High blood pressure (Hypertension): Causes, symptoms and treatment

ACC/AHA guidelines

What does systolic and diastolic blood pressure stand for?

The systolic pressure describes the pressure inside the arteries during heart contraction, when blood leaves the heart cavity into the circulation. The diastolic pressure, on the other hand, describes the pressure values during heart relaxation. The systolic value is always higher than the diastolic one.

Why was a blood pressure of 100 plus age still considered normal in the past, but today count much lower values?

In former days, in Germany, physicians used a mathematical formula to calculate each person´s individual blood pressure goal. All you had to do is take “100” and add a person´s age. Yet, practical experience shows, that goal values calculated turn out to be too high, especially for older people.

For example, in a 70-year-old, according to the old formula, systolic (upper) blood pressure levels up to 170 mmHg still were within the normal range. Values as high as these are nowadays known to the risk of heart attacks, strokes and other diseases in the long term.

Do I have high blood pressure even if only one pressure level is increased?

Even if only one of the two measured blood pressure levels are elevated, formally you suffer from high blood pressure. The first, systolic value is often above the standard range, especially in older people, usually due to atherosclerosis, stiffening and narrowing of the large arteries or aorta. If only this first value is increased and the second, diastolic value is normal, it must still be treated.

Do blood pressure values change within one day?

Yes, blood pressure typically fluctuates over the 24-hour course of the day. During the day, the values are generally higher than at night. Daily activities and strains also have an impact on blood pressure.

Many functions of our body vary depending on the time of day, including blood pressure. Physicians speak of a circadian rhythm. For example, at night, blood pressure in healthy people decreases by 10-15%. A 24-hour measurement can show this. It provides information on how blood pressure behaves during day and night.

In the total average over 24 hours, values up to 130 / 80 mmHg are normal. During the waking phase, the limit values are slightly higher; a daily average up to 135 / 85 mmHg is allowed. This corresponds roughly to the otherwise specified 140 / 90 mmHg of a single measurement.

High blood pressure in the morning: stress and internal clock

The probability of suffering from a heart attack is highest in the early morning hours. This may be due to the fact, that blood pressure reaches its highest levels in the morning hours.

Night and day rhythm

Blood pressure follows a so-called circadian rhythm; it fluctuates naturally throughout the day. In the morning after awakening, it reaches its highest values, at night during sleep the lowest. Therefore, pressure lowering medications are often taken in the morning. Depending on your individual 24-hour daily course, your doctor will adjust your medication.

Impulse generator of our night-and-day fluctuations are sunlight and chemical changes in our brain. A specialized area, the suprachiasmatic nucleus, adapts to this rhythm and regulates various body functions and hormone balances depending on the time of day including the production of melatonin and cortisol, a stress hormone.

The two opponent of our brain, sympathic and parasympathic nervous system, also change their activity level with the night-and-day rhythm. The sympathetic nerves fuel “activity” and "escape" and the parasympathetic ones are responsible for “relaxation” and “digestion”. Accordingly, the sympathetic part is more active during the day, while the parasympathetic takes over at night.

Healthy: lower blood pressure at night

The nightly drop in blood pressure is called “dipping”. Thus, physicians differentiate between “dippers” and “non-dippers”. Dipping of blood pressure during sleep is important, because high pressure at this time is linked to increased disease burden and mortality.

Normally, blood pressure at night lies about 10-20% lower than the daily values. Standard values in healthy people should not exceed 135/80 mmHg during the day and 120/70 mmHg at night. Physicians can control the values in a 24-hour blood pressure measurement.

If your blood pressure drops only little or not at all at night, a secondary hypertension may be present with an underlying disease like sleep apnoea or diabetes with kidney damage causing the increased night-time values.

Stress and heart attacks in the morning

Heart attacks occur more frequently in the early morning hours. Among other things, this is due to increased blood pressure and faster pulse rate at this time.

Scientists at the University of Pennsylvania in the US have been looking into whether the increase in blood pressure in the morning is due to morning stress or due to the internal clock. They found out, that both is true: on the one hand, blood tests showed a strong increase in stress hormones with rising stress stimuli in the morning. At the same time, an inner clock polished for stress and high blood pressure reacts even more strongly.

Important: Blood pressure checks

In order to control your blood pressure during day and night-time, physicians usually perform a long-term measurement over 24 hours. It's a little troublesome because the arm cuff inflates every quarter or half hour, but it provides important insights into whether you are blood pressure is well-adjusted or whether you may need more medication during day or evening time.

Is blood pressure lower in summer than in winter?

In fact, yes. In summertime, when outside temperatures rise, high heat can lead to expanded blood vessels and your blood pressure can drop. Depending on the level of decrease, symptoms like dizziness, fatigue and weakness may occur. If systolic values drop below 110 mmHg, especially when several antihypertensive drugs are administered, individual preparations may be reduced in dose. However, this should always be done in consultation with the doctor.

Is low blood pressure always healthy?

Low blood pressure with values below 105 and 65 mmHg may have its own adverse health effects. Low blood pressure can particularly be dangerous in the elderly, when blood pressure drops too quickly. Dizziness, circulatory problems and falls can result. Even in pregnant women, a tight and low blood pressure can have an unfavourable effect on the care of the unborn child.

In addition, there are some medical diseases that can cause low blood pressure like thyroid dysfunction, dysfunction of the adrenal cortex, anaemia as well as heart valve disease and heart failure.

Is high blood pressure increasing in the population?

In Germany, an increase in overweight has already been observed in children and adolescents, so that it cannot be ruled out that the frequency of high blood pressure will also increase.

Still stable numbers, but increases still possible

High blood pressure (hypertension) is one of the leading risk factors for cardiovascular diseases. Blood pressure increases with age, overweight, alcohol, stress and diabetes mellitus, for example.

Although the population is getting older and the number of overweight (obese) people is increasing, the group of people with high blood pressure seems to be stable in size. At least, this is what evaluations of population-based epidemiological studies between 1994 and 2012 have shown.

Even if the incidence of hypertension has thus been described as constant since the 1980s, a future growth does not seem to be ruled out. On the one hand, the population structure continues to age; on the other hand, the proportion of obese people, especially children, is also continuing to increase. And both factors can lead to high blood pressure.

Signs and Symptoms

How do I notice if I have high blood pressure?

Many people with high blood pressure do not notice it at all or even feel very comfortable with it. They feel strong and fit. But high blood pressure can also be accompanied by symptoms.

Careful with following alarm signals

Do not forget to check your blood pressure if one of the following symptoms occurs:

• Headache
• Dizziness
• Palpitations
• Break out into a sweat
• Nose bleeds
• Shortness of breath
• constant state of weakness
• tingling in hands or feet

Especially in the early morning hours, when blood pressure is at its highest, symptoms may occur. Still, these symptoms are the exception. Many people do not notice their increased blood pressure. Make sure to get your blood pressure checked regularly, if you already suffer from hypertension. You can have it measured by your medical doctor (standard examine) or also at a pharmacy.

How many people have high blood pressure without noticing it?

Many people do not know that they have high blood pressure. The frequency of unrecognized cases is even higher in men than in women. Studies have shown that there are about 35% undetected cases of high blood pressure among women. Among men, the number reaches 45%. One reason could be that men may be even more negligent than women when it comes to health issues.

Constant headaches: Do I have high blood pressure?

High blood pressure does indeed often cause headaches. On the other hand, not every headache is due to hypertension. There is a big variety of headache types, all with different triggers and sources.

Over 200 types of headache

Headaches can have very different causes and triggers. The most common type is the so-called tension headache. It is often caused by tension in the back, shoulder and neck area, which activates pain nerve fibres. The second most common form of headache is due to migraine.

