high blood pressure_ new research suggests see-sawing readings are the key danger sign for strokes

8/22/2019 High Blood Pressure_ New Research Suggests See-sawing Readings Are the Key Danger Sign for Strokes..

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1/22/13 High blood pressure: New research suggests see-sawing readings are the key danger sign for strokes... | Mail Online

www.dailymail.co.uk/health/article-2266234/Hig h-blood-pressure-New-research-sug gests-sawing -reading s-key-dang er-sign-strokes-.html?printingPage=true 1/21

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Have we got it wrong about high blood pressure? New researchsuggests see-sawing readings are the key danger sign for

strokes...

By Simon Crompton

PUBLISHED: 03:39, 22 January 2013 | UPDATED: 03:39, 22 January 2013

One in three of us has high blood pressure. It causes strokes and heart attacks, which is why doctors spend

around 10 per cent of the NHS drugs budget trying to treat it.

But theres a problem: checks may not be picking up those most at risk.

Traditional wisdom about blood pressure may be wrong, according to authoritative new research.

And privately some blood pressure specialists acknowledge that they are having to re-think everything they

once took for granted about blood pressure.
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Large numbers of people are being told by theirGP that their blood pressure is acceptable, when

it may be spiking dangerously when they are

stressed or exerting themselves

For years it was thought the greatest risk for stroke was consistently high blood pressure.

But evidence now suggests the real risk lies in how dramatically blood pressure varies from hour to hour, day

to day, week to week.

At the moment, guidance to doctors doesnt reflect this, so large numbers of people are being told by their GP

that their blood pressure is acceptable, when it may be spiking dangerously when they are stressed or

exerting themselves.


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My Mum was one of them. She died of a stroke exactly a year ago, at a sprightly 84.

She had been active, happy and in excellent health apart from two years of struggling with blood pressure,

which one moment was so low that she was losing consciousness and the next peaked at danger levels of

190 over 95 (the ideal blood pressure is 120 over 80, the two numbers indicating pressure when the heart

contracts and relaxes).

As her blood pressure readings at the health centre were sometimes high, her GP put her on an ambulatory

monitor that measured her blood pressure over 24 hours, and then a home monitor to try to chart patterns

long-term.

Noting her regular high readings, the GP and then a heart specialist tried to help bring them down with

conventional drugs such as beta blockers, diuretics and ACE inhibitors.

The trouble was they brought her blood pressure down all the time it went so low she felt sick and faint(low blood pressure results in not enough blood getting to the brain).

Her doctors knew of no way to simultaneously lower her peaks, and raise her troughs.

But they were not unduly worried: averaged out, her high and low readings gave an acceptable middle-ground

reading.

RISKS OF TAKING AVERAGE READINGS

The doctors were following current NICE guidelines, which say they should find the patients usual blood

pressure by averaging out many readings and be guided by that.

In the weeks before Mum died, she agreed with her GP they should lighten the drug dose because she felt

much better that way.


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He had provided her (and me) with assurances that her erratic home blood pressure readings were not too

worrying: averaged out, they were acceptable.

I felt his advice was reasonable: Mum was increasingly worried and preoccupied about her fluctuating blood

pressure, and felt so awful when the drugs took her blood pressure too low that lowering the dose seemed a

way to help her get on with living life.

But in Mums home readings the day before she died, it was clear her blood pressure was dramatically up and

down: 137/62 at 3pm, 208/68 at 4.30pm and 156/76 at 5.30pm.

She had a massive stroke the next day, and died three days later having never regained consciousness.

Her doctors did nothing wrong. But if the guidance to them had reflected what research is now showing, the

story might have been different.

WHY SPIKES MAY BE IMPORTANT

Since Mums death I have discovered how common these perilous blood pressure variations are.

I have also discovered there are drugs available that might have helped her if only I had known earlier.

The Blood Pressure Associations specialist hypertension nurse, Liz Pidgley, says about 40 per cent of the

calls to the associations helpline are from people worried that their blood pressure is all over the place, one

minute high, the next low.

Its a nightmare to treat, she says.

Andrew Booker, 52, had his blood pressure checked by his GP every six months due to a family history of


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strokes. The readings, he was assured, were fine and he was given no medication.

But taking his blood pressure at home with a digital monitor revealed occasional high peaks of 190/130.

