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Inadequately Controlled Blood pressure

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 Posted 10/31/2012 5:16:54 AM
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In the LEF book Disease Prevention and Treatment – Fourth Edition, a ‘new’ type of hypertensive drug (angiotensin IIreceptor antagonist) called Benicar, is highly recommended. When my husband, who is currently having a difficult time controlling his blood pressure, mentioned it to his doctor, he was advised that Benicar is really not a new drug – just a new name for one of the drugs he’s already taking called Captopril.

 

Benicar, because of its true once-daily dosing, was my primary interest since currently, my husband is taking 1 Captopril three times a day plus 1 Tenex at bedtime plus 1 Amlodipine in the morning. Still, his readings – using a high quality computerized BP machine, are for the last six days: 168/101; 155/89;165/99; 169/103; 157/97; 163/97. This week, he had an MRA which determinedthat blood flow to the kidneys is not impaired so we are still looking for acausative factor.

 

Meanwhile, my husband is beginning the regimen of supplements recommend in the LEF book although he has been taking all of them- CoQ10, vitamin C, vitamin E, garlic, L-arginine, and aspirin for some timenow – but at lower dosages.  The LEF book also recommend calcium, magnesium and Potassium but I have concerns; he had kidney stones that required surgical removal when he was younger and we fear the calcium may not be a good idea. In addition, the Amlodipine (Aliskirin) has (I think) warnings regardingPotassium intake.

 

We are looking for assistance in reducing his BP toreasonable levels and if possible, reducing the number of meds required to do so. Are there any recommendations?

   


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 Posted 10/31/2012 5:34:07 AM
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hi Willow,

The Disease Prevention and Treatment book was compiled several years ago, when Benicar was new.  Many of the online versions of the sections in book have been updated since then.  See http://www.lef.org/protocols/heart_circulatory/high_blood_pressure_01.htm#introduction 

Linus Pauling recommended high doses of vitamin C and the amino acid L-lysine for hypertension. 

Biofeedback has been successful for some individuals.

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 Posted 11/1/2012 1:51:15 AM
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Add breathing exercises - see this article from the Journal of Human Hypertension
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 Posted 11/1/2012 4:17:44 AM
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Experiments have shown that calcium, magnesium, and potassium supplements do not cause kidney stones.  However, excessive amounts of certain foods like tea, chocolate, and cheese can.

"The LEF book also recommend calcium, magnesium and Potassium but I have concerns; he had kidney stones that required surgical removal when he was younger and we fear the calcium may not be a good idea." 
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 Posted 12/21/2012 2:12:12 PM
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I had worse BP, up to 185/110. Supplements were worthless. When you find the right combination of drugs, they will work far better and cost far less.

Benicar is an ARB while Captopril is an ACE inhibitor. The ACEI inactivates the enzyme that generates angiotensin and could have the same effect as the ARB which blocks angiotensin from accessing its target receptors.

There are issues.  ACEIs inactivate other enzymes and cause a persistent cough. Some see life-threatening swelling of lips, mouth and throat termed angioedema. There are other enzymes not blocked by ACEI that can also generate angiotensin. Those take over in as little as six months in a process termed angiotensin escape. Finally, there are two forms of angiotensin. A1 increases blood pressure while A2 reduces it. The ACE inhibitor blocks production of both.

The ARB blocks only the A1 receptor and is a far better choice. The early ARBs such as losartan are off patent and cost less than a branded ACEI. I take 100 mg of losartan at night.

Aliskirin (not the same as amlodipine) is a direct renin inhibitor. It prevents the precursor of angiotensin from binding to ACE or a few similar enzymes. It helped me greatly when combined with the ARB valsartan but in mass testing the combination resulted in more total deaths. The manufacturer recalled the combination and recommends against combining aliskirin with any ARB.

Current board recommendations are to begin with either a thiazide diuretic or an ARB. If either is insufficient they may be combined. Some physicians choose a calcium channel blocker (CCB) or ARB and then combine those.

