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 AT YOUR FINGERTIPS

HIGH BLOOD
PRESSURE

THIRD EDITION
Professor Tom Fahey,
Professor Deirdre Murphy
and Dr Julian Tudor Hart
 Comments on High Blood Pressure – the ‘at your
fingertips’ guide from readers
‘. . . readable and comprehensive information for anyone with high
blood pressure . . .’
Dr Sylvia McLauchlan MB, ChB, MSc, FFPHM
Former Director General, The Stroke Association

‘It is very readable, I think pitched at just the right level.’

Professor Godfrey Fowler
Emeritus Professor of General Practice, University of Oxford

‘I have thoroughly enjoyed reading this book, it has covered all the
questions that I and most people especially those with high blood
pressure would like to ask.’
Evelyn Thomas SRN, Glyncorrwg

‘This book answers the questions you always wanted to ask about high
blood pressure, plus many you haven’t even thought of.’
Gwen Hall RMN, RGN, BSc, Hindhead

‘I have enjoyed reading High Blood Pressure – the ‘at your fingertips’
guide and now feel much better informed.
Mrs Shirley Wallwork

‘. . . a clear and comprehensive review of hypertension, its causes,

clinical picture and treatment. A must for the bookshelf of all those
interested in, or suffering from, high blood pressure.’
H. Rees, Killay

‘I have always been health conscious and a believer in taking control

of my own health. When I was told by my GP that I had high blood
pressure, I wanted to find out everything I could about it before
starting any treatment. This book has not disappointed me – it has
answered all my questions, and I now feel more confident about
arranging a suitable treatment plan with my GP.’
Andrea Bagg, Tunbridge Wells

‘This is a really excellent book and a very valuable addition to the

series.’
Professor Paul Wallace, Royal Free Hospital School of Medicine
‘As someone who has had high blood pressure for 29 years I still found
this book enlightening and was impressed by the fact that I felt
because of the way the author had written the book that it was really
speaking to me, and as a result I didn’t find it wearisome reading like
some information books.’
Babs Walters, Port Talbot

‘The language is pitched at just the right level so that the reader feels
he has been taken into partnership with the doctor in understanding
his condition.’
Dr A. G. Donald, Edinburgh

‘Exactly the right style for dealing with the sort of problems that
patients regularly have. It is not only educational but extremely
enjoyable.’
Professor John Swales, Professor of Medicine, University of Leicester

Reviews of High Blood Pressure – the ‘at your

fingertips’ guide
‘This well written book is capable of informing health professionals . . .
The question and answer format of the book gives comprehensive
coverage.’
Adrienne Willcox, Practice Nurse

‘Dr Julian Tudor Hart has produced an excellent book . . . with a

comprehensive question and answer format which will solve any
query.’
Dr Donald McKendrick, Saga Magazine
 HIGH
BLOOD PRESSURE
THIRD EDITION

Tom Fahey MSc, MD, MFPHM, MRCGP

Professor of Primary Care Medicine,
Tayside Centre of General Practice, University of Dundee;
General Practitioner at Taybank Medical Practice, Dundee

with a chapter on high blood pressure in pregnancy by

Deirdre Murphy MD MRCOG

Professor of Obstetrics, University of Dundee;
Consultant Obstetrician, Ninewells Hospital, Dundee

Julian Tudor Hart MB, BChir, DCH, FRCP, FRCGP

Honorary Research Fellow at Welsh Institute for Health
and Social Care, University of Glamorgan, Pontypridd

