people with high BP require two different drugs to adequately control their BP (and reach their treatment target level). It usually takes a minimum of 3 months to make sure that people have stable BP readings, are comfortable taking their BP medication and suffering no side effects. Blood test monitoring is often recommended to assess kidney function in people taking ACE inhibitors and diuretics. In addition, other conditions such as high cholesterol readings may also be monitored by regular blood tests.
Does it make any difference who’s involved in my follow-up care?
There is no strong evidence to suggest that any one professional group is superior to another in terms of managing a long-term follow-up of high BP. Nurses, pharmacists and physician/pharmacist teams have all been evaluated. All professional groups have produced equivalent outcomes in terms of BP control. Many practices now delegate routine hypertension monitoring to practice nurses and most people find this method of delivering ongoing care entirely satisfactory.
Is there any evidence whether hospital outpatient clinics or general practice is the best place to have my BP monitored and followed up?
There is no firm evidence to suggest either general practice or outpatient clinics are the best place to have your BP followed up and monitored. The main issue concerning BP monitoring is that there is a regular review and recall system ensuring that your BP is monitored consistently over time and that your medication review is regularly checked. This involves you being registered as a person with hypertension who is then contacted regularly to make sure that monitoring and review takes place. Whether this is done in the hospital outpatient department or in a general practice is immaterial. As high BP is such a common condition, most care is delivered in the community through general practice.
I’ve been told that I’ve got difficult to control BP. What makes it difficult?
Failure to control BP to target treatment levels is relatively common. It has been estimated that up to 40% of people fail to meet treatment levels (this proportion varies depending on the target level quoted).
There are several factors associated with poorly controlled BP that need to be addressed in a systematic way by the doctor or nurse who is managing your care.
• Inaccurate BP measurement
• White coat hypertension
• Insufficient treatment
• Not sticking to the BP-lowering drugs
• Medications that interact with BP-lowering drugs such as non-steroidal anti-inflammatory drugs (NSAIDs), and
• Other conditions and diseases that make BP more difficult to control.
If you have poorly controlled BP, your GP should systematically rule out these factors as a cause for it. This often requires additional blood tests and modification of your antihypertensive medication.
I have been on some other drugs that the doctor said had caused an increase in my BP. Which drugs cause this?
The following substances may be associated with an increase in BP:
• Corticosteroid tablets
• Excessive alcohol consumption
• Amphetamines, particularly in the form of appetite suppressants
• Excessive caffeine intake, usually in the form of coffee or tea
• Non-steroidal anti-inflammatory drugs
• Oral contraceptives
• Sodium-containing medications, particularly antacids used in the treatment of heartburn, and finally
• Illicit drugs such as cocaine.
You need to be vigilant to make sure that you are not taking drugs that antagonize the effects of BP-lowering drugs. This is another reason why you should attend for regular review so that your medications and BP can be checked regularly.
My doctor is referring me to a specialist as he says I have secondary hypertension. Why?
Secondary hypertension accounts for less than 1% of the cases of high BP. The main causes relate to kidney or hormonal disorders. If you have poorly controlled high BP and the common causes of uncontrolled high BP have been ruled out, you will be referred to a hospital specialist so that investigations can rule out or detect rare, secondary causes of hypertension.