Every drug which lowers blood pressure does so, at least in part, by interfering with calcium ion transport.

The thiazide diuretic HCTZ (hydrochlorothiazide) is a pure diuretic with short duration of action and little secondary value as a CCB.  When tested against the pure CCB amlodipine, it resulted in less control and more deaths.

A related thiazide diuretic chlorthalidone has a long duration of action and has major CCB benefits. Chlorthalidone tested against amlodipine gave as good control and the same or fewer deaths. I take 25 mg of chlorthalidone in the morning so that the diuretic effect wears off somewhat before night. With just two drugs that cost me a copay of about $3 for 90 days my morning BP is 104-108 over 64-70. I am salt-sensitive. After one party dinner, I was 138/85 the next morning.

Why not just amlodipine? It has rapid action yet keeps BP less variable than the alternatives. Men need as little as 2 mg and few need more than 10. There are issues. Many patients get edema in their extremities which can usually, but not always, be controlled by combining with an ARB or diuretic. It is such a good vasodilator that it can hide frank angina allowing many small infarcts to damage the heart. Although I have not yet heard a mechanism for this, patients on amlodipine progress toward heart failure more rapidly than on other treatment regimens. Experts do not prescribe it for anyone younger than 55 or for anyone who already has cardiac problems.

I hear Tenex is great but haven’t tried it. The Brits had great success with 1 mg every day in the morning. It helps with ADD, with BPH and to a lesser extent with ED but hasn't helped your husband much.

I suggest that your husband swap the branded captopril for generic losartan and then add a 30-day trial of 25 mg chlorthalidone. If that does not help, he just might have primary aldosteronism in which aldosterone rises even without angiotensin. There are tests for that (renin/aldosterone ratio) but a 30 day trial of 25 mg spironolactone (Aldomet) is cheap and definitive. Many patients find that spiro is all they need and often at a lower dose. Eplerenone costs little more and has fewer side effects for those who don't tolerate spiro.

Hope this helps!

 
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 Posted 12/22/2012 3:15:12 PM
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Welcome to the Forums, Bob.

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 Posted 12/24/2012 8:00:07 AM
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Willow, you may want to check your husband's thyroid status.  I've read that both hypo and hyper thyroid can cause high blood pressure. My guess is that hypo thyroid is more under-diagnosed than hyper. The lab readings for hypothyroid do not always tell the whole story. If there is a thyroid issue and you fix that, they blood pressure issue likely goes away too. Think of it in terms of the high blood pressure could be a symptom of some other issue (thyroid). Of course, there could also be other issues - overweight, sedentary lifestyle, other hormones could be out of whack.
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 Posted 1/29/2013 1:32:40 PM
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Blood pressure derives from only a few variables but each of those can be changed by multiple factors. Among the variables are circulating fluid volume, cardiac pumping effort, vessel static flow resistance, vessel response to vasodialatory stimuli and vessel elastic response to cardiac effort.

The one variable that can change most rapidly is circulating fluid volume. Negative symptoms such as weakness and fainting can result from losing 2% of fluid volume (2-4 lbs). Women can gain more than that during their hormonal cycles and both sexes can gain more than that in the hours after a single salt-laden meal. Pearson & Shaw complained in the 1980's that it was unfair to mandate lower sodium for everyone when only 10% of the population was sensitive. In today's older population that number is more like 30% and it is far easier to add salt to a meal than to remove it.

Remember that I was able to resolve my hypertension with only two drugs and neither was at its maximum recommended dosage. I need to qualify that with the modifier "absent excess sodium intake".

Perhaps some numbers will make that clearer. I normally wake up with pressures like 110/70. A single large sodium-laced meal such as a restaurant holiday dinner can yield 138/99 the next morning and require several days to subside.

