Ask a Doc: High Blood Pressure

• By:  Emily Laubham
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High blood pressure, or hypertension, is extremely common; nearly half of adults in the U.S. have it. Due to the pressure it puts on the arteries and heart, it contributes to other disease processes like stroke, heart attack and kidney disease.

Developing hypertension is often a silent process that happens over many years. It is largely symptomless, so it is difficult to catch if people don’t proactively get their blood pressure checked. Those who are diagnosed as hypertensive may feel a perceived lack of agency or concern that this means a lifetime of needing medication. However, Dr. Raghu Tadikamalla, a certified specialist in clinical hypertension, emphasizes that lifestyle changes like diet and exercise can often make a big difference. He took time to discuss the basics of high blood pressure, what people can do to take control of their health, and the resources provided by the Allegheny Health Network (AHN) Comprehensive Hypertension Center.

The basics of high blood pressure

Emily Laubham: What are the current recommendations around blood pressure?

Dr. Raghu Tadikamalla: The definition of hypertension is any number above 130/80 mmHg. When the systolic blood pressure (the top number) is 120 or above, that is seen as evidence that health may not be optimal. So, ideally, you want to be under that.

Emily Laubham: How often should someone be screened for hypertension?

Dr. Raghu Tadikamalla: For young people with no risk factors, once a year is reasonable. If you’re at a higher risk, you should have it checked more frequently.

Although it’s been impacted by COVID-19, one thing we’ve been focused on is increasing screening for at-risk populations by offering screening in places like farmer’s markets, churches, and at community events.

I’ll add that blood pressure is a valuable health metric to track in general. Unlike many other diagnoses, you can quantitate high blood pressure. You can follow it on a scale and it gives you insights into how well someone’s health is being managed. If someone has high blood pressure, we can monitor the impact of dietary changes, exercise, and medication when necessary, by tracking improvements in their blood pressure over a period of time.

Risk factors

Emily Laubham: What are the risk factors or potential causes of high blood pressure?

Dr. Raghu Tadikamalla: The vast majority of hypertension in this country is what we call primary or essential hypertension. I generally call it “lifestyle hypertension,” because it is so associated with a lack of physical activity, a diet high in salt and processed foods and low in potassium, and being overweight or obese. Secondary hypertension, which is due to another diagnosable medical cause, is less common. Other risk factors to include are family history, advanced age, smoking, and drinking too much (more than two drinks a day for men, one for women).

Emily Laubham: I read that roughly 75% of Black men and women develop hypertension by age 55 compared to 54.5% of white men and 40% of white women. What’s behind that disparity?

Dr. Raghu Tadikamalla: Multiple factors — some may have a genetic component, but much of it is about differences in access to healthy foods and environments or situations that make it easy to exercise. For example, when you look at food deserts — meaning an area that doesn’t have nearby grocery stores or options for fresh produce and nutritious food choices — you see that this impacts a higher percentage of the Black population.

Emily Laubham: Is there a connection between hypertension and sleep?

Dr. Raghu Tadikamalla: The condition that most people associate with hypertension is obstructive sleep apnea, but really any sleep disturbances, including from insomnia or lifestyle factors, can be associated with high blood pressure. For example, shift workers and people who work overnight have a higher risk of hypertension.

Prevention and treatment of high blood pressure

Emily Laubham: What are the first-line efforts in terms of prevention and treatment?

Dr. Raghu Tadikamalla: For prevention, and even for treatment in some cases, we want to start with prescribed lifestyle changes. Diet is key. We never like to get into a situation where we’re fighting food with medicine, because it can take quite a lot of medication to offset the impact of food if it’s bad enough.

That’s why we have dietitians with the AHN Comprehensive Hypertension Center who discuss different eating patterns with patients, go over the basics like sodium intake, provide guidance on reading nutrition labels, and even share simple meal recipes. We also work with AHN’s Healthy Food Centers to help people with dietary evaluations and provide access to healthier, low-sodium food.

Emily Laubham: You mentioned reading labels — why is label literacy so important?

Dr. Raghu Tadikamalla: Sodium is hidden everywhere, which means you really need to check the label for everything you eat. For example, I recently had a patient who was retaining a lot of fluid and still had high blood pressure despite dietary changes. At one point, he told me he’d been eating a lot of cottage cheese to stay healthy, but cottage cheese is loaded with sodium. That’s not something that’s commonly known; even some health professionals aren’t aware, but if you look carefully at the label, you’ll see that it’s high in sodium. Bread is another example — you might not think of bread as being salty, but many slices of bread have up to 100 mg of sodium to keep them fresh on the shelf.

