BY CLAIRE SAFRAN The .body rings no alarms and signals no symptoms. You have no pain, no wound that you can see, no sense of being sick. One day, A you are feeling just fine. The next day, in a routine examination your doctor wraps black cuff around your arm and pumps it up. Seconds later, the doc- tor frowns at a column of mercury that has stayed too high in the measuring device. And then you are giv- checked once or twice en the bad news. It's easier than ever to control these What then? This year, if ypu or days-in many c8ses without drugs. a year to be sure it doesn't edge up into Read the new nmiid evidenaz and the 90s. Most doctors someone you love has high blood pressure, new approaches to treating it *ill provide learn what the options are. also think that a dia- stolic in the 80s is a sig- nal to start doing something to keeD it more g&d-heaith options than ever be- fore. Highblaod pressure (or hyperten- sion) has been making headlines in re- cent months, the result of an explosion of research. The wonderful news is that science now knows how to defuse the danger and control the disease. The confusing news is that doctors don't al- ways agree on the best ways to do that. Yet there's one point on which opinion is unanimous: Today we have a reper- toire of effective remedies. Depending on how high your pressure is, how you live and what kind of changes you're willing to make in your lifestyle, treat- ment can be tailored specifically to you. Because it can lurk in the body with- out your knowing it's there, high blood pressure has been called "the silent kill- er"; it's the leading cause of strokes an+ a major factor in `heart attacks and kidney failure. Between 40 and 60 million Americans have this disease, and the gap in that es- timate is part of the perplexity. Blood- pressure experts are still working out an answer to the most basic question: How high is too high? What the Numbers Mean For the av- erage adult, a healthy blood pressure 26 WOMAN'S DAY 5/l //a3 reading is 120 over 80 or lower. The first, or top, number is the systolic read- ing, a measure of the pressure in the ar- teries when they are filled with blood and at their highest tension. The sec- ond, or bottom, number is the diastolic, the pressure in the arteries after they have moved the blood along and are re- laxed. Both numbers are important, but because they depend so intimately on each other, going up and down in tan- dem, people often find it simpler to talk about just one, the lower, or diastolic, reading. If the diastolic goes over 105, and stays there through several readings. there's no argument. That's the begin- ning of the danger zone, "moderate" hypertension. Once the diastolic rises above 115, the condition is considered "severe." At these levels, almost all doctors will prescribe one or more med- ications as the-surest, swiftest way to bring the pressure down. A diastolic between 90 and 104 falls into the gray area of "mild" hyperten- sion. Three-fourths of those with high blood pressure are in this category. Ex- perts agree that most of these people re- quire some form of treatment, especial- from rising higher: lose weight, reduce salt intake, cut back on alcohol, start exercising, curb stress. When Drugs Are the Best Therapy For people in the danger zone, the cases of 105 or more, today's standard medical treatment is remarkably effective. It works for almost every patient who will follow it. Because it begins with the mildest possible drug at the lowest pos- sible d&age and climbs up step by step from there, it's called "stepped care." The first step is usually a diuretici a drug such as Diuril, Enduron, Hygroton or a dozen others. These drugs lower the body's volume of fluid by flushing sodium, which raises it, out ofthe body. That decreases pressure, and for many people that's all the treatment needed. If step one doesn't bring the pressuie down to a safe level, the doctor will add step two. Traditional1 y, this has been a. 1 beta-blocker (Inderal, Corgard and oth- ers), something to calm down the sym- pathetic nervous system and so ease the pressure. In years to cotie, step two may be one of a new class of drugs called the calcium channel blockers, which doctors are experimenting with now. Too (contintred on page 28) HIGH BLOOD PRESSURE much calcium often causes blood-ves- sel wails to contract so that pressure is increased; these drugs act as gatekeep- ers, blocking calcium's entrance into the cells. (The Food and Drug Adminis- tration hasn't approved these drugs as blood-pressure treatments yet, but some doctors have begun to prescribe them for hypertension nonetheless.) For those few patients whose pres- sure is still too high, step three usually is a vasodilator (Loniten, Apresoline and others), a drug to relax the muscles of the blood-vessel walls. If pressure still isn't controlled, even more power- ful drugs are available. Every drug, of course, has its possi- ble side effects. Diuretics can cause fa- tigue, muscle weakness, leg cramps, a low potassium level or an elevated uric acid. Beta-blockers may slow the heart and pulse `rate, aggravate asthma or bring on fatigue and depression. Vaso- dilators may step up the heart rate and cause headaches, stuffy noses and fluid retention. Lists of possible side effects can be frightening, but the cure is not worse than the disease. Not all patients have side effects, and for those who do, doc- tors often can change or adjust medica- tion to eliminate them. After many I years of caring for patients on these drugs, Dr. Edward Freis of the Veter- ans' Administration in Washington, D.C., has a reassuring report: "I haven't seen anything yet to alarm me." The Treatment Options for Mild Cases Stepped care also plays a role in treat- ing some cases of mild hypertension. Most doctors will start drug treatment if the diastolic is over 100. Many will also prescribe it for those with other risk fac- tors for cardiovascular disease. Studies have found that even mild hypertension is dangerous if you are overweight. Smoking multiplies the threat. Other risk factors include being overstressed or having high cholesterol levels, diabe- tes or a family history of hypertension. Even for those who have