More drugs or higher dosages are not a safe solution. That number of 110/70 is for unremarkable sodium intake. After two days of being especially careful, I regularly hit 101/60. This morning after 3-4 careful days I hit 89/60. While I suffered no symptoms of hypotension they probably would have occurred if I had been taking a larger number of drugs or higher doses.

While I plan to comment on the other variables later, today's take-home is to eliminate large dollops of salt and then seek a drug combination that works with one's less variable fluid volume. A combination that is tuned for one's most or least virtuous day would be more troublesome on a day at the opposite extreme.


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 Posted 2/5/2013 2:41:20 PM
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Willow,

 

I have been collecting info on High Blood Pressure for 13 years now.  For the sake of brevity, I have omitted most references.

 

Bad Foods and Drinks

High salt foods

Medium salt foods

All hydrogenated and partially hydrogenated oils

Don’t cook with olive oil (it’s great if you don’theat it up)

Genetically modified food (GMO)

Animals that have eaten GMO feed (feed-lot animals)

Lunch meats

All pork

High fructose corn syrup (read the label! It’s in most processed foods)

Reduce your intake of processed foods to a minimum

All meat/fish served in a fast food restaurant (have a salad - without the dressing)

Farm raised fish (especially GM salmon, aka Frankenfish)

Reduce sugar to a minimum

Reduce /eliminate alcohol

Reduce /eliminate all grains, except oats (yes, this includes pasta)

Foods/drinks with caffeine

Water with chlorine and/or fluoride

 

GoodFood and Drink

 

Foods that are high in potassium

            Bananas

            Broccoli

            OrangeJuice

Apples

Avocado

Fish (cold water, wild caught)

Grapes

Oats

Cook only with organic virgin coconut oil

Organic grass-fed beef

Organic free-range turkey

Organic free-range chickens (and eggs)

Bison

Elk

Water without chlorine and fluoride (take 1 gallon glass jugs to the reverse osmosis filter in your local grocery store)

Maintain a high fiber diet

Nuts

Seeds

Fruits

Veggies

Sprouts (especially broccoli sprouts)

Green tea

Green tea taken together with citrus juices or vitamin C

 

Vitamins (all doses are per day)

 

A (natural beta-carotene) 10,000 IU

B complex (buy one with a high dose of B12 – at least 1000 mcg)

C (500 - 3000 mg) in divided doses

Citrus Bioflavonoids – 100 mg

D3 (500 – 2000 IU) in divided doses

E (at least 600 IU)

Niacin (100 mg of the flush kind; 450 mg of the non-flush kind)

CoQ10 (100-300 mg)

 

Minerals

 

Calcium – 600 mg

Magnesium (citrate or orotate 200-300 mg)

Potassium – 2500 mg

Zinc – 30 mg

 

Amino Acids

 

Lysine 3000 mg

Proline 550 mg

Arginine 250 mg

Carnitine 300 mg

Taurine 1100 mg

 

These vitamins, minerals and amino acids (in these doses) were discovered by Drs Linus Pauling and Matthias Rath to reverse (their word) plaque accumulation in arteries: The less plaque, the more flexible thearteries and the more normal the blood pressure.  To prevent yourself from going broke buyingthe individual supplements, there are a number of powdered supplements that provide most of the vitamins, minerals and amino acids listed above.  They go under the generic name “The PaulingTherapy.”  Google: “remove plaque from arteries” supplements, and check out the ingredient lists. 

 

Other Supplements

 

Flax oil (1 tablespoon)

Fish oil with a balance of EPA and DHA (at least 500 mg each)

Hawthorn Berry (1.5 g)

Garlic – as much as you can eat (best: fresh garlic bulb; 2nd best: powdered organic garlic in veggie caps; last best:  those pills you get in the healthfood/drug store)

Grape seed extract

Olive leaf extract (1000 mg)

 

Lifestyle

 

Stop smoking

Get down to a healthy weight 

Get 71/2 to 8 hours of sleep at night

Meditate/Self-hypnosis tape/Relaxation response (book of the same name) for at least 20 minutes a day.  20 minutes twice a day is even better.