Nevertheless, unclear headaches can also be caused by a blood pressure problem. Although hypertension itself often causes no or little discomfort, a longstanding or quick and dramatic increase in blood pressure does typically lead to headache problems.

Dizziness and headache after physical exertion

Headache may become noticeable after physical exertion. Acute increases in blood pressure are often accompanied by a feeling of dizziness, possibly even shortness of breath or a tightness in the chest. In such cases, treatment by a doctor is urgently required.

If you suffer from unclear headaches, especially after physical exertion, you should have your values checked. A long-term measurement may be helpful.

Can visual disturbances indicate high blood pressure?

Vision disturbances can occur acutely in the context of very high blood pressure or as a late symptom of longstanding hypertension since permanently high blood pressure damages the retinal vessels and nerves. Also, the risk of blood clots forming in eye can be increased.

So-called glaucoma is also more common in cases of high blood pressure. This is characterised by high intraocular pressure, which also damages the retina and optic nerve and can lead to acute visual impairment. And finally, also a stroke due to high blood pressure can lead to visual impairment.

What is a hypertensive crisis?

A hypertensive crisis goes along with very high blood pressure, usually above 180/120mmHg, whereas upper limits of values vary among the different experts and countries. Physicians differentiate between a hypertensive emergency and hypertensive urgency.

In a hypertensive emergency, the blood pressure increase impairs the circulation of the heart, brain or other organs, symptoms include chest pain, dyspnoea, nausea or vomiting, severe headache or even stroke or cerebral bleeding. It is an emergency and requires rapid treatment in order to prevent organ damage. In a hypertensive crisis, on the other hand, patients have high blood pressure but do not yet suffer from symptoms or organ damage.

Diagnosis and Blood Pressure Measurement

In most cases, blood pressure is measured with the known pressure cuff around the upper arm. However, a long-term measurement over 24 hours is also available. Many patients additionally have own blood pressure devices at home. In the following text you will find detailed information on how and when to check your blood pressure and how to deal with everyday problems in hypertension.

How do you detect and diagnose high blood pressure?

It is not so easy to track down people with hypertension. Often patients have no symptoms and therefore do not measure their blood pressure. 20% of people with hypertension are in fact unaware of their condition. Thus, the first step is to start measuring the blood pressure. If control shows elevated values, further investigations must be carried out.

Blood pressure measurement at the doctor and at home

There are different ways how to measure blood pressure and various types of devices to do so. This includes blood pressure control at home, at your doctor´s office or in the context of a 24-hours blood pressure measurement test. The standard procedure at your MDs office includes a manual test, where a cuff is placed around your right (or left) arm, which is inflated with air. When draining the air, your physician or nurse uses a stethoscope placed in your elbow and listens for pulse sounds indicating the height of your systolic (first) and diastolic (second) blood pressure.

In addition to manual measurements, there are automatic devices on the market that can be applied to the upper arm or wrist. They enable you to measure your blood pressure at home. The cuff press is triggered at the push of a button and the pressure is then released automatically. In most cases, systolic (upper) value, diastolic (lower) value and pulse are displayed. Home measurement with automatic devices may be beneficial for people with so-called white coat hypertension, high blood pressure due to fear in the physician´s office.

Is a single blood pressure measurement sufficient?

One single measurement is not enough. It can always be false elevated, too many factors influence your blood pressure. In addition, the pressure fluctuates during day- and night-time. Therefore, several different measurements are generally recommended on at least three different days.

24-hour measurement and stress-test ECG

If single measurements repeatedly show increased values, a 24-hour long-term measurement is usually carried out, in which values are automatically checked every half-hour or even quarterly for one day. A stress ECG, in which pressure is regularly measured under defined physical exertion, can also provide further clues for the diagnosis of hypertension.

Can I ask my doctor to measure blood pressure?

Of course, and you should do so regularly. It is important to regularly check blood pressure in younger people in order to detect high blood pressure at an early stage. Precautionary examinations are also suitable for controlling blood pressure. In Germany, at the age of 35, men and women are entitled to a health check every two years. This screening is used for the early detection of cardiovascular diseases and kidney diseases.

At the doctor's blood pressure was too high – how can I be sure that this is also the case in everyday life?

If the blood pressure at the doctor was too high and no high blood pressure is known so far, a repeat measurement should be made a little later. If the values are increased even then, a long-term blood pressure measurement over 24 hours often follows for safety.

What, if my blood pressure is higher at home than at the doctor's?

A so-called "masked hypertension" is rare, but possible. “Masked” stands for “hidden" from the doctor. It can be an indication of increased disease risks of the cardiovascular system. This is why physicians keep checking for it.

When and how often should I measure my blood pressure?

You should talk to your physician, what he or she recommends. It may be useful to measure twice a day in the morning and in the evening. Measuring more than three to four times per day is usually not useful.

It is important to measure blood pressure at about the same time under the same conditions. Values vary for example with physical activity or house cleaning. Also, coffee and alcohol influence the measurement. Before checking your blood pressure, make sure to rest for a few minutes.

Which arm should blood pressure be measured on?

Your blood pressure should be measured a few times on both arms, because values may differ. After that, you should measure your blood pressure on the side that supplied higher values. So goes the theory. In everyday life, this may be practiced differently.

What to do, if there is a side difference in values

In general, if there is a slight difference in left and right arm measurements, experts advice to always measure the side that gives the higher values. Larger differences (more than 10 - 20 mmHg), on the contrary, may be due to vascular diseases and need further tests and investigation.

How do I get a good blood pressure device?

In Germany, you can buy devices in the pharmacy or in medical centres. Be careful with devices from supermarkets or the Internet since you cannot check their quality. According to the German consumer journal “Stiftung Warentest”, incorrect results can be expected in one out of four to six measurements.

Also make sure that the device meets the latest standards. There are devices that can store up to 200 values to document the course of blood pressure. If the device has a USB interface, it is easier to report your measurements to the doctor's office.

Seal of the “German High-Pressure-League”

One big technical challenge play measurement in accompany rhythm disturbances like as atrial fibrillation. The German High-Pressure-League regularly checks various devices for quality and measurement accuracy and awards test seals. For a device to receive a test seal of the German High-Pressure-League, it is tested on 95 test subjects. Blood pressure is automatically measured, and results are then re-checked manually by two independent, well-trained persons. On the website of the German High-Pressure-League you will find a long list of devices that have received a seal of approval from the German High-Pressure League since 2001.

Blood pressure measurement in arrhythmia

If you have cardiac arrhythmias, it can be more difficult to measure your blood pressure, because it may vary from heartbeat to heartbeat. In the case of atrial fibrillation, blood pressure should be measured three times and an average value should be calculated from these values. There are devices where you can select this automatically.

Upper arm and wrist equipment

In principle, you can choose between upper arm and wrist devices. Different sizes are offered for the cuffs for the upper arm. The circumference should match your individual arm. Too narrow or wide cuffs lead to false measurement values. When self-checking blood pressure at home, it is important to place the cuff at heart or chest level. This is usually the case with automatic upper arm devices. With wrist cuffs you must pay a little more attention and make sure, your wrist is at the same level as your heart is. A height above or below your heart distorts the values otherwise.

Should I keep a blood pressure diary?

The documentation of blood pressure values during self-measurement at home is advantageous, because this allows your doctor to quickly get an overview of the development of blood pressure under current treatment. An increase in blood pressure can also be detected at an early stage. You can see which measures or behavioural changes have a positive effect on your blood pressure and which are more likely to increase the pressure. However, observation over longer periods of time is generally recommended.

How does a 24-hours measurement test work?

Blood pressure can be recorded with a portable recording device for more than 24 hours. The frequent measurements have the advantage to not only provide a single value.