CLASS PUBLISHING • LONDON

Text © Tom Fahey, Deirdre Murphy and Julian Tudor Hart 1996,1999, 2004
© Class Publishing (London) Ltd
All rights reserved. Without limiting the rights under copyright reserved above,
no part of this publication may be reproduced, stored in or introduced into a
retrieval system, or transmitted, in any form or by and means (electronic,
mechanical, photocopying, recording or otherwise), without the prior written
permission of the publisher of this book.
The authors assert their rights as set out in Sections 77 and 78 of the Copyright
Designs and Patents Act 1988 to be identified as the authors of this work
wherever it is publisher commercially and whenever any adaptation of this
work is published or produced including any sound recordings or files made
of or based upon this work.
Printing history
First published 1996
Reprinted 1997
Reprinted with revisions 1997
Second edition 1999
Reprinted 2000
Reprinted 2001
Reprinted 2002
Reprinted 2003
Third edition 2004
The authors and publishers welcome feedback from the users of this book.
Please contact the publishers.
Class Publishing (London) Ltd, Barb House, Barb Mews,
London W6 7PA
Telephone: 020 7371 2119
Fax: 020 7371 2878 [International +4420]
email: [email protected]
Visit our website – www.class.co.uk
The information presented in this book is accurate and current to the best
of the authors’ knowledge. The authors and publisher, however, make no
guarantee as to, and assume no responsibility for, the correctness, sufficiency
or completeness of such information or recommendation. The reader is
advised to consult a doctor regarding all aspects of individual health care.
A CIP catalogue record for this book is available from the British Library
ISBN 1 85959 090 X
Edited by Susan Bosanko and Michèle Clarke (1st and 2nd editions),
Michèle Clarke (3rd edition)
Indexed by Michèle Clarke
Cartoons by Julian Tudor Hart
Line illustrations by David Woodroffe
Typeset by Martin Bristow
Printed and bound in Finland by WS Bookwell, Juva
 Contents

Acknowledgements ix

Foreword by Dr Julian Tudor Hart xi

About this book xix

INTRODUCTION What you most need to know

in 11 questions 1

CHAPTER 1 Blood pressure and high blood pressure 7

About blood pressure in general 8
Low blood pressure 15
High blood pressure 15
Types of high blood pressure 18

CHAPTER 2 Symptoms, causes and diagnosis 25

Symptoms 26
Causes 29
Diagnosis 35

v
vi High Blood Pressure – the ‘at your fingertips’ guide

CHAPTER 3 Measuring blood pressure 42

Types of BP measuring devices 43
Accuracy of readings 47
Ambulatory monitoring 52
Monitoring at home 54

CHAPTER 4 Non-pharmacological treatment 58

Cholesterol levels 59
Diet 63
Smoking 72
Exercise 74
Weight loss 77

CHAPTER 5 Treatment with drugs 80

Taking your tablets 84

CHAPTER 6 High blood pressure with other problems 91

Heart problems 92
Diabetes 95
Kidney problems 96
Raised cholesterol levels 97
Problems requiring beta or alpha-blockers 99
Blood-thinning drugs 100
Racial differences 101
Pain – particularly joint pain and arthritis 102
Psychological problems 104

CHAPTER 7 Pregnancy, contraception

and the menopause 105
High BP and planning a pregnancy 106
High BP in pregnancy 109
Pre-eclampsia and eclampsia 113
 Contents vii

Blood pressure after pregnancy 125

Contraception 127
Menopause and HRT 129

CHAPTER 8 Living with high blood pressure 131

Work 131
Travel and holidays 133
Sports 136
Sex 137
Insurance and mortgages 141
Your local surgery 143
Everyday life 145

CHAPTER 9 Monitoring and follow-up 146

CHAPTER 10 Research and the future 153

GLOSSARY 156

APPENDIX 1 Drugs used in the treatment of

high blood pressure 166

APPENDIX 2 Useful addresses 179

APPENDIX 3 Useful publications and websites 189

Index 193
 Acknowledgements

We should like to thank our colleagues at Taybank Medical

Practice, Dundee, and the Department of Obstetrics and
Gynaecology and the Cardiovascular Risk Clinic at Ninewells
Hospital, Dundee, for their continuing support. Professor Mark
Caulfield (St Bartholomew’s and The London, Queen Mary’s
School of Medicine) provided additional material relating to
genetics and high blood pressure for which we are grateful.
Thanks also to Debbie O’Farrell for administrative support and
our colleagues at Tayside Centre for General Practice and the
Division of Maternal and Child Health Sciences, University of
Dundee. Michèle Clarke provided excellent editorial guidance.
We should like to thank Dr Philip Kell, author of Sexual Health
for Men – the ‘at your fingertips’ guide, for providing a question
on sex and high blood pressure.
Our largest debt of gratitude is to Professors Julian Tudor Hart
and Wendy Savage, who wrote the original edition of this book.
This third edition has been modified to reflect the recent evidence
concerning detection, treatment and management of high blood
pressure. However, large parts of the text have remained
unaltered, a tribute to the original work done by Julian and
Wendy. We alone are responsible for any errors in the text.