They coincided with times I got splitting headaches and felt hot, says Andrew, a safety administrator from

Oxford.

Variability in blood pressure is incredibly

common. Research suggests it's most common

in people over 60, women and diabetics, and


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rigidity in the blood vessels may play a part

Then, last April, Andrew suddenly felt unusually lethargic and his face went tingly.

His GP sent him to casualty and after a range of checks he was told hed had a mini-stroke (a transient

ischaemic attack or TIA) most likely caused by high blood pressure.

Hes now fully recovered and on blood pressure medication.

Paul Bryan, a GP from Wantage in Oxfordshire, with a special interest in blood pressure, says variability is

incredibly common.

Research suggests its most common in people over 60, women and diabetics, and rigidity in the blood

vessels may play a part.

Some patients who check their blood pressure with home monitors have variations of 20 per cent from one

day to another, says Dr Bryan .

But not all GPs are as alert to the challenges as Dr Bryan. Its not necessarily their fault: its a long-held

medical assumption that everyone has an underlying usual blood pressure.

As long as thats all right, its safe to ignore variations outside the norm.

SURGES THAT DAMAGE VESSELS

But one British neurologist has led the way in warning that this ingrained dogma is dangerously wrong.

Professor Peter Rothwell, director of the Oxford Stroke Prevention Research Unit, has demonstrated that far

from being something to ignore, blood pressure fluctuation is closely linked to stroke.


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His studies, first published in the Lancet in 2010, painstakingly re-examined findings from earlier research.

Put together with statistics from major trials on thousands of stroke patients, he concluded that variations in

blood pressure predict stroke far more powerfully than average blood pressure.

It instinctively makes sense to most of us, says Professor Rothwell, that sudden increases in blood pressure

are likely to make you damage a blood vessel in your brain.

We say, calm down or youll have a stroke, and thats what happens.

It may well be that sustained high blood pressure gradually weakens blood vessels and causes them to

harden.

But the new thinking is its the sudden surges of blood pressure, particularly as we get older, that are the

stroke risk.

His research also indicated that, although everyones blood pressure rises and falls with stress and exertion,

for some people the variations are more extreme.

If a persons blood pressure varies greatly during monthly readings at the doctors say 130/80 one month,

then 170/90 the next it is also likely to vary greatly week by week, day by day, hour by hour, even minute

by minute.

Professor Rothwells findings are supported by leading stroke researchers in the U.S. and Belgium, and

reflected in other studies over the past decade.

A pan-European trial of 774 people with hypertension reported in 2003 that night-time blood pressure

variability was a risk factor for stroke in older people.


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The medical journal The Lancet has said Professor Rothwells papers have transformed the landscape of

stroke prevention.

HOW STANDARD DRUGS COULD HELP

Treating variations is extremely hard because prescribing medicines to lower blood pressure can result in

dizziness and falls, while doing nothing raises risk of stroke and heart attacks.

But Professor Rothwell has evidence that if GPs identified patients with dangerous levels of variability, there

are medications called calcium channel blockers that could help them.

A large Anglo-Scandinavian trial of blood pressure treatments reported in 2005 that these drugs are more

effective at preventing strokes than commonly-used beta blockers.

Professor Rothwells analysis of the trial results provided an explanation, showing that calcium channelblockers are good at raising the troughs and lowering peaks in blood pressure variations effectively ironing

out extremes.

He also found other drugs, notably beta blockers, can make varations more extreme, though they result in a

lower average reading.

Calcium channel blockers, which work by widening the blood vessels, are among the four most commonly

prescribed hypertension drugs: the others are ACE-inhibitors (which also widen your blood vessels), diuretics(which remove water from the body) and beta-blockers (which slow the heart).

But calcium channel blockers have not usually been the first line of treatment and many doctors never move

patients on from what was first prescribed.

Although an update of guidance to GPs recommends calcium channel blockers for the over 55s, it doesnt


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specify them for variability.

DO GUIDELINES NEED UPDATING?

Professor Rothwell is critical of guidance that says anyone whose blood pressure is raised when a doctor

takes it at the surgery should be monitored for 24 hours with an ambulatory blood monitor to address so-

called white coat hypertension.

Treating blood pressure is a major problem for GPs, says Professor Rothwell.

Guidelines push them in the wrong direction. We need to get GPs measuring variability in blood pressure.

