]]]]]]]]]]]]]]]]]]]]          HYPERTENSION        [[[[[[[[[[[[[[[[[[[[    
                                                          (10/31/1989)
             From the newsletter of Thomas A.Dorman, M.D., 
                           (Freeman 93401DORM)

       58 million Americans have hypertension. Is one in four of us 
diseased? Officially, yes. The concept of disease separating the sick 
from the healthy can be traced to ancient times when evil spirits were 
let out of the body to restore health. In the late Renaissance, when 
modern medicine crystallized, the hypothesis or model of disease as a 
distinct entity was the lattice work upon which the major advances in 
medical sciences occurred and which have contributed so marvelously to 
modern well-being. The microbial cause of infectious disease developed 
by Pasteur is the most distinct example. Other mental lattice works 
for considering health and disease have been thought of at different 
times. The notion of ill health occurring in some of us from an 
idiosyncrasy to the environment, from an allergy to environmental 
agents and to toxic substances, is such an example. The harmful effect 
might be subtle; the discipline of allergy has only recently emerged 
from a century long shadow and homeopathy is still taboo. The disease 
concept has been a great boon P a useful hypothesis. It is possible 
however that nature is running out of secrets which yield to this 
model; perhaps we have harvested most of the diseases and syndromes. 
It is true that some new diseases are being discovered, Legionnaire's 
disease (on the 200th anniversary of the American revolution) Lyme 
disease and AIDS, but their number is a mere trickle compared with 
former times.

Cheating Nature
       The disease concept implies that in the absence of disease 
there is health. Nonetheless, aging, degeneration and death overtake 
us all. Improving the well-being of a person, postponing the symptoms 
of aging and deferring death can be thought of in the category of 
cheating nature. Here the disease model doesn't serve very well.
       Hypertension tends to affect most of us with advancing age and 
certain sections of the public are at increased risk, black people, 
diabetics and those with kidney disease. It is well established that 
by lowering the blood pressure artificially, life is prolonged and 
degenerative processes in the brain, the heart, the kidneys and other 
organs are delayed. As one cannot sense one's own blood pressure 
subjectively it is obviously sensible to record it with an instrument, 
a sphygmomanometer, and take action if there is an elevation. This is 
where preventative medicine enters the picture. Your doctor prefers 
the term disease deferment or cheating nature. They define the mind-
set for this category of bodily change. In a previous newsletter we 
have dealt with the problem of thinning bones in elderly women and 
cheating nature with hormones. If you are philosophically attuned to 
this approach, you may wish to maintain a low blood pressure and 
prolong your life. However, for this discussion, lets get away from 
the notion that low pressure is natural and hypertension is a disease 
and abnormal. When interfering with the spontaneous changes in our 
bodies there is a trade off. We might prolong and savour more of the 
good life, but: 1) There is a price paid in dollars, the cost of 
medication, doctor visits and laboratory studies. 2) Side effects of 
the medication might be expected. 3) A longer life will increase your 
expenses due to living into an older age. It is perfectly true that 
hypertension affects some individuals during their working career, and 
from an actuarial point of view, treating them increases the gross 
national product, but most hypertensive patients are retired. An 
increase in life expectancy here is a boon to the individual but an 
expense to someone.

New Zealand Leads the Way.
       The population of several civilized countries has adopted the 
approach that good health is public property. A typical example we
have narrowly avoided in California is in laws which mandate crash 
helmets for cyclists. When motor cyclists are injured, the expense is 
charged to the public purse. The inevitable logic is that if the care 
of the elderly is a public expense, then the public purse will be 
drained least by early death.
       About 15 years ago the Ontario government introduced their 
form of national health with the slogan: Rprevention is better than 
cureS. At that time your doctor was in charge of the internal medicine 
services for a community in Ontario. The health minister graced our 
town with an image-building visitation and his healthful policies were 
discussed over a mediocre meal. I put it to him that the cost of 
hypertension clinics was unknown, but clearly very large, because 
every postponed stroke would increase pension costs and the patient, 
still being a member of a mortal species, would have a terminal 
illness at an older age. As the government was taking on the cost of 
sickness, by adding a number of years to the person's life they were, 
on the average, taking on the cost of the preventive care in addition 
to the inevitable cost of the degenerative and terminal illness. The 
minister was shocked at what he called my callous approach, but 
admitted that no one in his government had even considered the matter. 
It was good policy for electoral purposes to promote public health and 
bring in national health on that basis. Soon after this encounter, but 
for other reasons I left Canada. You can imagine that I am not 
surprised to hear they now have long waiting lists for surgery, etc. 
In socialized medicine New Zealand takes the cake. It has the oldest 
socialized medical regime. This year New Zealand spawned two seemingly 
unashamed articles actually advocating the withholding of treatment 
for hypertension in __mild__ cases because of the cost. So rationing has 
arrived and you have no choice.