ix
 Foreword
by Dr Julian Hart
MB, BChir, DCH, FRCP, FRCGP

High blood pressure is the most common continuing medical

condition seen by family doctors. At just what measurement
‘normal’ blood pressure becomes ‘high’ blood pressure that
justifies action being taken to reduce it is still a subject for
professional argument among doctors (although most now agree
on a pressure of somewhere around 160/90 mmHg). Whatever the
definition, the numbers of people needing some sort of treatment
for high blood pressure include at least 10% of any large group of
adults, up to 33% of poorer city adults, and about 50% of all
people over 65 years of age – a lot of people.
If you are one of this 10–50%, and you need medication for
your high blood pressure, you will probably go on needing it for
the rest of your life. If you read, understand, and remember the
following few pages, you will be well on the way to understand-
ing the nature of your high blood pressure, what can and what
can’t be done about it, and both the benefits and risks of treat-
ment. If not, your alternative is to let doctors take decisions
about your life, without your help or informed consent. Most
doctors today understand how dangerous it is for the people they
treat to be so uninformed and uncritical. Safe doctoring depends
on the cooperative work of two sets of experts: expert profes-
sionals who know a lot about how the human body works but
little about the personal lives of the people they are treating; and
the people being treated, who are experts on their own lives but
know rather less about how their bodies work. Just as doctors
can’t look after you properly if they are completely ignorant of
your life, so you can’t interpret their advice safely if you are com-
pletely ignorant of human biology.

xi
xii High Blood Pressure – the ‘at your fingertips’ guide

Even if you remember only these few pages, you will know
more about the practical management of high blood pressure
than many health professionals, who usually have to cover a
much wider range of medical conditions and cannot concentrate
only on this one. With or without this knowledge, you, not your
doctors, will be responsible for actually using the treatments they
recommend. Many different drugs are used to treat high blood
pressure, but they all have one thing in common: they don’t work
if you don’t take them. Yet many (if not most) people treated for
high blood pressure don’t take their tablets regularly. They take
them if they feel as though their blood pressure is high, but miss
them if they feel well or plan to have a few drinks, or need to take
other tablets for something else and are afraid of mixing them, or
if they’re afraid of side-effects and even more afraid of admitting
this to their doctor. Unless you are in hospital you have to take
your own treatment decisions – there are no nurses’ rounds to
see that you follow orders. To medicate yourself safely you need
far more information than any doctor or nurse can impart in the
few minutes usually available for a consultation, and one purpose
of this book is to provide you with that information.

What high blood pressure is and what it is not

Everybody’s blood is under pressure, otherwise it wouldn’t circu-
late around the body. If blood pressure is too high it damages the
walls of your arteries. After many years, this damage increases
your risks of coronary heart disease, heart failure, stroke, bleed-
ing or detachment of the retina (the back of the eye), and kidney
failure. High blood pressure itself is not a disease, but a treatable
cause of these serious diseases, which are thereby partly pre-
ventable. All these risks are greatly increased if you also smoke
or have diabetes.
Unless it has already caused damage, high BP seldom makes
you feel unwell. It can be very high without causing headaches,
breathlessness, palpitations, faintness, giddiness, or any of the
symptoms which were once thought to be typical of high BP. You
may have any or all of these symptoms without having high BP,
and you may have dangerously high BP with none of them.
 Foreword xiii

The only way to know if you have high blood pressure (and
how high it is) is to measure it with an instrument called a
sphygmomanometer while you are sitting quietly. Because BP
varies so much from hour to hour and from day to day, this
should be done at least three times (preferably on separate days)
to work out a true average figure before you take big decisions
like starting or stopping treatment.