Get some sun on your bare skin (Vit D)

Eliminate stressors (yes, I know, easier said than done. Or learn to deal with them in a more peaceful way: Your favorite religious/spiritual book, The Sodona Method, the Emotional Freedom Technique (EFT), A Course in Miracles, Conversations with God books, talk to your pastor /psychologist)

Listen to music you like (doesn’t have to be Mozart)

Exercise (the best exercise for you is the one you will actually do; even better if you enjoy the activity)

Replace toxic cleaning chemicals in home with non-toxic ones

Appreciate all the good things in your life (write them down in a book along with all the reasons you appreciate them.  Briefly review the book every day and add to it.)

Avoid drinking out of plastic bottles/cups and aluminum cans (use glass, ceramic or stainless steel)

 

Insulin

 

Insulin is a MAJOR player in regulating blood pressure. Two-thirds of people who are insulin resistant also have high blood pressure.  If your husband’s hypertension is the direct result of an out-of-control blood sugar level, then normalizing his blood sugar levels will help lower his blood pressure.

 

MedicalDevice

 

ZonaPLUSTM is a handheld, computer controlled device, which lowers your blood pressure thru a clinically proven isometric protocol. The program takes just 12 minutes a day, 5 days a week to help reduce high blood pressure.  TheHarvard Heart Letter states that the ZonaPLUS "…has been shown to lower blood pressure as much as a first-line anti-hypertensive drug."  A number of websites offer more info on the device.  I recommend you start your search by Googling "ZonaPLUS (TM) Blood Pressure Device".

 

Medical Odds and Ends

 

1) A group of blood pressure medications known as angiotensin-receptor blockers (ARBs) "significantly increased risk of new cancer"…”by 8 to 11 percent”…”risk of lung cancer was increased by 25 percent.” There was no increase in breast cancer.  

 

Source: University Hospitals Case Medical Centeras reported on http://www.medicalnewstoday.com/articles/191644.php

2) Clinical trial: when the supplement
conjugated linoleic acid (CLA) was combined with Ramipril, an anti-hypertensive medication, the combo helped to reduce the blood pressure in obese hypertensive patients.

 

ZhaoWS, Zhai JJ, Wang YH, Xie PS, Yin XJ, Li LX, Cheng KL. Conjugated Linoleic Acid Supplementation Enhances Antihypertensive Effect of Ramipril in Chinese Patients With Obesity-Related Hypertension. Am J Hypertens. 2009 Mar 19. Published Online Ahead of Print.

 

3) A number of studies have linked common blood pressure medications with developing diabetes. Dr. Nieske Zabriskie, ND, lists 17 studies in his paper. A good review article can be found here:

 

National Institutes of Health. Who is at Risk for High Blood Pressure? Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/Hbp/HBP_WhoIsAtRisk.html.Accessed on: 02-07-09.

 

I disagree with the person who said “find the right medicine.”  Medicine may be helpful, but ask the question, “Is this medicine going to fix the cause of theproblem?”  High blood pressure is a distress signal sent from your body to your mind.  Listen to this signal and try to decipher the message and take the appropriate actions. Dr. Mercola (mercola.com) states, “… 85 percent of those who have hypertension cannormalize their blood pressure through lifestyle modifications, whereas statistics show over half of people taking multiple medications for high blood pressure are still not able to manage their condition.”

 

Ithas been my observation that 3 diseases are linked: Atherosclerosis (including high blood pressure), diabetes and hypothyroidism. If you have one of these diseases you are likely to get the other2.  And if you have 2 of them, you haveto treat both of them simultaneously in order for either one to get better; dittofor all three.  I have been observing this “Trifecta” since the late 1990’s. In 2005 Dr. Mark Starr, MD wrote a wonderful book wherein he dubbed mytrifecta hypothyroidism Type 2 (also the name of the book).  His observation is that an underperforming thyroid is causing all three (and more) of these diseases.  I highly recommend this book for anyone with1 or more of these diseases.  It may unlock the reason why the medicine your doctor is giving you is not working.

