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Hi Dr. Falkinburg,

I couldn't get through to you earlier as you were maxed out for a bit.  But in answer to your questions:
1.  What is your age?   55
2.  Have any tests been performed on you to determine whether or not you have something causing your hypertension? A TEST FOR A PHEOCHROMOCYTOMA WHICH WAS NEGATIVE
3.  Are you diabetic?  And if so, what glucose lowering meds do you take?  If you are not diabetic, why are you monitoring your A1C?  An A1C of over 6.5 is considered diabetic by most physicians.     YES WAS DIAGNOSED AS A DIABETIC, WAS PRESCRIBED METFORMIN, BUT CHOSE TO TRY -AND WAS SUCCESSFUL AT DIET CONTROL.
4. What is your blood sugar and your creatinine?  A1C WAS 7.5 AT THE HIGHEST NOW IS 5.2, GLUCOSE WAS 143 NOW 103; DO NOT KNOW CREATININE LEVEL - SORRY!!
5. Do you eat salt?  SOMETIMES
6. The only blood pressure med  that you are taking is micardis and you have only been on it for 2.5 weeks.  You have significant  hypertension.  Why are you not on more meds? If you have been on other meds, what were they?  
HAVE TRIED MANY DIFFERENT MEDS, BUT LIKE THE MICARDIS, THEY DO NOT DO MUCH TO LOWER THE BP - WILL LOWER A FEW POINTS BUT THEN THE BENEFIT STOPS AND IT DOES NOT GO ANY LOWER -AFTER ABOUT 4 WEEKS ON MICARDIS - LAST NIGHT WAS 161/103 HR 98, THIS MORNING WAS 151/94 WITH AN HR of 96.  THERE HAS BEEN A REDUCTION OF ABOUT 3-9 POINTS SYSTOLIC AND MAYBE 2-7 POINTS DIASTOLIC LEVELS I STILL HAVE THE SEVERE HIGHS WITH BPS AT/ABOUT 200/113

below i have repeated the original question.

have tried everything to contain my rather poorly controlled hypertension (averages range from 149/98low - 202/115high ; HR from 90-115) most days.  Last April 1st, i began a weight loss program and from April to September lost about 40 lbs.  I have been stuck at that loss and been unable to lose anymore.  The weight loss did had an added benefit.  From April to July, My A1C went from 7.7 to 7.5; from July to October, it dropped again from 7.5 to 6.5.  And surprisingly from October to January (with no additional weight loss) went from 6.5 to 5.1.  These drops were accomplished without medication.  My thyroid levels also dropped from 5.95 to 2.5 (October to January).  While these numbers continue to drop (i don't quite understand why they are still dropping without additional weight loss, but i guess it is a good thing), my BP stubbornly refuses to budge.  Is there anything else i can try?  In October, I had an ablation to control paroxysmal Afib.  My concern is without better HPN management, the Afib will return, will result in a damaged heart or worse a stroke.  
I am currently on Xarelto and Micardis-I have been on the Micardis for about 3-1/2 weeks now, but it really hasn't done a darn thing to lower the BP.  I started the Micardis in order to be more able to exercise.  Within 2 mintues of even mild exercise, my bp rises to well over 220/110 and the HR over 160.  It is frustrating to say the least.  I had planned on exercise as a main component in helping me reach my goal - which was 52 lbs in the first year, but i am so far from that goal, that it is getting disheartening to continue.  I don't want to lose all the benefits the weight loss has afforded me, but i don't know how to continue, so any advise would be greatly appreciated.

   
thank you!!!
andey

Answer
Good afternoon Andey,

Let me pontificate a little bit and tell you why we worry about high blood pressure (hypertension) and how it is most successfully treated.

Blood pressure is to your arteries as traffic is to roads.  The more traffic you have, the faster the roads wear out. Likewise, the higher your blood pressure, the faster your arteries wear out.  This is manifested in humans as accelerated hardening of the arteries which causes heart attack, stroke and kidney failure.  Additionally, the heart will eventually fail due to propelling blood against a high pressure head. I won't get into the signs and symptoms, suffice it to say that it isn't pretty.

