Heart Failure Treatment: High Blood Pressure

HIGH BLOOD PRESSURE

Untreated high blood pressure over time can cause significant damage to the heart. We often don’t realize that our blood pressure (BP) is high. This is why high BP (hypertension)  is called “the silent killer”. The problem with high BP is that it often goes untreated.  One often feels ok until the BP gets very high.  Think of the BP as a door outside the heart.  When the heart beats and ejects blood out to the body we would like a gently swinging door (low BP) rather than the blood hitting a heavy door or a brick wall (high BP)!  If the blood is meeting the brick wall and it can’t exit then pressure pushes backward into the heart and causes the heart to enlarge. This is not good!  An enlarged heart does not pump efficiently.

BP is made up of two numbers.  The top number is the systolic and the bottom number is diastolic.  So for example – normal BP of 120/80 is 120 systolic over 80 diastolic.  The top number or systolic pressure represents the force that the heart is ejecting the blood against.  The bottom number or diastolic pressure represents the pressure exerted against the heart when it should be resting.  During the resting phase (diastole), the coronary arteries that feed the heart with oxygen from the lungs are filled.  If the pressure is too high then this impairs this filling.

Monitoring your BP at home is essential.  BP monitors can be purchased over the counter.  Be sure to take your BP correctly: sitting relaxed in a chair with both feet on the ground, no talking or eating. Put the cuff directly over your skin, not over clothing.   Don’t take your BP repeatedly.  This will only cause it to go higher. Take your BP and record it with the date and time to bring to all appointments at SDCA.  We may ask you to take your BP at different times of the day so we can monitor how your meds are acting.  Start with first in the am before meds unless we tell you otherwise.  This will let us know if your meds are working overnight.

BP guidelines have changed over the years with the current guidelines below.

New ACC/AHA High Blood Pressure Guidelines

Blood pressure categories in the new guideline are:

  • Normal: Less than 120/80 mm Hg;
  • Elevated: Systolic between 120-129 and diastolic less than 80;
  • Stage 1: Systolic between 130-139 or diastolic between 80-89;
  • Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
  • Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

Beta-Blockers

Many seniors, especially women, have untreated high BP which has caused the heart to fail.  So the treatment is to bring the BP down with medication.  There are several drugs we use to drop BP.  Beta-blockers are one category.  The heart and the rest of the body all have receptors on them.  One of these receptors is for adrenaline.  We need these receptors to MOVE FAST in case the house is on fire or we have to chase a child out of traffic. During this event, the BP increases, heart rate increases, and blood is shunted to the muscles. Beta-blockers attach to these receptors so the BP drops and the heart rate drops. These drugs need careful attention and dosing because you don’t want a BP or HR that is too low. This can cause dizziness, vertigo, headache, weakness, fatigue, and nightmares. The most common Beta Blockers we use are Carvedilol (Coreg), Metoprolol Succinate (Toprol) or Metoprolol Tartrate (Lopressor).

ACEI (Angiotensin Converting Enzyme Inhibitors)

Another class of drugs we use are called ACEI (Angiotensin Converting Enzyme Inhibitors).  These drugs block the conversion of a hormone called Angiotensin. Blocking this hormone causes the blood vessels to dilate and relax.  Thus the BP drops taking the workload off the heart so it can pump more efficiently.  There are side effects to the use of these drugs prompting us to follow blood work closely and monitor BP.  Diabetics are frequently prescribed these drugs because they protect the kidney.  However, one side effect is high potassium and high creatinine (kidney test).  A life-threatening side effect is angioedema:  localized facial swelling around the eyes, lips, tongue, and larynx ( the tube that you breathe through).  If this occurs you should go promptly to the ER for evaluation. A dry nagging nonproductive cough is another side effect and the drug should be stopped if this occurs.  This class of drugs are called the “pril” drugs because their names end in “pril”.  Remember that each drug has at least 3 names!  Examples of these are Lisinopril (Zestril or Prinivil), Enalapril (Vasotec), and Quinipril (Accupril).

ARBs (Angiotensin Receptor Blockers)

Another class of drugs related to ACEI are called ARBs (Angiotensin Receptor Blockers).  These drugs work by blocking another angiotensin hormone thus the blood vessel dilates and BP drops.  Examples of these are Valsartan (Diovan),  Losartan (Cozaar), Olmesartan (Benicar), and Candesartan (Atacand). These also can cause elevations of potassium and creatinine so frequent blood tests are needed.  Remember to check your BP and record.  Call if your BP drops below 100 systolic (the top number) or if you have dizziness or lightheadedness.  All medications take a while to adapt to.  You may initially feel worse until you get used to the medication or need to be switched to another drug.

Calcium Channel Blockers

We also use a class of drugs called calcium channel blockers to control BP in patients with an EF of 55-60%.  These do not increase the EF as the other ones do but are used to bring the BP down and take the workload off the heart. The common one used is Amlodipine (Norvasc). How do these work?  Calcium moves in and out of the cells in your blood vessel walls normally.  This causes your vessels to stiffen and BP increases. These drugs work by blocking the calcium from entering the blood vessel cell so the vessel relaxes and the BP drops. One side effect is lower leg swelling.  Remember to monitor your BP!

Aldosterone Receptor Agonist 

In the heart failure setting we also use Spironolactone (Aldactone) which is an Aldosterone Receptor Agonist.  This class of drugs blocks aldosterone (a hormone produced by the adrenal glands) in the kidney and causes you to urinate sodium and water.   It also helps to hold onto potassium and is commonly used when you take water pills like Furosemide (Lasix). By eliminating excess fluid your BP will drop. The more common side effects that can occur with Spironolactone include diarrhea and abdominal cramping, nausea and vomiting, high potassium levels, leg cramps, and headache. We will be monitoring your blood levels for sodium, potassium, and creatinine.  And you will be monitoring your BP!

In the heart failure patient we often use a combination of many of these drugs.  So you may be on a Beta Blocker, an ACEI or ARB, and Spiro.  Amlodipine may also be added.  Not only do these control BP but also help the squeeze of the heart and so improve your ejection fraction.

UP NEXT- Treatment of Heart Failure continued.  SDCA has a bimonthly heart failure class open to the public.  Unfortunately all classes are on hold during the COVID crisis.  We will offer these classes again after this passes.