 

But even Dr. Starr doesn’t address the root cause of Type 2 hypothyroidism.  I think it is caused by another trifecta:  multiple nutritional deficiencies caused by poor quality food, unhealthy lifestyle, and the cloud of toxins we are exposing ourselves to every day.  Fortunately allof these causes can be addressed.



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 Posted 3/6/2013 4:18:13 PM
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I previously described the sodium/volume hypertension that is most common among the obese and rare among the skinny. A bad literary allusion might say that fat hypertensives are all hypertensive in the same way while thin hypertensives are all different. The good news is that drugs whose primary or secondary mechanism is diuresis are quite effective on fat hypertensives.

(If it puts any of the reader's minds at ease, the observation that ARBs might increase cancer risk did not hold up for larger statistical samples. Most diuretics do however increase uric acid, blood lipids and blood sugar. Blood sugar and insulin have been shown to increase the rate of cancer growth. Obese patients who are worried about this might lean toward a ketogenic diet.)

Obese patients can enhance the benefits of their drug regimen by reducing their body fat especially intra-abdominal fat.  Some researchers have noticed arterial de-stiffening from weight loss with no obvious changes in blood chemistry. This process continued as long as the patients were losing weight but ceased or reversed under a maintenance diet. There must be a different set of chemical messengers present during weight loss but researchers have not characterized the differences. If the messengers were discovered, they might block hypertension at an earlier stage with greater efficacy and fewer side effects. They would not be likely to help already-thin patients.

Obesity often results in obstructive sleep apnea (which I have experienced). When the brain gets insufficient oxygen it up-regulates the pressure and volume of blood delivery. Hypertension from this cause gets worse over time because the real problem is lung ventilation. When OSA is properly treated the component of hypertension from that source reverses. Prompt diagnosis and treatment are essential because the damage to heart, kidneys and arteries (especially loss of elasticity in the aorta) is only partially reversible and has a degree of momentum. I have a right bundle branch block that is blamed entirely on the OSA and that only became detectable AFTER the OSA had been treated for over a decade. OSA changes the set point of the cerebral pressure sensors and can result in long-term hypertension with no obvious cause. Negative inotropes such as beta blockers do appear to help in such cases.

The kidneys also respond to changes in oxygenation. When deprived they secrete a variety of inotropes to increase blood pressure as well as erythropoietin to increase hematocrit. They also conserve sodium and water to increase blood volume. Renal artery blockage alone can cause drug-resistant hypertension even in thin patients. Treatment usually requires correcting the blockage because even if the hypertension can be controlled by other means the hypoxia results in cumulative renal damage.

The kidneys exchange inotropic signals with the CNS via the renal sympathetic nerves. The downward component is most important with the kidneys raising blood pressure through the mechanisms already described in response to the signals from the brain. Severing those nerves can cure many cases of drug-resistant hypertension. Once this was a rather invasive bilateral surgery but Medtronic has recently released an RF nerve ablation device that can be delivered through a catheter with no major incisions. This can be miraculous for selected patients.

It is uncommon for pituitary/hypothalamic issues to produce hypertension but both thyroid tumors and a class of adrenal tumor called pheochromocytoma can do that even in thin patients. The former is diagnosed through a blood draw and the latter through a 24-hour urine collection. Most physicians will check for both early in the diagnostic process.

Henry Black MD was one of the first to differentiate obese hypertension from thin hypertension. He tells physicians that drugs which depend on diuresis are unlikely to help the thin patient and recommends CCBs for thin patients in spite of the CCBs long-term side effect profile. He says that hypertension in thin patients may be due to an inflammatory process but has not yet described that in detail. Having been rather negative regarding the efficacy of dietary supplements I admit that they might benefit these patients.

 
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