Blood pressure measurement over 24 hours at home

In Germany, a 24-hour measurement test can be performed by various doctors. These include family doctors, internists, cardiologists and many others. You usually must come to practice in the morning to pick up the device and bring it back the following day. The blood pressure cuff and measuring computer are your companions for one day and one night.

The blood pressure device is provided by a medical assistant or medical specialist. They attach the measuring cuff to one of your upper arms, usually it is the left one. A cable leads around your shoulders, behind your neck to the other side of your body. A small computer is attached to the end of the cable to carry out the measurements and save the results. Its case is attached to your body or hip.

Measurements every 15 to 30 minutes

The device usually measures every 15 minutes during the day, and every 30 minutes at night. This gives an overall good picture of your blood pressure behaviour. Such a long-term measurement is useful for monitoring the success of hypertensive treatment and for detecting blood pressure spikes at otherwise normal values.

Also, typical fluctuations during night and daytime (circadian rhythm) can be recorded. And finally, the so-called “white coat hypertension” can be ruled out (rising blood pressure due to excitement when visiting the doctor).

Newly discovered high blood pressure: What blood values need to be determined?

In the case of a newly discovered high blood pressure, the following blood values must be determined:

• Cholesterol and triglycerides levels
• Kidney values (creatinine)
• Electrolytes (sodium and potassium)
• Blood sugar
• Uric acid
• Urinary protein
• Urinary glucose (sugar)
• other special urinary components

Further diagnostics: from ECG to angiography

In order to trace the causes of high blood pressure and in order to exclude other diseases as underlying causes, the following examinations are commonly checked (or at least one of them):

Electrocardiogram (ECG)

Almost everyone knows the ECG. It shows the electrical currents of the heart. For this purpose, electrodes are glued to the chest and then measured for a while. The doctor can see on an ECG, whether the heart may already be damaged by high blood pressure or whether there are circulatory problems.

Echo (echocardiography)

The echocardiogram is an ultrasound of the heart. The diagnostic technique is like that used for ultrasound examinations of the abdomen or during pregnancies. With an echocardiogram you can examine and visually see the heart, its muscle, walls and valves.

Treatment

In most cases, the treatment of high blood pressure is based on taking medication. But lifestyle also has an important impact. Read more about treatment options including self-help, medicines, alternative therapy, nutrition and impact of lifestyle changes in the following pages.

Can high blood pressure improve on its own?

Under certain circumstances, elevated blood pressure values may drop again even without drug therapy. But usually this does not happen without any effort: most times it requires consistent changes in lifestyle.

Recommendations of the European Society of Cardiology

According to the guidelines of the European Society of Cardiology (ESC) from 2018, the following lifestyle measures can improve blood pressure values, delay the onset of hypertension and postpone the start of drug therapy:

• Salt restriction
• Moderate alcohol consumption
• Nutrition high in vegetables and fruits as well as whole grain products, fish and olive oil (Mediterranean diet)
• Weight reduction
• Regular physical exertion
• Smoking cessation

Of course, it's never easy to change your lifestyle and keep up your new habits.

Little salt and alcohol, lots of vegetables

Excessive salt consumption is harmless with regards to your blood pressure. Excessive means > 5 g sodium per day, which equals one small teaspoon of salt. Especially the systolic (first) blood pressure value increases with high salt intake. In contrast, with low sodium consumption, your numbers improve. In patients with hypertension, the blood pressure decreased by 5.4 mmHg points (systolic, first value) and 2.8 mmHg points respectively (diastolic, second value) alone with salt reduction.

Alcohol also increases your pressure in the vascular system, particularly “binge” drinking (sporadic excessive consumption). Conversely, moderate consumption with alcohol-free days stabilizes your values.

In addition to salt intake and alcohol consumption, nutrition plays a role in the development and therapy of hypertension. Experts recommend a balanced and healthy diet with large amounts of vegetables, fresh fruit, low-fat dairy products, wholemeal products, fish and olive oil.

Weight and physical activity

It's not easy to lose weight. However, a few pounds or kilograms less have a positive effect on your blood pressure and overall health. According to guidelines, a weight reduction of about 5 kilograms already pays off for people with high blood pressure. The systolic value decreased by 4.4 mmHg and diastolic one by around 3.6 mmHg. Reducing weight is always recommended to patients with obesity and high blood pressure.

Irrespective of your weight, physical activity is recommended to everybody. For people with high blood pressure, regular endurance sports can reduce the average values by 8.3 mmHg (systolic) and 5.2 mmHg (diastolic) respectively.

Experts advice 30 minutes of moderate training on five to seven days a week, for example. Also, healthy people should exercise. The overall aim here is to create 300 minutes of moderate or 150 minutes of intensive physical exertion per week. The most difficult part is often just to start.

What can I do myself to improve my blood pressure?

The first and most important measure in the treatment of high blood pressure is "lifestyle adjustment". This includes above all a lot of exercise, a healthy diet, a reduction in overweight and, of course, not smoking.

Change of lifestyle and everyday life

Taking medication is much more convenient and easier than changing habits. Even though medications are one cornerstone of treating high blood pressure, checking and if needed adjusting your personal lifestyle is also very important.

One big problem of high blood pressure is that is does not hurt. So, why bother if you don't feel anything? But, the risk of developing atherosclerosis, heart problems or even heart attacks or a stroke in the long run is still existent.

How low should blood pressure values be lowered?

As a rule of thumb: The blood pressure values should be below 140 mmHg with the upper value (systolic) and below 90 mmHg with the lower value (diastolic), i.e. below 140/90 mmHg. Even lower target values apply to people with kidney diseases. In these cases, the systolic and diastolic pressure should be 10 mmHg lower or even lower to prevent further damage to the kidneys.

What is the benefit of lowering elevated blood pressure?

Lowering blood pressure can reduce various disease risks since permanently increased pressure damages the arteries and organs. Damage to the inner lining of the arteries causes arteriosclerosis; the most affected organs are heart, kidneys and eyes.

Lowering the systolic blood pressure (upper value) by only 10 mmHg means:

• A risk reduction of heart attack by 11%
• A risk reduction of stroke by 17%
• A risk reduction of developing heart failure by 15%

Unfortunately, elevated blood pressure is often discovered not before organ damage has already occurred and symptoms have subsequently developed. Even small drops in blood pressure are helpful whereas even slight increases in blood pressure are associated with increasing disease risks.

Does elevated blood pressure still have to be treated in older people?

Yes, older people also benefit from lowering their blood pressure if it is too high. For them, too, the treatment of high pressure can prevent serious secondary diseases such as heart attacks or strokes.

Age is therefore not an argument against treating high blood pressure. However, it is important to lower blood pressure gently to avoid side effects like fatigue, dizziness and reduced performance.

Which medicines and drug classes treat high blood pressure?

There are many different types and groups of blood pressure medications, all of which are generally useful. In addition to the type of drug, it is also important to decide whether you take only one or a combination of antihypertensive medications. Quite some people do need combination treatment for high blood pressure, meaning one, two or even three or more types of substances.

These are common types of medicines, used to lower high blood pressure:

• Beta blockers: Beta blockers reduce your heart rate, calm down your heart muscle and lower blood pressure.
• Diuretics: Diuretics increase the excretion of fluids via your kidneys and decrease blood pressure.
• Calcium antagonists: They are also called calcium channel blockers. They directly reduce the tension of the vessel wall. Vessels become more flexible and dilate and the blood pressure drops.
• ACE inhibitors: ACE inhibitors act on the hormone system, which significantly influences the blood pressure regulation through the so-called renin-angiotensin system. ACE inhibitors widen vessels indirectly and decrease pressure. In addition, they have positive effects on your heart muscle and your kidneys.
• Angiotensin receptor antagonists: Angiotensin receptor antagonists (in German also “sartanes”) have a similar effect as do ACE inhibitors with a little less side effects.