Unfortunately, it takes ten years to change concepts like this. The research is there, its now an educational

issue.

For people like me, the thought that a loved one could have been helped if guidelines had reflected this is

difficult.

WHY IT'S HARD TO CHANGE OPINIONS

Some who were involved in making earlier guidelines have been reluctant to talk to me about Professor

Rothwells papers implications.

Others acknowledged their interest, but played down their practical implications, while others face the issue

head on.

But they are aware of the challenge: if existing guidelines do not reflect current knowledge, do we know

enough to replace them with something more useful?


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www.dailymail.co.uk/health/article-2266234/Hig h-blood-pressure- New-resear ch-sug gests-sawing -reading s-key-dang er-sig n-strokes-.html?printing Pag e= true 10/21

Professor Neil Poulter is chair of the British Hypertension Societys guidelines working party, which

collaborates with NICE on producing blood pressure guidelines.

He says the findings clearly have implications for monitoring and treating blood pressure but he doesnt believe

there is yet enough hard data to justify overhauling guidelines.

What measures of variability would GPs use? New trials would be needed to demonstrate the benefits of anew approach.

Its good work, its hugely important and it will cause a sea change in GP practise, but I dont know how soon

that will be, he says. The next NICE guidelines will acknowledge it.

The Stroke Association, too, is cautious. It is funding studies on blood pressure variability in people who have

already had a stroke but is unlikely to fund research into the general population until 2014.

I think this research does mean a re-think about blood pressure is required, said Dr Peter Coleman, the

associations deputy director of research.

But theres always resistance to new ideas.

WHAT YOU CAN DO NOW

The case for action may become unavoidable when Professor Rothwell publishes more research later thisyear.

His new studies will provide evidence from 30 trials to support his earlier observations and more information

about the most dangerous patterns of variability.

Its been controversial, but this next set of papers will make it very difficult for people not to come on board,


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says Professor Rothwell.

In the meantime, Liz Pidgley, of the Blood Pressure Association, advises that patients should talk to their GP

when they notice variations in home blood pressure readings.

Very often it will be nothing to worry about a reflection of normal daily ups and downs, an irregular

heartbeat or an inaccurate digital monitor.

You should get it taken by a doctor with a manual monitor and a stethoscope, she says. Ask questions, and

ask about variability.

Doctors often make out there are only limited options but there are so many hypertension drugs and

combinations. Dont feel youre wasting the doctors time.

WHAT TO WATCH OUT

If youre monitoring your blood pressure at home, check how to do it with your doctor or practice

nurse. Make sure your digital monitor is working correctly (again, check with your practice nurse).

Look at the systolic reading this is the first number (which measures the pressure when the

heart is contracting). It is not unusual for this to vary by up to 60 from one hour to the next

during the day if you are alternately stressed and relaxed. This is normally nothing to worry

about.

Its also normal for readings taken once a day or once a week (at the same time) to vary by

around 20.

However, with variable blood pressure, the readings taken once a day or once a week are likely to

vary by 50 or more. People with variable blood pressure show wide fluctuations daily, weekly and


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monthly.

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1/22/13 High blood pressure: New research suggests see sawing readings are the keydanger sign for strokes | Mail Online
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15/21



View all

what havent you got wrong lately that is the question

- me , Merseyside, 22/1/2013 09:20

Click to rate Rating 1

Report abuse

I have been treated for hypertension for the last ten years, i am now seventy, my pulse rate varies between

48 - 54 but my bp can variey hourly, not outrageously but slightly on the high side,I take a calcium blocker,

Amlodopine, 10 mg, excercise daily, feel pretty good fit and strong, no side effects from the tablet. one per

day.

- dingo , perth w.a, 22/1/2013 08:57


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As a diabetic with high blood pressure I take my pressure at home once a week and according to my annualcheck it is all fine but when I have the pressure taken at the surgery it shoots up. Apparently I have what is

known as "White coat syndrome" so really how the doctor know what my blood pressure really is. I am 78 so

am not unduly worried.li

- Pammie , Seaford, United Kingdom, 22/1/2013 08:42

1/22/13 High blood pressure: New research suggests see-sawing readings are the keydanger sign for strokes | Mail Online
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16/21




