27/04/2019

Big arm-to-arm difference in blood pressure linked to higher heart attack risk

The next time you have your blood pressure checked, ask your health care to check it in both arms, rather than just in one. Why? A big difference between the two readings can give you an early warning about increased risk of cardiovascular disease, a new study suggests.

Researchers at Harvard-affiliated Massachusetts General Hospital and colleagues measured blood pressure—in both arms—in nearly 3,400 men and women age 40 or older with no signs of heart disease. The average arm-to-arm difference was about 5 points in systolic blood pressure (the first number in a blood pressure reading). About 10% of the study participants had differences of 10 or more points. Over the next 13 years or so, people with arm-to-arm differences of 10 points or more were 38% more likely to have had a heart attack, stroke, or a related problem than those with arm-to arm differences less than 10 points. The findings, which appear in the March 2014 American Journal of Medicine, uphold earlier work on arm-to-arm differences in blood pressure.

Small differences in blood pressure readings between the right and left arm are normal. But large ones suggest the presence of artery-clogging plaque in the vessel that supplies blood to the arm with higher blood pressure. Such plaque is a signal of peripheral artery disease (cholesterol-clogged arteries anywhere in the body other than the heart). When peripheral artery disease is present, there’s a good chance the arteries in the heart and brain are also clogged, boosting the odds of having a heart attack or stroke.

While most cardiologists routinely measure blood pressure in both arms as part of an initial evaluation, most primary care doctors don’t. “Our study suggests that a baseline blood pressure measurement in both arms by primary care clinicians may provide additional information about cardiovascular risk prediction,” says study co-author Dr. Christopher O’Donnell, a cardiologist at Massachusetts General Hospital and associate professor of medicine at Harvard Medical School.

Here’s another reason to check blood pressure in both arms: if the pressure in one arm is higher, that arm should be the one upon which to base any treatments and to check your blood pressure in the future. (The current guidelines for managing high blood pressure are discussed here).

This study didn’t look at whether more aggressive treatment in people with high arm-to-arm blood pressure differences would help protect them from heart attack or stroke. Still, it’s worth finding out if you face a high risk of heart disease. That might inspire you to redouble your efforts to improve your cardiovascular health. To that end, the top six steps are:

    Don’t smoke. Tobacco smoke is as bad for the heart and arteries as it is for the lungs. If you smoke, quitting is the biggest gift of health you can give yourself. Secondhand smoke is also harmful, so avoid it whenever possible.
    Be active. Exercise and physical activity are about the closest things we have to magic bullets against heart disease and other chronic conditions. Any amount of activity is better than none; at least 30 minutes a day is best.
    Aim for a healthy weight. Carrying extra pounds, especially around the belly, strains the heart and tips you toward diabetes. If you are overweight, losing just 5% to 10% of your starting weight can make a big difference in your blood pressure and blood sugar.
    Enliven your diet. Add fruits and vegetables, whole grains, unsaturated fat, good protein (from beans, nuts, fish, and poultry), and herbs and spices. Subtract processed foods, salt, rapidly digested carbohydrates (from white bread, white rice, potatoes, and the like), red meat, and soda or other sugar-sweetened beverages.
    Drink alcohol in moderation (if at all). If you drink alcohol, limit your intake — one to two drinks a day for men, no more than one a day for women.
    Ease stress. Finding ways to ease stress, such as exercise, meditation, mindfulness, and other techniques, can take a load off the heart and arteries.
History is repeating itself in my family. My mother has Parkinson’s disease, and my father is her caregiver. Forty years ago, my mom was the caregiver for her own mother, who had advanced Parkinson’s disease and dementia.

I didn’t know my grandmother before she became frail and sick, but I knew that her children adored her. They couldn’t bear to place her in a nursing home, so they took six-month turns caring for her in their own homes. Every day, my mother would bathe my grandmother, dress her, feed her, and make sure she took her medications. She had no additional help, and no support from my grandmother’s doctors. It was exhausting for my mother, and I felt her anguish.

That was in the mid-1970s, when being a caregiver wasn’t a defined role. Now it’s so commonplace that researchers study caregiving. They estimate that 43.5 million people in our country provide in-home, long-term care for older adult family members with a chronic illness. There’s even an entire industry of services tailored to aging in place.

But despite the awareness of these roles, and the support services now available, the attention paid to caregivers isn’t much different than when I was a kid. In fact, a report published today in JAMA finds that many physicians overlook caregiver burden.

“Most physicians haven’t been trained to ask patients about it, and it’s a new clinical habit that you have to consciously adopt and work on,” says geriatrician Dr. Anne Fabiny, medical editor of Caregiver’s Handbook, a Special Health Report from Harvard Medical School.

The authors of the JAMA study found that caregivers are typically women who spend about 20 to 40 hours a week providing care. They also found that most caregivers feel abandoned and unrecognized by the health care system. Spousal caregivers face greater challenges than caregivers helping a parent for a variety of reasons, one of which is that they tend to be older.