no other risk factors, a few doctors now pre- scribe drugs when the diastolic hits the low 90s. But for most people with mild F ases of high blood pressure. the newest thinking is that the treatment ought to be mild, too. Dr. Freis was one of the pioneers who proved how effec- tive drugs could be in controlling high ,blood pressure. Today he says that for the average person the danger from mild hypertension is so low that drugs aren't warranted. The research on this is contradictory. THE GREAT SALT DEBATE When the cause of a disease is a mystery, the cure is often a controver- sy. With high blood pressure, the most heated argument is over sodium, or really salt, because salt is our main source of the substance. Most doctors advise people with high blood pressure to go on a low-salt diet. The American Medical Associa- tion, the American Heart Association. the American College of Physicians and other prestigious groups would say amen to that.. Yet new voices are being heard from. The dissenters are led by Dr. John H. Laragh, director of the hyper- tension center of the Cornell Universi- ty Medical Center in New York City and a man who likes to talk about "the great virtues of salt." He believes that much antisalt advice is based on opin- ion, not proven fact. As Dr. Laragh explains, "Every- body with high blood pressure doesn't have the same disease." According to his research and that of other medical scientists, about 30 percent of hyper- tension patients can lower their pres- sure by reducing the amount of salt they use. In another 30 percent,, according to Dr. Laragh, the major factor is too much renin, a hormone manufactured by the kidneys. "A low-salt diet won't help these people," he says, "and may harm them." Renin gets little at- tention from the medical community, but Dr. Laragh reports that he's been able totally or partially to correct high blood pressure in 70 percent of his pa- tients by giving a drug (captopril) that works specifically against renin. Dr. Laragh believes another 30 per- cent of hypertension is caused by a mixture of salt and renin,,with one or the other out of balance. Some of these patients may be helped by a low- salt diet. he says, but others may not. The remaining 10 percent have a specific physical cause such as kidney or adrenal disease. For some, a new, nonsurgical procedure, balloon dila- tion, can open blocked kidney arteries and so cure the disease. Five years ago, hardly anyone be- lieved in these subtvoes of hvuerten- sion. Today, most dbctors ad%t they exist but don't always agree with Dr. Laragh's percentages. Nor do they think the different forms are very im- portant. The medical consensus is to treat almost all hypertension with diet and/or diuretics that flush out sodium. Who's right`? You may want to do your own bit of medical research. If your doctor prescribes an antisalt drue or diet. trv it for a while. Dr. Lar- agh>uggests a'week, but a month may sound more reasonable to your doc- tor. If your blood pressure comes down, you've proven that salt is guilty in your case. If it doesn't, you may want to ask your doctor about a new test, the renin-sodium profile, that can reveal which type of hypertension is at work in your body. Some studies show that treating mild cases reduces the risk of death from hy- pertension-related disorders like stroke; others show little or no effect until pressure rises to the upper limits of the mild zone. More and more doctors, though, now believe that it's safest and wisest first to try nondrug ways of low- ering the pressure, giving them six months or so to work before consider- ing drugs. Many people can bring their pressure down just by reducing their weight. As you lose weight, you lower the volume of cells that the body needs to pump blood to, and that eases the pressure. Depending on how many extra pounds you're carrying, you need to lose ten to twenty pounds before you see an effect. Though there's a growing controver- sy about it (see box), most doctors still believe that salt is always a culprit in this disease. Without drugs for mild cases, along with them for severe cases, many will prescribe a low-salt diet. That means very low, cutting intake by half, getting down to five grams or less a day. The ways to do that include cooking without salt, banning the salt shaker from the dining table and avoiding smoked meats, potato chips and other highly salted foods. Most doctors also advise cutting down on coffee and tobacco, because both are stimulants. Others suggest that you start eating such potassium-rich foods as bananas, orange juice and prune juice; there is a certain amount of preliminary evidence that raising your potassium level will help push down the blood pressure. Some physicians urge that you exercise, preferably in cardio- vascular ways such as jogging, biking, swimming or brisk walking. Exercise can help you work off pounds and daily stress. Beyond that, experts are still ar- guing about the different studies that show that exercise does-or does not- lower blood pressure. For a few people in the mild zone, these lifestyle changes may keep drugs away forever. For those who already take drugs, these changes can lower blood pressure enough so that only low dosages are needed. But even without changing their lifestyles, some people with high blood pressure may not be facing years of pill-taking, as most doc- tors once thought. Rose Stamler, professor of communi- ty health and preventive medicine at Northwestern University, has found that many people can bring their pres- sure down to normal with drugs, then stop the drugs and, after a year and a half, still be normal without doing any- thing else to lower the pressure. Twice as many of her patients have been able to stop pill- (continlred on page JO) HIGH BLOOD PRESSURE taking if they also followed the doctor's orders to lose ten pounds, cut salt in- take, increase exercise and reduce alco- hol to two drinks or less a day. Beyond Drugs and Diet So we know that pills work for some people and di- etary changes work for others. Another approach, based on a new and intrigu- ing idea, is also being proved effective. If you were to read the previous sen- tence out loud, your blood pressure