Report abuse

I was diagnosed with BP at age of 43, in 2008. It was high: 165/120. I was on Lisinopril tablets. The dose I

had was 20mg a day. This had helped reduce my BP to an acceptable level from the medical viewpoint. I

could not live with those tablets anymore. The side effects are terrible. - Brainless , Mars, 22/1/2013 07:26----

-- You and Me both. After bad side effects I stopped the tablets and finally got round to reading the

information with them - "These tablets are vasodilators.- drugs which widen the blood vessels making it easier

to pump blood around the body"----- Now I think that a stroke is caused by a blood vessel bursting in the

brain? These tablets dilate the veins and arteries which must make the walls of them thinner? This frightened

me bit I might have missed something? Any other opinions? I almost turned to drink with the worry which is

far, far worse for the BP!

- Roy , Billericay, United Kingdom, 22/1/2013 08:38


Report abuse

I have had higher than the standard figure blood pressure since I can remember, in England I was given

medication to lower it, I never felt as well as I did before the pills. Once in France I needed to continue withthe pills so I went to my doctor, The difference in attitude was unbelievable, first I was taken off the pills, I

was then monitored on a daily basis for a month in the surgery, at the end of the month I was given a blood

pressure monitor, that I had to wear from when I got up to when I went to bed, for two weeks, then I had to

wear it whilst in bed for two weeks. Reporting once a week for the readings to be taken from the monitor. At

the end of the two months I was told that my blood pressure was fine, it was consistent throughout my day

1/22/13 High blood pressure: New research suggests see-sawing readings are the keydanger sign for strokes... | Mail Online
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17/21

1/22/13 High blood pressure: New research suggests see sawing readings are the key danger sign for strokes... | Mail Online


and I should never have been prescribed medication. My doctor then told me what was wrong with the British

system, and basically it was that everyone is an individual and should be treated as such not put into boxes.

- alan , Its not important, France, 22/1/2013 08:38


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My blood pressure went up when I was in a stressful job and was being bullied a couple of years ago. Since

then it has slowly risen and I have had to do home readings a lot. My readings fluctuate wildly and yes, being

stressed or angry seriously raises it so you might want to tell people to take it easy with you! At its worst, my

highest reading was 210/115 which is ridiculous. After all the usual tests I am now on Ramipril and it seems to

have brought it down lower, I have had no side effects luckily. Now about to do my next set of home readings

to get a better picture of how things are day to day. I think people underrate how dangerous high BP is, both

those living with it and the people who think nothing of winding them up! Do get your BP checked, you can

even buy a cheap home monitor but it is something you need to keep a close eye on.

- Master blaster-1 , Guildford, 22/1/2013 08:31


Report abuse

My dad died at 79, at 84 any kind of blood pressure would have been a bonus

- SimonS , London, United Kingdom, 22/1/2013 08:30

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18/21

g p gg g g y g g |



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Interesting that so many people think their GPs are pushing drugs on them. When my doctor took my blood

pressure and got a high reading, I said you better give me something for it. She said ok go and take some

exercise. The only thing she said I needed was to stop being lazy and exercise regulary. After one week of 5

mins a day exercise my BP was 120/80. The effect of exercise on my blood pressure is instant and dramatic.

- surreymac , surrey, United Kingdom, 22/1/2013 08:10


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I , according to my GP and his machine readings had a higher than high reading of 240/120, 4 days prior to

Christmas 2012, i had been on many tablets to bring this appalling figure down to an acceptable level of which

showed up , on his machine some months earlier, he explained i must go immediately to my local Hospital in

Dublin 4 to stay in for observation .... Sorry to write i refused the offer and left his surgery , letter in pocket

and went on my way , as i have 'suffered' the illness of Ank Spon for years, i am / was concerned the

medication was interfering with the real problem of ank spon and somehow they were missing something not

showing up when bp required , i had stopped the prescribed medication as i had been unable to walk andother matters when on the meds , my blood pressure is now 160 / 120 , no medication since taken , just

plenty of rest and less stress absorbed seems to me at least to be the best solution ....Plus No Smoking , if i

may also add .

- Dave. , Wicklow, Ireland, 22/1/2013 08:09

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19/21



Report abuse

It is stress that is the major problem for younger people, as is diet and obesity. Doctors will continue to be

drug dealers, however, and will take a lot of educating to look at these other factors.

- Colin , Coningsby, United Kingdom, 22/1/2013 07:57


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