How long should I take antihypertensive medication?

Antihypertensive medications do not eliminate the cause of hypertension. Usually, you must take your medication long-term. If you truly manage to change your lifestyle by increasing the amount of physical activity or losing weight if you are obese, you may be able to reduce or even discontinue your medication.

Should I take tablets for high blood pressure if I feel healthy?

If you have been diagnosed with high blood pressure (hypertension) and require medical treatment, taking your medication is important to protect you from long-term damage to the cardiovascular system caused by high blood pressure.

Do antihypertensives also help against strokes?

According to experts, any blood pressure above 140 mmHg (upper value) or 90 mmHg (lower value) should be treated. If you have diabetes, the threshold value is even 130/80 mmHg, because there is an increased risk of stroke anyway. Which of the numerous drugs you take to lower your blood pressure, in general, does not matter much. As far as the risk of stroke is concerned, all drugs are approximately equally effective (exception: the rarely prescribed alpha receptor blockers have a worse effect).

Which blood pressure medications provide the best protection from heart attacks and strokes?

Whether beta blockers, water pills, ACE inhibitors or calcium blockers: they all work similarly well. In any case, an effective reduction in blood pressure usually requires several drugs. Drug combinations are usually more successful than the so-called monotherapy with just one medication.

Do antihypertensive drugs work immediately?

Basically yes. When lowering blood pressure, a distinction is made between emergencies and a long-term approach. Depending on the situation, medication is injected or taken in tablet form.

Blood pressure crises and emergencies

If the blood pressure reaches high levels above 180/120 mmHg, physicians speak of a hypertensive crisis. Headaches, shortness of breath or chest pain can occur concomitantly.

With blood pressure values starting from 230/120 mmHg frequently the blood circulation of the organs is impaired. Heart attacks or even strokes can occur. This is called a hypertensive emergency, which requires an immediate, but careful blood pressure-lowering therapy.

Rapid lowering of blood pressure via veins and tongue

If the blood pressure is severely increased, the patient receives medication in an emergency room or doctor's office that takes immediate effect. In addition to substances administered intravenously (into the vein), there are sprays and capsules to bite on.

These medicines are absorbed very quickly by the mucous membranes inside your mouth and reaches the bloodstream within seconds to minutes. It is important that the blood pressure is checked regularly after medication has been administered.

Permanent lowering of blood pressure with tablets

If the blood pressure must be adjusted in the long-term, this is done with pills and tablets. They help and act as soon as the active substance has reached the bloodstream through your stomach. Which drug is right for you depends on whether you have concomitant diseases like diabetes, heart failure or kidney disease.

Step by step increase reduces side effects

Depending on your initial blood pressure, your doctor will choose one or two active ingredients, sometimes as a combination. It usually takes a few weeks for your medication to change. By increasing the dosage step by step, side effects can be avoided.

If you were to administer antihypertensive drugs in the prescribed maximum dosage right from the start, this would quickly and possibly strongly lower your blood pressure. Yet, it is better and more comfortable, if the circulatory system gets used to the lower blood pressure values with time. Especially for the elderly, a rapid reduction in blood pressure can lead to discomfort including fatigue, weakness, dizziness and loss of performance.

The maximum effect of a blood pressure-lowering medication is usually achieved after 4 to 6 weeks. Then your doctor will decide whether further or other medications are necessary.

My blood pressure medicine is not working. What should I do?

If a medication to lower blood pressure does not work, your doctor can either change the dose, try a different drug, or use a combination of several drugs. It is even possible to combine three, four or more antihypertensive drugs. Finding the optimal medication and the most effective combination for a person is sometimes difficult and takes time. So, don't be too disappointed if you can't lower your blood pressure immediately.

Even if you are taking several medications, it is sometimes not possible to lower your blood pressure sufficiently. It is possible that it is not yet the right combination of active ingredients or the optimal dosage.

Do people get used to blood pressure medication so that it no longer works?

Usually, there is no habituation effect with medication to lower high blood pressure. If medication does not work as well over time as it did at the start of treatment, the hypertension may have worsened.

However, medications may also have too little effect because too little has changed in your lifestyle so far. If, for example, overweight, lack of exercise and stress are not reduced, the medication may not be able to effectively help.

What can you do if your blood pressure is too high in the morning despite antihypertensive treatment?

If you have high blood pressure values in the morning, despite a blood pressure-lowering therapy, it is possible that your medication may not work long enough. Your doctor can adjust the treatment accordingly.

Blood pressure medications with different times of duration

The duration of action of a blood pressure pill varies from drug to drug. It depends on the chemical composition and structure of the drug. Some tablets only need to be taken once a day, others up to three times a day.

However, the interval with which a medicine needs to be taken does not say anything about if it is better or worse than others. Which drug is right for you depends on accompanying diseases like diabetes mellitus, heart failure or kidney failure, for example.

24-hour blood pressure measurement gets things straight

Our blood pressure isn't rigid, it's fluctuating: At night, when we sleep, it reaches lower values than during the day, for example.

If you yourself have measured elevated blood pressure values in the morning, in some cases a long-term blood pressure measurement over 24 hours may be appropriate. It shows your personal blood pressure behaviour and the values can be compared with your own measurements.

You wear the device at home or at work. During the day the blood pressure is measured every 15 minutes and at night every 30 minutes and stored by the device. This is the most objective way to check your values. “Normal" values in a 24-hour measurement lie around 135/85mmHg at daytime and around 120/70mmHg at night-time.

The long-term measurement can also help to adapt the distribution of medication to the course of the day of the blood pressure values if the values fluctuate.

Medications can be adapted

If you have high blood pressure in the morning despite regular medication, talk to your doctor about it in any case. Your physician may check a 24-hour blood pressure test. Many family doctors, general practitioners, internists or cardiologists usually offer this examination. It may be necessary to postpone the time of taking the medication until the evening or to prescribe a medication that is effective for a longer period.

What is better for high blood pressure: a single drug or several in combination?

Whether a single drug or a combination of two or more drugs is more effective in lowering blood pressure must be decided individually. Unlike many other conditions, high blood pressure often benefits from a combination of several drugs. If a single antihypertensive drug or several substances do not work sufficiently, the administration of additional antihypertensive drugs can lead to the desired success.

Combinations have the advantage that the dose of the individual substance is often lower and causes fewer side effects, but the success of the treatment increases.

Do several antihypertensive drugs cause more side effects than one single drug?

Usually, this is not the case, since most times, side effects occur more frequently with higher doses. The combination of different drugs allows lower doses of each medicine and thus less side effects.

Can I take twice the amount of my blood pressures medication if I forgot to take them?

You should not take a double dose if you have forgotten your medication, but just take your next dose, monitor your blood pressure and wait until the next dose is due. By taking a double dose you may run the risk of side effects.

What helps for elderly people who forget taking their blood pressure pills?

Older people, who sometimes must take many tablets due to various illnesses, do not always take their medication reliably for various reasons.

Some seniors think that the drugs do not help, or they fear side effects. Sometimes they simply think that they are taking too many pills. Also, a slight forgetfulness can play a role.

If you simply forget to take your tablets again and again, a drug donor can help. There are digital medicine boxes with alarm functions and clock, to support patients by taking their medication on time.

Do I have to be treated if my blood pressure fluctuates a lot?

Some people have a normal blood pressure at times, but then suddenly (sometimes without any apparent cause) quite high blood pressure values arise. Occasionally, this is associated with complaints such as dizziness, nausea, restlessness, headaches, etc.

Whether treatment is advisable or whether other measures like weight reduction and exercise may be enough is not always easy to answer. A long-term blood pressure measurement can help to assess how often and when blood pressure increases.