would go up. If you were talking to an- other person, it would go still higher. If the conversation were with your boss, your pressure would go higher than his or hers. If you were speaking to some- one of the opposite sex, your pressure would show less change if you're mar- ried than if you're single. Dozens of times each day, your blood pressure zigs and zags, adjusting to what you're feeling and doing, even something as simple as speech. These ups and downs take place in everyone, but the swings are wilder and higher in people with high blood pressure. That discovery is the basis for the newest therapy: con- trolling blood pressure by learning to control everyday stress. At the Psychophysiological Clinic at the University of Maryland in Balti- more, Professor James Lynch has been monitoring what happens during ordi- nary conversation. He's found that the higher the blood pressure is to start with, the more it soars during conversa- tion, With normal people, the increase is IO to 20 percent, but it can go as high as 50 percent for people with high blood pressure. Within half a minute of start- ing to speak, the pressure begins its rise. It comes down just as quickly when you stop speaking and start listen- ing to the other person. "People with high blood pressure tend to be bad communicators," says Professor Lynch. "They speak more rapidly and they breathe more quickly than other people. Their pressure doesn't go down when it's the other person's turn to speak, because they're not really listening. Instead, they're feeling angry or critical at what they're hearing. Or they're planning an answer, getting ready to interrupt." The solution is not to avoid communi- cation; alienation and loneliness take their own toll. Some doctors are trying instead to help people with hyperten- sion learn to communicate better and so bring pressure down. "Try to be aware of the subjects that are stressful to you," Professor Lynch advises. "May- be there's something you can change in those areas of your life. Notice when you're breathing too fast, speaking too fast or not really listening. Then try to slow yourself down." Talking to other people is only part of "our dialogue with our environment," as it's called by Dr. Aaron H. Katcher, professor of psychiatry at the Universi- ty of Pennsylvania School of Medicine. We also have a dialogue with the non- human world. We react to stresses like the jangle of telephones or the wailing of police sirens. We respond to plea- sures such as trees, running water, a blue sky. As Dr. Katcher points out, "We can improve dialogue and lower blood pressure by choosing what to concentrate on." Very simply, that's the key to the meditation or relaxation methods that a growing number of doctors are pre- scribing for people with hypertension. Techniques vary in how they're done, but almost all encourage turning away from what's negative and troubling to contemplate the pleasant. Something remarkable happens when you do this, according to research done at the Beth Israel Hospital in Boston. Truly relaxing the mind and body mi- mics the effect that a blood-pressure pill would have. (continued on page 154) HIGH BLOOD PRESSURE continued from puge 30 What's more, the blood pressure stays low- er, just as it would with a pill, after you've stopped meditating and have returned to the stresses and demands of daily life. In his practice, Dr. Katcher prescribes two fifteen-minute periods a day of effec- tive relaxation. Many of his patients try "the relaxation response." developed by Dr. Herbert Benson of the Harvard Medi- cal School. This takes four simple things: a quiet environment; a comfortable position (sitting or lying down, as you prefer); a pushing away of the thoughts that may come into your head, sometimes just by telling them "go away" or "not now"; and the repetition of a word, prayer, sound, or phrase while breathing rhythmically. Other patients try even simpler tech- niques. Dr. Katcher has found that genuine relaxation can come from watching the flow of a brook, the sunlight on leaves or a fire in the grate. Some people calm down with a dog or cat (talking to a pet is one form of speech that doesn't raise the pres- sure). In his research, Dr. Katcher asked people to look at tropical fish swimming in a tank. For normal people, blood pressure ebbed about IO points; for those with hy- pertension, it fell as much as 20. Still, not all doctors are convinced. In some studies, relaxation caused blood pressure to go down very little or not at all. It's odd, but researchers tend to get the re- sults they expect. The same thing is true for patients. They get better results when they believe in the treatment. Learning to relax or to communicate bet- ter can help some people wean themselves from pills. Or it can make drugs or diet work better. If the diastolic is in the 8Os, it's a way to practice preventive medicine. Like any other remedy, relaxation can only work if you stay with it. That's the rub. All along the problem with high blood pressure has been that people drift away from the treatment. It's not easy to lose weight, for example, or to change the eating habits of a lifetime. People have more success when the rest of the family goes along. We now know that there are many different ways to make food taste good, and that anyone can benefit from a healthful diet. With children who don't want to give up whatever is forbidden to you, you can make a contract that they munch those temptations outside the home, not in front of you. Nor is it easy to remember to take a pill, especially when you don't feel sick. Some people find the motivation by charting their own progress. Once or twice a week, they take their own blood pressure with a cuff sold at medical supply and drug stores. In the end, effective blood-pressure ther- apy is up to each person. The answer may be in the supermarket, in the pharmacy or in your head. It may be in all three places. It's there for the taking, and it's tragic that not everybody reaches for it. Science doesn't yet know how to prevent prema- ture death from some forms of cancer, but it does know how to keep people living long and well with high blood pressure. w 154 WOMAN'S DAY 5/l 7183