It has been PROVEN that lowering the blood pressure with medications can prevent these phenomena from occurring.  It has also been proven that certain lifestyle changes, such as weight loss, dietary salt restriction and aerobic exercise can facilitate these changes, often reducing the dosages of medications that required to achieve normal blood pressures.  It is rare for lifestyle changes to be adequate by themselves.

Diabetes mellitus (the usual form of diabetes), by itself, is associated with accelerated hardening of the arteries and is very often associated with heart attack. In fact, so striking is the association that diabetes is called a coronary equivalent and blood pressure targets are lower than non diabetics (less than 130/80) as are cholesterol lowering targets. The "bad cholesterol" or LDL's is lowered to "less than 70".

Therefore, you are at great risk for developing the above complications because of your poorly controlled blood pressure and your diabetes, even though you have done an excellent job of treating it with diet and weight loss alone. You are still at great risk.

There are a few diseases that can cause hypertension and these are associated with hypertension that is very difficult to treat (called resistant hypertension).  These should be excluded in your case.  You have already excluded one of these (a pheochromocytoma).  There is also a NONcancerous tumor of the adrenal gland that produces a hormone called aldosterone that increases blood pressure. You need to have this condition excluded.  Additionally, a narrowing of the artery to one or both of your kidneys can cause hypertension.  Usually a MRI renal angiogram or a Doppler renal artery ultrasound will exclude this.  Lastly, kidney disease can cause hypertension and you need to have your creatinine checked as well as a urinalysis preformed.

Now you need to normalize your blood pressure. Here's how I'd go about it.

The cornerstone to treating hypertension is adhering to a low salt diet.
   1. Take your salt shaker and throw it away; no salt at the stove or at the table.
   2.  Eat no foods that you can see salt on.
   3.  Eat minimal food from a vacuum plastic wrapper (like luncheon meats, they are preserved with a ton of salt).
   4.  Eat minimal foods from a can, they too are preserved with salt.  Eat fresh or frozen vegetables.

This is an approximate 4 gram sodium diet and will facilitate BP control.

I would continue your micardis and slowly increase the dose to 80 mg a day, if you are not taking that dose now.  Micardis is a class off drug called angiotension receptor blockers .  In addition to their BP lowering effect, they protect the kidney from the complications of diabetes (as does a low A1C). You should continue your weight loss efforts.

All hypertensives need to be on a diuretic and the one that seems to be the best is called chorthalidone.  This should be ADDED (we add meds in the treatment of hypertension) to your micardis and the dose slowly increased to 25 mg per day.  Uncommonly, chlorthalidone lowers the potassium so it should be checked from time to time and treated if appropriate. If a third medication is required a medication such as Toprol or norvasc should be used.

Yes, I know.  This is a far cry from life style changes making medications unnecessary, but the bottom line is that life style changes are rarely sufficient alone and most patients do not maintain them over the VERY long term.  And, considering the dire consequences of poorly controlled BP it is important to be aggressive!

Lastly, Even though your weight loss has produced some wonderful results in controlling your diabetes, you will remain insulin resistant.  This tends to result in triglycerides that are too high and HDL's (good cholesterol) that are too low as well as LDL's (bad cholesterol) that remain too high.  It has been shown that metformin helps reverse this.  Although I don't feel very strongly about it, if I were you, I would consider going back on the metformin.

Many, if not all experts feel that ALL diabetics should take a statin like Lipitor or Zocor because of their propensity to develop cardiac issues.

I recognize that all of this is complicated both for you as well as most primary care physicians.  Therefore, I would recommend that you be followed and treated by a nephrologist.  He/She considers the above a "typical day at the office" and would by best qualified to keep you out of trouble over the long term.

Andey, believe it or not, the above is incomplete and barely scratches the surface, but it is important.

Feel free to follow up.

Good luck!

Sincerely,

Dr Falkinburg  

Hypertension

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Newell R. Falkinburg, M.D. FACP

Expertise

Any question regarding hypertension or clinical nephrology

Experience

35 years of experience in the field of nephrology & hypertension. Emeritus Professor of clinical Medicine at a major medical school and director of Nephrology & Hypertension at a university affiliated medical center.

Education/Credentials
M.D. Board certified internal medicine Board certified Nephrology & hypertension

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Fellow, American College of Physicians

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