Not always constant values

Blood pressure levels can fluctuate. Sometimes they're high, sometimes they're low. Various factors influence the pressure in our circulation. The cardiac output - the amount of blood the heart pumps (usually in one minute) - and the vascular resistance of the blood vessels are the main components that form your blood pressure.

Various factors like hormones, nervous system and fluid balance can influence and change the pressure. It increases during stress and physical exertion and decreases during sleep. Fluctuations to a certain degree are therefore normal and healthy.

In people with high blood pressure (hypertension), the level rises overall, whereby the values continue to change depending on the situation and the day. However, it can be difficult to adjust the medication if the differences between high and low values vary too much.

Special forms with fluctuating pressures

In addition to primary and secondary hypertension, physicians also differentiate between special forms in which blood pressure is elevated only in certain situations. These include isolated practice hypertension, also known as "white coat hypertension". In these cases, patients only ever measure high values in practice, but never at home. A 24-hour blood pressure measurement confirms normal values.

In addition, there are people with isolated outpatient hypertension for whom the measured blood pressure is normal in practice, but too high at home. This is more common among young men. Nicotine consumption, alcohol, stress or diabetes play a role among other things.

Low values when standing, high values when lying down

Some people have high blood pressure and at the same time a so-called orthostatic dysregulation with so-called hypotension, in which the blood pressure drops while standing. This can be caused, for example, by autonomic neuropathy (disease of the autonomic nervous system) or by medication. When standing, affected people becomes dizzy, in severe cases they may pass out.

In these cases, physicians control pressure and pulse while lying down and standing up (directly and after 2 minutes). If your blood pressure fluctuates a lot, it becomes more and more difficult for the physicians to adjust your medication optimally. Older people are often affected by such a problem; their vessels have difficulties regulating tension and pressure.

Can high blood pressure be lowered with acupuncture?

Positive effects of acupuncture on high blood pressure have been proven (Circulation 2007; 115: 3121-3129). Especially in the case of slightly elevated blood pressure values, a treatment attempt can be worthwhile.

For higher blood pressure values, acupuncture can be combined with medication if necessary. However, acupuncture must be performed continuously. Therefore, a considerable amount of time is necessary for this form of treatment.

Can high blood pressure be treated homoeopathically?

If you ask a homeopathic doctor, he or she will say "yes". Yet, there is no proven benefit of homeopathic treatment of hypertension and thus it plays no rule in the “conventional” treatment recommendations of experts and physicians.

Particularly in patients with truly increased blood pressure values, the risk of missing treatment and serious damage to health is simply too great. With slightly elevated blood pressure values, you may be able to try a homeopathic treatment attempt in addition to lifestyle changes. In the case of moderately to severely elevated blood pressure values, a medical treatment is usually unavoidable.

Our opinion and recommendation are that high blood pressure should not be treated "only" with homeopathy, unless stable values below 140 mmHG (upper value) are achieved.

Does yoga help against high blood pressure?

Yoga probably helps with high blood pressure (hypertension), it does not harm in any way. Large studies are still lacking, but smaller ones point out a benefit.

In 2011, a small study was published to investigate the effect of Iyengar Yoga. It had its own independent positive effect on blood pressure. All participants had borderline or slightly elevated blood pressure values, none of them took medication.

One part of the group went to a yoga class for twelve weeks (first twice, then once a week for 70 minutes each), the other part received diet recommendations. At the beginning and after six and twelve weeks, respectively, the effect was monitored in 24-hour blood pressure measurements.

In both groups the values decreased by 3 to 6 mmHg, partly systolic (first value) and partly diastolic (second value), whereby the antihypertensive effect occurred at different times within the twelve-week therapy.

Additional benefit to drugs

Even if you already need medication for hypertension, yoga can help. In 2013, a small study was published in Sweden that examined its influence on blood pressure in 83 people, almost all (92%) of whom took tablets.

One third of the group attended a yoga class here, while the second third did their own daily yoga exercises at home. The third group did not receive any extra therapy. Blood pressure (individual measurements) and questions about quality of life were compared at the end of the study.

The diastolic (second) value improved by 4.4 mmHg for those who practiced yoga alone at home every day. In contrast, no effect was observed for the class participants in this study, but their blood pressure did not deteriorate.

The fact that endurance training is particularly good and important for heart, circulation and blood pressure, is generally known and has been proven several times. Yoga alone also seems to have a positive effect, so give it a try!

Can high blood pressure be treated by bloodletting (phlebotomy)?

Bloodletting (phlebotomy) has been a medical treatment since ancient times. Up until the 19th century, it was regularly used. Later it was found that bloodletting is only effective for very few diseases. For this reason, it has almost completely disappeared from modern medicine.

No proven effect in hypertension

Medical bloodletting is currently experiencing a certain renaissance, especially in the treatment of high blood pressure. Proponents are convinced that it can have a lasting effect. However, bloodletting also has negative health consequences including anaemia, dizziness, weakness and fainting. There is no scientific research that supports this treatment in patients with high blood pressure.

In addition, there are numerous contraindications like pregnancy, physical weakness (children, older people), dehydration, cardiac insufficiency, cardiac arrhythmias, diarrhoea or infections. Therefore, we advise you to refrain from this type of therapy for treating high blood pressure.

Vitamin pills in hypertension

The positive effects of fruit and vegetables are not only due to individual healthy nutrients, but also to the interaction of numerous ingredients, which presumably complement each other in a special way. This means that the artificial supply of vitamins or minerals, for example via vitamin tablets, is not an enough substitute.

The German Nutrition Society recommends eating 600 grams of fruit and vegetables a day. When consumed raw, there is no loss of nutrients due to the preparation. Not a single substance lowers blood pressure, but the interaction of a healthy, balanced diet as a whole - it is worth it!

Exception: If you are not able to take in enough fresh fruit and vegetables for other health issues or reasons, vitamin supplementation may be one way to go. From our point of view, for example, we recommend a special health juice whose effectiveness has been scientifically tested and confirmed.

Everyday life with hypertension

From losing weight, alcohol and salt intake

High blood pressure is usually be treated with medication, and optimal lifestyle. Three factors are decisive here:

• Reduction of overweight
• little salt intake
• little alcohol consumption

Losing weight lowers blood pressure

If you are overweight, this can be one of the causes of your high blood pressure. Therefore, it is important to reduce excess pounds as well as drug therapy. Three aspects are helpful:

• You need a negative energy balance. This means that you should consume more energy than you take in with food.
• You need to be physically active. Sport helps you losing weight and additionally decreases high blood pressure.
• You should switch to a healthy, balanced diet, if not already done.

Moderate consumption of alcohol

Drinking less alcohol can also have a positive effect on blood pressure. You do not necessarily have to live a completely abstinent life. But the amount of alcohol should not exceed 20 grams per day for women and 30 grams per day for men. This is equivalent to 100 ml and 200ml of wine respectively. It is best to drink occasionally, not regularly.

Coffee and sugar

Caffeinated drinks like coffee, black tea and coke can also increase blood pressure. Excessive consumption of animal fats and sugar can also have a negative effect on blood pressure. Yet, moderate intake of these drinks is usually allowed.

Salt intake

Whether salt plays a major role in the development of hypertension is debatable. Yet, German experts recommend not to exceed six grams of table salt per day. People's daily needs are far lower. Two to three grams per day are enough. However, the average consumption amounts up to ten to twelve gram daily.

Keep in mind that all of us consume a lot of hidden cooking salt. Salt is contained in sausages, cured meats or pickled fish, and ready meals also contain a lot of cooking salt. In addition, the salt content of drinks should also be considered.