Mechanisms
Your level of BP depends on how hard your heart pumps blood
into your arteries, on the volume of blood in your circulation, and
on how tight your arteries are. The smaller arteries are sheathed
by a strand of muscle which spirals around them: if this muscle
tightens and shortens, it narrows the artery. In this way smaller
arteries can be varied in diameter according to varying needs of
different organs in different activities. In people with high BP
something goes wrong with this mechanism, so that all the arteries
are too tight. The heart then has to beat harder to push blood
through them. This tightening-up may be caused by signals sent by
the brain through the nervous system, or by chemical signals (hor-
mones) released by other organs in the body (such as the kidneys).

Causes
The causes of short-term rises in blood pressure which last only
seconds or minutes are well understood, but these are not what
we normally mean by high blood pressure. High blood pressure is
important only when it is maintained for months or years – it is a
high average pressure which is significant, not occasional high
peaks. The causes of a long-term rise in average pressure are not
fully known, but we do know that it runs in families. This inher-
ited tendency seems to account for about half the differences
between people; the rest seems to depend on how they live and
what they eat (not just in adult life, but what they ate in infancy
and childhood and how well-nourished they were before they
were born). We don’t know enough about this to be able to pre-
vent most cases.
xiv High Blood Pressure – the ‘at your fingertips’ guide

One cause we do know about is overweight (particularly in

young people) and weight reduction is a sensible first step in
treatment. Weight loss depends mainly on using up more energy
(measured in calories) by taking more exercise, and reducing
energy input (the number of calories eaten in food). In practice
the most healthy way to do this is by reducing the amount of fats,
oils, meat, sugar and alcohol in the diet, and instead eating more
fruit, vegetables, cereal foods and fish (some of these foods have
other good effects as well as helping weight loss). Eating less fat
and oil is by far the most important of these changes. Another
benefit from these changes in diet is that they help lower blood
cholesterol levels and so reduce the risk of developing coronary
heart disease.
Another known cause is excessive alcohol (which means
more than 4 units of alcohol a day for a man or 3 units a
day for a woman – a unit of alcohol is one glass of wine or
one single measure of spirits or half a pint of average
strength beer or lager). Again, the biggest effect is in young
people. Limiting alcohol intake often brings high BP back to
normal without any other treatment.

Stress
If you are anxious, angry, have been hurrying, have a full bladder
or if you are cold then your BP will rise for a few minutes or even
a few hours (so BP measured at such times is not reliable) – but
none of these things seem to be causes of permanently raised
blood pressure. High blood pressure seems to be just as common
in peaceable, even-tempered people without worries as it is in
excitable people with short fuses. However, feeling pushed at
work or at home may be an important cause in some people, if
not for everyone.
The word ‘hypertension’ is used in medical jargon with exactly
the same meaning as high blood pressure. This does not mean
that feeling tense necessarily raises blood pressure, nor does it
mean that most people with high blood pressure feel tense.
Blood pressure falls considerably during normal sleep, both in
people with normal blood pressure and in those whose blood
 Foreword xv

pressure is high. Training in relaxation certainly lowers blood

pressure for a while, and may have a useful long-term effect on
high blood pressure in people who learn how to switch off often
during the day, but there is no evidence that treatment by relax-
ation alone is an effective or safe alternative to drug treatment
for people with severe high blood pressure.

Salt and sodium

Table salt is sodium chloride: it is the sodium which is important
for your blood pressure, not the chloride. High blood pressure is
unknown among those peoples of the world whose normal diet
contains about 20 times less sodium than a normal Western diet,
and even very high BP can be controlled by reducing sodium
intake to this low level. The diet required for this consists
entirely of rice, fruit and vegetables and would be intolerable to
most people in this country.
The usual British diet contains much more salt than anyone
needs. It certainly does no harm to reduce sodium intake by not
adding salt to cooked meals, and by reducing or avoiding high
sodium processed foods (crisps, sausages, sauces, tinned meats
and beans, and ‘convenience’ foods generally), Chinese take-
aways (which contain huge quantities of sodium glutamate) and
strong cheeses. Salt can be found in the most unexpected foods –
for example, both milk and bread contain salt in amounts which
would surprise most people.
There is no convincing evidence that the roughly one-third
reduction in sodium intake you can achieve by these dietary
changes is an effective alternative to drug treatment for severe
high blood pressure. Reducing fat in your diet by about a quarter
reduces the potential complications of high blood pressure much
more effectively than reducing your salt intake by about half.
Most people find it difficult to reduce fat and salt at the same time,
and fat reduction deserves a higher priority (especially as cutting
down on fats will help you lose weight). However, people whose
blood pressure is high enough for them to need to take drugs for it
may manage on lower doses of their tablets if they reduce their
sodium intake, and very heavy salt-eaters should try to cut down.
xvi High Blood Pressure – the ‘at your fingertips’ guide

