Turn Down The Pressure

Blood pressure is important. High blood pressure (hypertension) complications affect many organs, including your heart, brain, and kidneys.

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In 2022, high blood pressure was a primary or contributing cause of almost 700,000 deaths in the United States. Hypertension is the strongest risk factor for stroke and it is the #1 modifiable risk factor for heart disease. For every decrease of 10mmHg in your systolic blood pressure reading, you lower your risk of stroke by 27%, heart failure by 29% and heart disease by 17%.

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You may be surprised to learn that it actually took the medical community a while to realize this. In fact, the association of adverse health effects with high blood pressure was initially a discovery made by insurance companies in the early 1900s. Through large-scale actuarial analyses performed in the early 20th century, insurers noticed that applicants with elevated blood pressure died younger, particularly from stroke and heart disease. These findings were based on routine health exams performed during the underwriting process, which provided early population-level data before formal clinical trials were common. Life insurers at the time often used this data to raise premiums or deny coverage to applicants with hypertension—well before physicians agreed it was a disease worth treating.

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Perhaps unsurprisingly, the association of high blood pressure and poor health was initially denied and criticized by the medical profession.  In the early and mid-20th century, many in the medical community were skeptical or even hostile to the idea of treating what they saw as “benign essential hypertension.” It was widely believed that high blood pressure was just a natural part of aging, and attempts to lower it might actually be harmful. This was actually a common belief through the 1940s and even into the 1950s (and probably cost FDR his life, but that’s a topic for another time). 

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It wasn’t until much later, when effective therapies became available, that high blood pressure was recognized as being worth treating. (Funny how that works, and we are still seeing it today: once Big Pharma develops a treatment, the disease becomes recognized far more frequently. Yes, I’m looking at you “Low Testosterone”). 

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The change began in the 1950s-60s with studies like the Framingham Heart Study, which provided strong epidemiological data linking hypertension to increased risks of stroke, heart attack, and other cardiovascular events. When randomized trials in the 1960s–70s demonstrated that lowering blood pressure actually reduced mortality, medical opinion shifted dramatically and the medical profession began to embrace the diagnosis of hypertension and made it a central focus of preventive medicine.

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But I think that the message has gotten a little lost: While chronic high blood pressure is a very bad thing; intermittent high blood pressure is not. 

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We receive calls all the time from patients worried that their blood pressure was high for a few hours. And of course, that worry only makes their blood pressure even higher. But as I tell people all the time: Blood pressure is intended to be variable. In order for us to survive as a species, we had to develop the ability to change blood pressure rapidly.

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Why are patients so worried about isolated high BP readings? Because they learned from us. Once the medical community finally learned and accepted that high blood pressure was a big deal, we became zealots in a campaign to end it at all costs. Generations of doctors have been misled into believing that all high blood pressure needs to be fixed instantly. Every night during residency training, we would receive calls from well-meaning nurses that a patient’s blood pressure was high, and we were taught by our mentors to order IV meds to rapidly bring the numbers down. 

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But does this help the patient? The answer is actually quite clear: No.

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In a study of 22,834 adults from 2020, inpatient hypertension treatment of blood pressure with oral and/or intravenous medications was actually associated with higher rates of subsequent acute kidney and heart injury. Another study of VA patients from 2023 showed the same thing: intensive blood pressure treatment with medications in the hospital was associated with a greater risk of adverse events.

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So despite the evidence to the contrary, doctors (and nurses and patients) have been and continue to be trained to worry about single high blood pressure readings. 

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In fact, doctors will frequently send patients from their offices directly to the ER simply because of a very high blood pressure reading, even if the patient is feeling fine. This occurs despite the fact that we know it doesn’t help! A research study from 2016 proved that this did not lead to improved outcomes. That study looked at patients who presented to the office with systolic blood pressure >180mmHg. When comparing the patients who were “allowed” to go home with those who were sent to the ER, there were no differences in outcomes at any time point over the next 6 months.

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So what really is the danger of having intermittent high blood pressure for a day (or an hour)? And is there a level that is dangerous no matter how briefly it lasts?

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Well, we actually do have some data about how high blood pressure can go, and how it isn’t imminently dangerous. 

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In a study from 1985, a research team found that systolic and diastolic blood pressures can rise rapidly to extremely high levels during exertion.

This research group looked at weight-lifters, and wondered how high their blood pressure went during exercise. They used catheters (small tubes) inserted directly into the arm arteries of the research subjects, and found that blood pressures could go extremely high. 

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How high?

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The greatest peak blood pressures occurred when the weight lifters were doing a double-leg press, where the average blood pressure value for the group was 320/250 mmHg, with pressures in one subject exceeding 480/350 mmHg!!

Peak blood pressures with the single-arm curl exercise reached a mean group value of 255/190 mmHg, when repetitions were continued until the subject couldn’t do any more. 

These results were replicated a few years later in another similar study where the authors documented extremely high blood pressure elevations of up to 345/245 mmHg during weight-lifting.

These studies proved 40 years ago that the human body can withstand extreme elevations in blood pressure. 

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So what does this all mean? Chronic high blood pressure is a very bad thing; intermittent high blood pressure is not. Even if it is very high.

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If one day you notice your blood pressure to be very high, don’t fret. Take a moment to think about what might have contributed to the reading. Were you upset about something? Did you go out to eat the night before (ANY restaurant food will be extremely high in salt)? 

Before “freaking out”about your blood pressure, try to relax. Do some mindfulness exercises or meditation. Go for a leisurely walk or bike ride. Check your blood pressure again the next day. If your blood pressure is high day after day after day, then you might indeed have hypertension, and you might need treatment. 

And that treatment shouldn’t always be medication. Evaluating salt intake, sleep quality, activity levels, alcohol intake can all lead to improved blood pressure control. 

But you also might find that the problem resolved on its own, just like we were built to do.

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At Wisconsin Cardiology Associates, we educate our patients on proper blood pressure measuring technique. Here is what we recommend:

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• Rest for at least 5 minutes in a quiet place.
• Avoid caffeine, alcohol and exercise for at least 30 minutes before checking.
• Sit in a comfortable chair with back support, feet flat on the ground, and relax.

• Sit upright with your arm resting on a table at heart level.
• Place the cuff on bare skin (not over clothing).
• The bottom of the cuff should be about an inch above the elbow.

• Stay still and silent as the cuff inflates and deflates. Don’t Talk!
• Take two to three readings, one minute apart, and record the LAST READING.
• Check Regularly! Check multiple days during the first week of every other month

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References:

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Rastogi R et al. JAMA Intern Med. 2021;181(3):345–352.

Patel KK et al. JAMA Intern Med. 2016 Jul 1;176(7):981-8

Anderson TS, et al. JAMA Intern Med. 2023 Jul 1;183(7):715-723.

MacDougal, J et al. J Appl Physiol 1985 Mar;58(3):785-90

Palatini et al. J Hypertens Suppl. 1989 Dec;7(6):S72-3.

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