Planning
       It is not part of our cultural heritage to plan the end of our 
lives. No one knows the date of his demise, but as your life insurance 
premium is decreased, if your blood pressure is low, so should your 
pension premiums increase, you expect to live longer. Your doctor 
holds the opinion that in this category of health intervention, here 
labeled cheating nature, the "purchasing decision" should be that of 
the customer. The government's actuary is apt to have a slightly 
different perspective.

Definition of Hypertension
       The blood flows in our arteries in tides or squirts. The 
hydraulic term is "pulsatile flow." This results from intermittent 
muscle contraction of the heart. Immediately after the contraction 
there is a peak pressure, the systolic pressure. While the heart 
muscle is resting there is a trough or diastolic pressure. Within 
certain limits, the lower the pressure, the healthier. For practical 
purposes, a systolic pressure of 140 mmHg and a diastolic of 90 have 
been defined as the demarcation point between normal and abnormal. 
Arteries vary as do individuals, and your personal physician would be 
wise to check the effect of hypertension on your body in order to form 
an impression how normal the usual standard is for you.

How Does Hypertension Harm Us?
       The amount of blood flowing to the organs is regulated 
automatically by a number of feedback control servo-mechanisms. Some 
of these are controlled through the nerves and some through hormones. 
When the interaction between these is strained in some way, the blood 
pressure may rise. Little arteries, arterioles, restrict the outflow 
of blood from the pressure reservoir and the heart works harder. The 
actual volume of flow is increased, normal or decreased. It is natural 
for the blood pressure to rise as the emotions rise and when we 
exercise. The harmful effect of hypertension is by making the arteries 
tense for long periods which makes their walls thicken, sometimes 
permanently. Although it is true that when the blood pressure is 
extremely high, one of the pipes may rupture, bursting is not the 
usual way harm comes about. It is better to imagine the silting up of 
a drain as an analogy.

How To Control the pressure.
       Lip service is paid to holistic means P biofeedback, stopping 
smoking, using less alcohol, being thin, living without stress, and 
exercising regularly. We pay homage to this list and perhaps follow it 
a little. However, the control of hypertension with medicines is the 
most effective way and what you come to the doctor for.
The Medicines.
       Since the 1950's we have had effective medicines for 
controlling blood pressure. The increase in effectiveness and the 
decrease in side effects are gratifying. Most loops of the several 
servo-mechanisms controlling blood pressure have been the subject of 
pharmacologic attack. It has been found that, except in mild cases of 
hypertension, the combination of several medications each working on a 
different portion of the vascular regulatory mechanism gives the best 
effect with least side effects. The price in dollars is another 
matter.

Recommendation
       You should have your blood pressure checked at every visit to 
the doctor. If it is elevated on more than one occasion, you should 
start recording it yourself. It is better and cheaper to acquire a 
blood pressure cuff and keep a record yourself. Most importantly, it 
is your problem and you will need to make a decision whether you want 
the trade-off a longer life for the bother of cheating nature. 
Doctor's Role
       Your physician believes that after looking for and ruling out 
secondary hypertension (that is to say, separate distinct diseases 
which may be responsible for the hypertension, and these are quite 
rare) you should start to take medicine which will control your blood 
pressure. The introductory period usually calls for frequent doctor 
visits. During this time you should be trained in regulating your 
pressure yourself, keeping a record and even modifying the medication 
within agreed ranges. As soon as you are stable, doctor visits become 
infrequent and are mostly to check that your heart and arteries remain 
healthy at the blood pressure levels you are holding. 

The Shopping List of Medicines
       There is a logic tree your doctor follows in choosing the best 
medicine for you. Considerations include any other illnesses you may 
have or which have affected your family. Not every hypertensive is 
managed with the same drugs. In any case, the trial and success 
process (I don't like the term "trial and error") will accommodate 
your individual tolerance and susceptibility to the best buy for your
particular case.

Failures
       There are no failures in the control of hypertension in modern 
practice except when the patient doesn't follow through. It must be 
admitted, however, that the amount of trouble in regulating people can 
vary quite significantly.
Getting Rid of Hypertension.
       Once it has arrived, the tendency to hypertension usually 
lasts for life. On the other hand doctors have found that after good 
control for a year or more, the body resets the "barometer" and less 
medicine my be sufficient. 
       Many of us develop hypertension in old age. It is a matter of 
individual interest and individual responsibility to control 
hypertension. Your doctor's role is only to guide you. If there is a 
decision to cheat the reaper of an early death, surely it should be an 
individual decision?! Or is it a matter of public health?


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