Liquorice

If you have high blood pressure, you should avoid liquorice. This advises the Federal Association of German Internists, since liquorice itself increases blood pressure through one of its ingredients.

Furthermore, it can also trigger cardiac arrhythmias, which is why people with heart failure should also avoid the sweat black candy. In addition, liquorice may trigger fluid accumulation in the surrounding tissue. Already 100 grams daily can be critical.

Exercise

Physical exercise is known to be good for blood pressure, unless current blood pressure levels are very high (diastolic over 115 mmHg and systolic over 180 mmHg). A further increase in pressure through physical activity can lead to problems. In those cases, it is important to first lower your blood pressure.

If you are uncertain, we recommend talking to your physician. If necessary, he may perform a stress tests to clarify to what extent physical stress is allowed.

Bungee jumping, hang-gliding or parachuting

In these sports, the focus lies rather on physical but more on psychological stress. Stress reactions can increase blood pressure. Head leaps also lead to pressure increases in the head area.

Especially untrained people with high blood pressure are therefore advised against risky sports. Experienced athletes with well-adjusted blood pressure are less at risk. Nevertheless, you should speak about it with your physician.

Mountain climbing

Keep in mind: with mountain climbing and biking you exercise at high altitudes. An increase in blood pressure is to be expected. If you are planning an adventure at high altitudes, you consult your attending physician beforehand.

What is the best diet for high blood pressure?

The German High-Pressure-League - that is an association, which dedicated itself to the fight high blood pressure - summarized the following dietary tips:

• Replace animal fats whenever possible with vegetable fats, use vegetable oils instead of butter and fatty meat.
• Eat fruits and vegetables regularly and abundantly. A total of 1 kilogram per day is recommended.
• Boiled potatoes or fresh fruit juices can also help.
• Eat fish twice a week. Not canned fish, but best sea fish.
• Eat plenty of wholemeal products (instead of white flour).
• If you eat meat, prefer low-fat varieties.
• Drink a lot. Mineral water or vegetable juices are best. Drink as little alcohol as possible.

Can I go to the sauna with high blood pressure?

In general, yes. Heat dilates blood vessels and thus blood pressure drops rather than rises. Yet, patients with high blood pressure on medication must be careful, because the effect of the medication can be intensified by heat. It is therefore safer to take the medication after a visit to the sauna. In addition, the duration of the sauna visit, and the temperature should only be increased slowly.

Patients with additional known heart disease should talk to their doctor prior to sauna visits.

What aspects of my professional life have negative effects on my blood pressure?

Stress, high workload, working under time pressure, persistent conflicts, excessive demands and shift work can have an unfavourable effect on blood pressure.

Heavy lifting and carrying should also be avoided if possible, as this leads to pressure increases in the vascular system. In addition, people with high blood pressure often do not tolerate working in high temperatures very well.

How does cold affect my blood pressure?

Cold temperatures raise blood pressure because blood vessels narrow. As a result, high blood pressure is more common in winter. For people who already have high blood pressure, this can lead to a further increase in pressure. The effectiveness of antihypertensive drugs can be affected and under circumstances, your medication may need to be adopted.

Can I take contraceptive pills with high blood pressure?

If you have high blood pressure, taking the contraceptive pill is not recommended as the pill increases your blood pressure further.

In healthy people, this increase is low, most women have normal blood pressure despite taking a contraceptive pill. However, if elevated blood pressure values are already present, a further rise in blood pressure should be prevented if possible. We recommend to your family doctor or gynaecologist about it.

What is a blood pressure pass?

A blood pressure pass contains all medications taken and their dosage. It should always be carried with you, e.g. in your wallet. In an emergency it can be useful for the treating physicians to know all medications and their dosage.

Should blood pressure-lowering medication be reduced in summer when it is hot?

Heat can increase the effectiveness of blood pressure medications. On hot summer days, this can lead to a drop in blood pressure, which can be accompanied by symptoms.

However, since heat waves in our latitudes do not last longer than a few days, a reduction of the tablet dose is usually not advisable. Exception: If the systolic blood pressure falls below 110 mmHg and there are complaints, individual substances can be reduced after consultation with your doctor, if you are taking several medications.

In addition, on hot days you should stay in the shade or indoors if you suffer from complaints.

Which antihypertensive drugs are particularly suitable for diabetes mellitus?

Because of their kidney-protective effect, ACE inhibitors are the first choice for patients with diabetes to lower blood pressure. Angiotensin receptor blockers also have a kidney-protective effect and are particularly suitable for patients with diabetes. Other active ingredients such as beta blockers, calcium antagonists and diuretics are also effective.

Hypertension due to hyperthyroidism: Which drugs do I have to take?

In the case of hyperthyroidism (hyperthyroidism), it is important to reduce the amount of thyroid hormone in the blood with adequate thyroid medication. Sometimes, if your heart is racing and your blood pressure is acutely increased due to an acute thyroid overstimulation, beta blockers are typically given to slow your heart and calm your circulation.

If you suffer from both, hyperthyroidism and hypertension, and your thyroid levels are well controlled, in the long-term you may need both, your thyroid medication as well as just regular blood pressure medication.

Can blood pressure medications trigger a sleep disorder?

Blood pressure medications like beta blockers (and so-called alpha-blockers) can cause sleep disturbances. Beta blockers sometimes even lead to nightmares. Beta blockers (as well as alpha-blockers) are said probably disturb the formation of the sleep hormone melatonin.

Also, the so-called alpha blockers may inhibit the release of norepinephrine and have a sleep disturbing effect. Norepinephrine leads to muscle relaxation during REM sleep. Alpha-blockers counteract this and thus impair sleep.

Changing preparations may help

If you suspect your blood pressure medicine may be causing sleeping problems, talk to your doctor. Since there are various ways of treating blood pressure with medication, a change of medication may help. Sometimes just switching from one to another beta blocker itself may help.

What helps if antihypertensive drugs cause erectile dysfunction?

If you have problems with erectile dysfunction and are taking blood pressure medication, talk to your doctor. By taking your history, he can differentiate what may be causing your problems. Sometimes changing your blood pressure medication or adding pills to support erectile function may help. On occasion, he may send you to see a urologist.

If the blood pressure medicine is the underlying cause, a simple reduction of the dose or change may possibly improve your problems. By the way, there are also antihypertensives that have been shown to have positive effects on potency, especially so-called angiotensin receptor antagonists (also called “sartane”). However, there are still no larger studies to confirm this.

Beta blockers, diuretics and others

How do beta blockers lower blood pressure?

Beta blockers are part of the standard treatment of high blood pressure. They have an overall calming effect on the cardiovascular system by slowing down the heart rate and decreasing the blood pressure. Different types of beta blockers vary a little bit in their exact mode of action. They can be prescribed as single treatment or, as often done, combination with other medications.

Blocking of adrenaline docking points

Arterial hypertension occurs when the pressure on the inner walls of the vessels, the so-called peripheral resistance, is increased or when the heart and circulatory system promote too much volume overall and the "tank" is too full.

Beta blockers start right here. They slow down the pulse, lower the cardiac output and thus the blood pressure. They achieve this effect by blocking special docking points, the so-called beta-adrenoreceptors, where our stress hormones adrenaline and noradrenaline normally start. These two hormones ensure that the body's heart pumping power increases and the heart beats faster in stressful situations. In high blood pressure, the system is also overactivated.

Beta blockers dock at the so-called beta receptors so that noradrenaline and adrenaline can no longer exert their effect on the heart. This lowers pulse and blood pressure.

What are advantages of beta blockers compared to other medications?