Of these caregivers, 32% have a high caregiver burden. There is no medical classification for “caregiver burden.” But it’s generally known as the toll that caregiving takes on a person. It can manifest in many ways, including physical ailments, mental illness, social isolation, and financial problems. “Caregivers get depressed. Then they neglect their own health or they miss doctor appointments because they can’t extract themselves from their caregiving role. They just don’t have support, so things like exercising, getting enough sleep, or engaging in a social life all fall away,” says Dr. Fabiny.

The JAMA study cites cases of elderly caregivers who are so distraught that they try to commit suicide just to get out of the situation. The authors of the JAMA report and others are urging physicians to help prevent or reduce mounting desperation among caregivers by playing a part in assessing the caregiver’s health during regular clinic visits for the person who is chronically ill.

Physicians can evaluate the caregiver by asking:

    How are you coping with these responsibilities?
    How would you describe your quality of life these days?
    How often do you get out?
    Do you have your own physician?

The answers can help physicians direct caregivers to various services and support systems. These include:

    respite for the caregiver, in the form of a home companion or an adult daycare program for the patient
    help with non-medical services such as housekeeping and cooking
    counseling about caregiver stress and its consequences, from either a therapist or support group
    training so the caregiver learns how to care for her or his loved one without injury, such as learning how to lift the person without suffering back strain.

It’s the type of support that would have eased my mother’s burden when I was a kid. And it’s especially important to me now that my parents are in a spousal-caregiver relationship. I might worry about my father, a prince who never complains, except that the situation is a little different this time around. First, my mother is not as ill as my grandmother was. Second, my parents have me, a bossy health reporter, who is aware of support options and quick to arrange them. Not everyone has that kind of inside scoop.

So I’m grateful that the medical community is stepping up to the plate and shining the spotlight on caregiver wellness.

“The person you’re caring for is only as good as you are, and if you don’t take care of yourself, you can’t take care of the person you love and are responsible for,” advises Dr. Fabiny.

The Caregiver’s Handbook includes a detailed questionnaire to help caregivers identify problems and solutions for their caregiving situations. It also offers suggestions for legal and financial planning and tips for taking care of yourself as the caregiver, with emphasis on your own health and remembering to exercise, eat right, and see friends and family. How bad can a little high blood pressure be? It turns out that it might be worse than we thought.

Fifty years ago, the rule of thumb for a healthy systolic blood pressure (the top number of a blood pressure reading [see “Blood pressure basics”]) was 100 plus your age. Today, a healthy blood pressure is below 120/80. High blood pressure (what doctors call hypertension) is any pressure above 140/90. In the spring of 2003, an expert panel appointed by the National Institutes of Health created a new category—prehypertension. It covers the 25% of Americans in the gray zone between normal blood pressure and hypertension, who have systolic blood pressures between 121 and 139 and/or diastolic pressures between 81 and 89.

Some doctors and pundits scoffed that this new definition was “disease mongering.” A study to be published in the April issue of the journal Neurology indicates that we should take prehypertension seriously.

Blood pressure basics
When the heart contracts, the pressure in the arteries rises—that’s your systolic pressure, usually written as the first number of a blood pressure reading. When the heart relaxes between beats, the pressure falls—that’s your diastolic pressure. The ideal blood pressure is 120/80.

Researchers from Southern Medical University in Guangzhou, China, examined the results of 19 high-quality studies looking at links between prehypertension and stroke. The studies included more than three-quarters of a million people, whose health and wellbeing was followed for 36 years. The researchers broke down the participants into two groups:

    Low-range prehypertension: Blood pressure between 120/80 and 129/84
    High-range prehypertension: Blood pressure between 130/85 and 139/89

People with high-range prehypertension had a 95% higher stroke risk compared to people with blood pressures less than 120/80. Those in the low-range had a 44% higher stroke risk.
Lifestyle changes lower health risks

The size of the study and the length of the followup make the results believable. They don’t mean that we should elevate prehypertension to a disease. But they do signal that we need to take it seriously.

How seriously? So far, there’s no solid evidence that people with prehypertension benefit from taking medications. Blood pressure drugs lower blood pressure, but they can also cause harmful side effects. In the prehypertension range, benefits and risks seem to cancel each other out.

Instead, lifestyle changes are the way to go for prehypertension. Here are several changes that can lower blood pressure:

    If you smoke, quit
    Strive to maintain a healthy weight.
    Stay physically active as much as you can all day.Get at least 30 minutes of moderate intensity exercise most days of the week.
    Make vegetables and fruits half of every meal. Potatoes don’t count as a vegetable.
    For the other half, aim for healthy protein and whole grain carbohydrates.
    Cut back on the amount of salt and sodium you take in. Much of the salt and sodium we consume comes from packaged foods, so check labels.
    Drink water instead of sugary beverages.
    If you drink alcohol, keep it moderate. That’s no more than one alcoholic drink a day for women, no more than two a day for men.

These changes will help beat prehypertension. Even better, they will almost surely lower your risk of having a stroke or heart attack, or developing heart failure, diabetes, kidney disease and some cancers.

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