People always ask me what the best diet is. I say — well, what’s your shoe size? Would you recommend that same shoe size to all of your friends and family? Everyone is different! We’re not just based on genetics, we also have different tastes and cultural preferences. Certain food patterns may work for one person and not for another, so we have to provide some leeway when we talk about diet while still paying attention to the basics like sodium content.

The Comprehensive Hypertension Center

Emily Laubham: What can someone expect if they come to the AHN Comprehensive Hypertension Center?

Dr. Raghu Tadikamalla: We see patients with hypertension and resistant hypertension, which is hypertension that requires multiple medications to control. So, we’ll first test to see which kind we’re dealing with, usually through blood work and imaging studies. If we diagnose something abnormal, we can treat that directly, but even those patients tend to also have primary hypertension that needs to be treated as well.

Many patients who come to our center are dealing with resistant hypertension that requires a high number of meds, or they may have medication intolerances that are creating challenges. One of the good things about hypertension treatment at this point is that we have many classes of medicine, with multiple medicines in each class, to consider. We have options.

Emily Laubham: What can the center do differently for patients as opposed to what they would get from a primary care provider?

Dr. Raghu Tadikamalla: We have more experience with these medicines, especially some of those that are less commonly used, including their potential side effects and how they interact with other medical conditions. We also have more experience with different patient profiles. All in all, hypertension is something we deal with on a daily basis, so some of the subtleties of diagnosing and treating it are more salient to us.

Our support staff is extremely good, too. They’re familiar with problems that might arise with treatments and questions that could come up, and again, it’s part of a comprehensive approach.

Emily Laubham: What is the significance of the American Heart Association (AHA) Comprehensive Hypertension certification?

Dr. Raghu Tadikamalla: Two AHN hospitals are now certified. West Penn Hospital’s hypertension clinic was the first in western Pennsylvania to be AHA-certified and one of only 25 certified nationally. Allegheny General Hospital also received certification. Basically, this shows that we meet the high standards AHA sets for both technical capabilities and our involvement in research, academics, and providing comprehensive care.

Dr. Tadikamalla shares his approach to caring for patients

Myths and misunderstandings

Emily Laubham: Are there myths or misunderstandings about high blood pressure you’d like to clear up?

Dr. Raghu Tadikamalla: Many misunderstandings have been addressed through the years. For instance, I think it’s better understood now that hypertension is a “silent killer,” and you need to get screened because there are no symptoms.

But it can still be hard to convince people that they need to go on medication even if they feel well. One common misperception is that people think that once they go on meds, they will need to be on them forever. That’s not necessarily the case — many patients who change lifestyles are able to decrease their medication burden, or go off medication completely. One of my favorite things to do is remove medications.

Something people may not know is that certain medicines can contribute to hypertension, including NSAIDS like ibuprofen and naproxen that are found in commonly used pain relievers. These meds can significantly increase blood pressure and cause fluid retention. I’ve seen a lot of patients come in with swelling in the legs and high blood pressure and it turns out they are taking high doses of these medicines.

Some people perceive that stress increases blood pressure. That’s true to some extent, but most of the impact comes from secondary effects of stress, meaning things like not eating well, not exercising, or missing medication.

Emily Laubham: Are there also challenges from the clinical side?

Dr. Raghu Tadikamalla: If you think about gaps in care, the first challenge is that not everyone with hypertension is aware of it. But even with people who are aware, not everyone is treated. There is some inertia on the clinical side. Let’s say a patient’s blood pressure is 145/85 when they come in for a check-up, but they say, “that’s just because I had a stressful drive,” or, “I haven’t been eating right recently.” Based on that, some doctors might tell the patient to come back in three month or six months. Well, if it turns out the high blood pressure wasn’t temporary, that delay in treatment means several months of potential damage to the heart, kidneys, and brain.

Patients and clinicians alike need to take the numbers seriously and be aggressive. That doesn’t necessarily mean treating everyone right away with medication, but it does mean following up quickly, having people check blood pressure at home to see if it remains elevated, strongly encouraging lifestyle modifications, and taking action with one or more medicines if necessary to get that person’s blood pressure under control. We practice evidence-based medicine, and there is plenty of evidence to show us what will work in different situations.

Emily Laubham: With or without medication, I know we keep coming back to the importance of lifestyle. But change is hard, and I’d imagine some people feel daunted by the prospect of shifting diet or fitting in more exercise or losing weight. How do you motivate people?

Dr. Raghu Tadikamalla: First, we need to help people recognize the seriousness of this condition. It is one of the primary drivers of heart attacks and stroke, which are the most common causes of death in this country. But I also emphasize to people that studies show there can be amazing improvement in blood pressure, cholesterol, and longevity even just from losing 5% of your extra weight. And these changes will impact other factors like mood, energy level, and how well they sleep. All in all, it’s about encouraging them. Small, consistent changes can make an enormous difference.