Antihypertensive substances besides beta blockers include, for example:

• Diuretics (water pills)
• Calcium antagonists (calcium channel blockers)
• Regulators of the renin-angiotensin-aldosterone system (ACE inhibitors and angiotensin receptor blockers)

Beta blockers are good for heart disease

Beta blockers have certain advantages if coronary heart disease (CHD, narrowed heart vessels) or cardiac insufficiency is present in combination with high blood pressure. This is because their mechanism of action is based on calming and relieving the workload on the heart. In people with obesity or diabetes, on the other hand, they seem to have disadvantages compared to other substances.

Since several antihypertensives are usually prescribed together, the question of pros and cons is in everyday practice of limited importance. Most beta blockers are primarily recommended if you have high blood pressure or additionally suffer from a heart rhythm disorder, especially if your heartbeat is too fast (tachycardia at rest, heartbeat above 90-100 beats per minute).

These beta blockers include primarily:

• Atenolol
• Bisoprolol
• Carvedilol
• Metoprolol
• Nebivolol
• Propranolol

Heart protection

Beta blockers have an overall beneficial effect on the heart. They can also be given to older people with heart disease. Primary areas of application include:

• coronary heart disease (narrowed coronary vessels)
• cardiac insufficiency
• angina pectoris
• after a heart attack

Beta blockers have long been proven antihypertensives. They also effectively prevent unwanted blood pressure peaks. At the same time, they protect the heart.

What are disadvantages of beta blockers compared to other drugs?

Beta blockers have disadvantages compared to other antihypertensive drugs, especially in certain accompanying problems like diabetes, severe asthma and COPD or obesity.

Beta blockers in patients with asthma or COPD

Depending on the severity of the disease, patients with asthma and COPD (chronic obstructive lung/ pulmonary disease) may suffer from increased shortness of breath when they start beta blockers. However, there are a few beta blockers, that they may tolerate a little better.

Yet, if mainly high blood pressure must be treated, physicians would prefer one of the other hypertensive drugs like ACE inhibitors, angiotensin receptor blockers, diuretics and calcium channel blockers. If patients suffer from both, COPD and heart attack or arrhythmia, they may require a very tiny bit of a specialized beta blocker.

Beta blockers in diabetes

Also, some patients with diabetes should be careful with beta blockers, since it can increase blood sugar levels. Yet, again, these patients often also suffer from heart disease and therefor usually require treatment with beta blockers in order to protect the heart.

What are typical side effects of beta blockers?

Frequent side effects of beta blockers, especially when starting a therapy, include:

• Headache
• Dizziness
• Insomnia
• Fatigue

What else is important

Other possible side effects of beta blockers include:

• Nightmares
• Circulatory problems, especially in older people, like feeling of cold and tingling limbs.
• Feeling tired
• Depressive mood swings caused by beta blockers.
• Erection problems in men and dry vagina in women.
• Increasing weight due to beta blockers
• Very low heart beat due to beta blocker if concomitant atrial fibrillation is present, for example.
• Slow stress reactions during traffic, for example.

Does the antihypertensive effect of beta blockers start immediately?

It usually takes one to two weeks after the start of treatment for the antihypertensive effect to set in.

Blood pressure effect after a few weeks

With a long-term blood pressure setting, the values can change in the first few days. As said, it often takes one to two weeks for the system to rebalance. This applies to most blood pressure medications. Doctors usually wait two weeks before increasing the dose or adding another drug, depending on your readings.

So, it takes a few weeks for the antihypertensive effect of beta blockers to start. It may take even longer until all drugs are found in their respective dosages and the blood pressure is finally well adjusted.

Fatigue and listlessness

While the blood pressure setting takes a few weeks to adjust, side effects may occur in the first few weeks. Doctors therefore start with rather low doses and gradually approach the required dose. Under beta blockers, some people initially feel weak, tired and listless.

These side effects usually disappear over time when the blood pressure is adjusted, and the body has become accustomed to the change in the system of noradrenalin, adrenalin and beta blockers. Since different subtypes of beta blockers are available on the market, it is sometimes worthwhile to change drugs in the case of intolerances.

Abrupt discontinuation leads to heart racing

Doctors usually discontinue beta blockers in several steps. The body has already become accustomed to the drug and has formed new docking sites due to the occupied receptors. If the beta blocker is abruptly missing, many receptors are free, at which noradrenaline and adrenaline can attack at once and thus lead to rapid heartbeat.

Beta blockers are therefore discontinued gradually over several weeks before the drug is discontinued completely. This should always be done in consultation with your doctor.

How do diuretics help against high blood pressure?

Diuretics are so-called water pills. They lower blood pressure and help draining excessive water accumulation and diseases like heart failure. There are different subgroups of diuretics like the so-called thiazides, loop-diuretic and potassium sparing water pills like spironolactone, for example.

Diuretics for older people

Thiazides like hydrochlorothiazide are generally recommended as one of the first medications used to treat hypertension, they can also be used in elderly patients. Examples of thiazides include e.g.:

• Hydrochlorothiazide (Disalunil®, Esidrix®)
• Benzothiazide
• Trichloromethiazide

Very similar to thiazides also work:

• Chlorthalidone (Hygroton®)
• Clopamide (Briserin®)
• Indapamide (Natrilix®)
• Mefruside
• Xipamide

Diuretics and asthma

If high blood pressure is accompanied by asthma or COPD, diuretics are often preferred to beta blockers (because some beta blockers can narrow the airways).

The so-called loop diuretics (furosemide, etc.) are preferred in patients with impaired kidney function and severe heart failure, they work particularly strong and fast.

What are the disadvantages of diuretics?

Some diuretics can increase blood sugar and should therefore only be used with caution in patients with diabetes or impaired glucose tolerance. Patients with severe damage to the liver or kidneys, should take loop diuretics or xipamide. Since diuretics increase uric acid concentration in the blood, patients with gout should be treated with caution.

What are typical side effects of diuretics?

Water pills lead to a strong urge to urinate. Therefore, you should take your diuretic in the morning so that you do not have to go to the toilet too often at night. If you take this medicine in small doses, this side effect will be less severe. Common side effects include a dry mouth, thirst, weakness and dizziness, maybe even pain or cramps in your muscles or headaches, which may be due to loss of fluid, salt or potassium. Talk to your doctor about it.

You can try to compensate for potassium deficiency with bananas, apricots, vegetables and dried fruit. However, there are also potassium-saving diuretics. If you suffer from vomiting, nausea or abdominal pain, your medicine needs to be changed.

Serious but rare side effects

Also, in the following cases - which occur rarely - you must see a doctor immediately:

• Allergic reaction with itching and rashes of the skin, particularly with tachycardia, weakness and shortness of breath.
• Yellowish coloration and itching of the skin, which indicates liver damage.
• Fever and chills.
• Very small skin bleeds (little red dots) or even blood in stool or urine can be indications of a serious disturbance in blood formation (platelets).
• Cramps.

Which antihypertensives can cause erectile dysfunction in men?

Some people may develop erectile dysfunction, impotence, or loss of libido when treated with antihypertensive drugs. Although this is the exception, it is still important to know about it.

The list of antihypertensive agents for which such side effects have been described is long and includes basically almost all agents:

• Beta blockers
• ACE inhibitors
• Diuretics (drainage agents)
• Calcium channel blocker
• and other antihypertensives

However, some of the medication like beta blockers tend to cause more often problems with erectile dysfunction than others. Usually, your doctor will try to change your pills and find something you may tolerate better.

Complications & Prognosis

High blood pressure: the world's biggest health risk

High blood pressure is the one health risk factor, that costs most years of life worldwide. This is one of the results of the systematic analysis by the Global Burden of Disease Study 2016. It is the largest epidemiological study that continuously evaluates health status of the world´s populations. The study evaluates number and occurrence of diseases, their impact on quality including the numbers of years of life lost due to premature death and years of life lived with illness or disability.

Good and bad news

According to the scientists' calculations, in women, the hypertension is the world's most important health risk, followed by obesity and diabetes. In men, high blood pressure ranks second behind smoking.

The good news are: if you have high blood pressure, you yourself can do something about it and influence your own risk of complications from it since serious complications, that is to say, are generally due to poorly controlled high pressure and insufficient blood pressure reduction.

Which organs are frequently damaged by reasons of high blood pressure?

High blood pressure typically leads to circulatory problems in brain, kidneys, eyes and heart. These organs have many small and delicate vessels that suffer under increased pressure. Particularly the heart suffers from hypertension, as it must fight and work against the increased pressure load with every single beat.

Does high blood pressure increase the risk of a stroke?

Yes, atherosclerosis and high blood pressure are one of the main risk factors for a stroke. Since high blood pressure also promotes atherosclerosis, there risk is doubled. The tricky thing about high blood pressure is that it itself causes comparatively minor discomfort but can have dramatic consequences like heart attack or stroke, etc...

Any additional risk factor like smoking, for example, increases the risk of cardiovascular disease even further. Thus, it is worthwhile to reduce all extra risk factors like smoking, lack of physical activity or obesity.

The risk of heart attack, stroke and other cardiovascular diseases is of course also determined by the level of blood pressure itself. Smokers with only mildly increased blood pressure values have a lower overall risk than those with moderately or highly increased pressures.

Why is high blood pressure particularly dangerous in diabetes?

Both diabetes (diabetes mellitus) and high blood pressure harm the vascular system and affect each other. Diabetes increases, among other things, the risk of general calcification of vessels.

Late effects of diabetes manifest themselves in eyes, kidneys and heart, where circulatory disorders occur and can lead to a loss of function of the organs. This process is accelerated by increased blood pressure levels. Therefore, it is particularly important for people with diabetes to lower not only blood sugar, but also blood pressure.

In numbers: The risk of heart attack is three-fold higher in patients with high blood pressure compared to healthy people. With additional diabetes, this risk increases six-fold.

Why is it dangerous when high blood pressure and elevated blood lipid levels come together?

Patients with both, high blood pressure and increased lipid levels, often feel completely fine and do not suffer from any concrete symptoms. Over the long-term, unnoticed hypertension combined with high cholesterol can thus damage blood vessels and lead to cardiovascular complications. Possible consequences are atherosclerosis or coronary artery disease, in the worst-case heart attack or even stroke.

The two types of blood lipids

The main two typical and best-known types of blood lipids are cholesterol and triglycerides. They are part of a healthy body and necessary as source of energy and for certain hormonal circuits, Furthermore, they serve as “cushion” between organs and for thermal insulation.

Cholesterol is needed by the liver, among other things, to produce bile acids. The adrenal glands produce cortisol from cholesterol and numerous other hormones, including sex hormones. Cholesterol is also a building material for the cell walls.

HDL and LDL

The total cholesterol is divided into the “good" cholesterol HDL and the potentially more harmful LDL cholesterol.

High blood levels of the “bad” LDL-cholesterol increase the risk of atherosclerosis, as LDL accumulates in fine artery walls and leads to inflammation there. With high LDL levels, the risk of vascular and heart disease also increases. HDL-cholesterol, on the other hand, is said to have protective effects.

Also increased levels of triglycerides increase the risk of atherosclerosis and organ damage. In combination with high blood pressure the risk rises even further.

Does the treatment of high blood pressure protect against dementia?

Yes. Vascular dementia (dementia caused by circulatory disorders) is less common under effective hypertension treatment. Several studies have shown this, as the British Medical Journal reported a few years ago.

Especially for the group of so-called angiotensin receptor blockers, a protective effect has been shown. These blood pressure medications, also known as “sartans” (German), are prescribed when blood pressure medications from the family of ACE inhibitors are not tolerated due to side effects.

However, the fact that dementia protection has now been most clearly demonstrated for modern angiotensin receptor blockers may also just be due to the fact, that the pressure itself was adequately lowered. Thus, general pressure reduction is more important than the type of medication that is used to achieve this gaol. Proper blood pressures improved cerebral blood flow and decrease the risk of stroke or stroke like events and thus lower the risk of dementia development.

When do I have to see the optometrist or ophthalmologist?

With long-standing high blood pressure, the risk of eye disease due to impaired circulation increases. Usually it is your primary physician, who tells you to see somebody to have your eyes and vision checked. The ophthalmologist checks the background of your eyes and may be able to see first changes of the tiny retinal vessels.

New visual impairment: is it due to age or high blood pressure?

Whether visual impairment is due to “harmless” presbyopia, which particularly affects close vision, or whether it is eye damage due to high blood pressure, must be tested and assessed by the ophthalmologist. This includes simple tests of your visual acuity in the near and far as well as the background examination of your eyes.

Blindness due to high blood pressure?

Even if this is an extreme, high blood pressure can potentially cause serious eye diseases in the long run leading to blindness. If levels are increased over years and decades, this damages the vascular system of the small vessels of the retina of the eye. Physicians talk of “hypertensive retinopathy”.

What is hypertensive retinopathy?

Hypertensive retinopathy is a disease of the eye retina due to hypertension. The retina contains nerve cells, which are essential for vision. With persistently high blood pressure levels, the small retinal vessels change in form and structure; as a result, blood circulation of the retina is diminished.

Decreased retinal circulation can lead to different eye changes. Nerve fibres submerge and perish and oedema with fluid accumulation appears. Also, retinal vessels become narrow or even close. When retinal bleeding and detachment of the retina follow, visual deterioration and, in the worst case, blindness possibly set in. Though, symptoms like visual impairment often arise late. Still, also sudden loss of vision is possible.

Is there a connection between high blood pressure and impotence?

High blood pressure (hypertension) can lead to sexual problems in terms of erectile dysfunction and impotence. This is due to damage and atherosclerosis of the arterial vessel by high blood pressure in the genitals. At the same time, some medications against hypertension can lead to problems with impotence as a side effect.

Sexual problems should be addressed to the primary physician in order to be able to determine causes and to initiate first treatment steps. Erectile dysfunction can often be treated, even with high blood pressure. Thus, many men shy away from addressing this problem to a doctor.

Can women also suffer from sexual problems due to their high blood pressure?

Even women with high blood pressure or cardiovascular disease are more likely to suffer from sexual problems. Missing pleasure, difficulties in arousal and orgasm, can occur and be debilitating. As in men, disorders of blood circulation or drug side effects can be the cause.

Is there proven benefit of lowering blood pressure?

At the end of 2015, the most comprehensive meta-analysis on blood pressure reduction (Ettehad D et al.) answered the question, to what extent lowering blood pressure in patients with hypertension is proven to benefit people and to lead to a better long-term prognosis.

Data from more than 600,000 patients from 123 large-scale controlled studies were examined. No meta-analysis had been this big before. Scientists from the British George Institute for Global Health and the University of Oxford examined the effect of blood pressure treatment in their study.

Their calculations proposed the following risk reductions for each decrease of 10mmHg in systolic blood pressure:

• For cardiovascular events (heart attack, stroke) by about 20%
• For coronary artery disease (CHD) by 17%
• For risk of stroke by 27% alone
• For resulting heart failure by 28%
• and for total mortality by 13%.

Thus, a reduction in blood pressure will reduce your personal risks of cardiovascular events, heart disease and stroke.

Sources:

• GBD 2015 Risk Factors Collaborators. Global, regional and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 195 countries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
• Ettehad D et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. The Lancet December 23, 2015. Doi: 10.1016/S0140-6736(15)01225-8.

Authors: Dr. med. Susanne Endres, Dr. Hubertus Glaser, Dr. med. Julia Hofmann & Dr. med. Jörg Zorn, Fedor Singer