Smoking
Smoking is not a cause of high blood pressure, but it enormously
increases the risks associated with it. If you have high blood
pressure already, then if you also smoke you are three times
more likely to have a heart attack than non-smokers if you are
under 50 years old, and twice as likely to have one if you are over
50. Heart attacks in people under 45, and in women at all ages,
happen much more frequently in smokers.
Smoking is a powerful risk factor in its own right, not only for
coronary heart disease and stroke, but also for cancer of the
mouth, nose, throat, lung, bladder and pancreas, and for asthma
and other lung diseases. Unlike all other risk factors, it also
affects your colleagues, family and friends (through passive
smoking and the example you set to your children) and it costs a
lot of money you could spend better in other ways.

When to have drug treatment

You will probably be advised to have drug treatment for your
high blood pressure if there is already evidence of damage to
your arteries, brain, heart, eyes or kidneys, or if you also have
diabetes As a very rough guide, drug treatment is otherwise
rarely justified unless your average blood pressure (averaged
from at least three readings on separate days) is at least 160/100
mmHg. While you don’t need to know exactly what these figures
mean, you should know what they are in your own case, just as
you do your own height and weight.
This threshold figure (plus or minus 5 mmHg either way) is
based on evidence from large controlled trials in Britain,
Australia, Scandinavia and the USA, which have shown
worthwhile saving of life in many thousands of people. The
benefits of drug treatment are greatest in the people with the
highest pressures, or those who already have evidence of organ
damage. Most of the benefit has been in reducing strokes, heart
failure and kidney damage; the effects on coronary heart attacks
have been much smaller (more important ways to prevent heart
 Foreword xvii

attacks are to stop smoking, maintain regular exercise, and stick

to a diet low in saturated fats).

Blood pressure-lowering drugs

When severe high blood pressure is reduced by drugs, people live
longer than if they are left untreated. Their treatment will not
affect how they feel – it seldom makes people feel better, and
they may sometimes even feel worse. The aim of all present
treatments for high blood pressure is not to cure it, but to prevent
its consequences by keeping pressure down to a safer level
(whatever the underlying causes of high blood pressure are, they
seem almost always to be permanent and are not affected by any
of the treatments now available). Treatment must therefore
nearly always continue for life – if you stop taking your tablets,
your blood pressure will probably rise again, although this may
take several months.
Unfortunately, all the drugs used for high blood pressure can
cause unpleasant side effects in some people, although the newer
blood pressure lowering drugs are generally easier to live with
than the older ones. If you think your drugs are upsetting you,
then say so, as there are alternatives. With so many blood
pressure-lowering drugs now available your doctor should be
able to tailor an individual treatment for you that minimizes side
effects or even eliminates them altogether. Included among the
side effects of blood pressure-lowering drugs are tiredness,
depression and failure of erection: if any of these happen to you,
then tell your doctor or nurse, as if they really are caused by your
drugs, they will clear up soon after your medication is changed.
If you have any wheezing or asthma, then some blood
pressure-lowering drugs can be very dangerous, so make sure
your doctor knows about this. Some drugs used for back and joint
pains can interfere with the effect of drugs given for high blood
pressure, and you should ask your doctor about these if you take
them. (Don’t try to alter your medication yourself.) The
contraceptive pill occasionally raises blood pressure very
seriously, so women with high blood pressure should discuss
other methods of birth control.
xviii High Blood Pressure – the ‘at your fingertips’ guide

Remembering to take tablets is difficult for many people. Take

them at set times, and ask your partner or a friend to help you
learn the habit of regular medication. Don’t stop taking your
tablets just because you’re going out for a drink – all blood
pressure-lowering drugs can be taken with moderate amounts of
alcohol.

Follow-up
Always bring all your tablets (not just those for your high BP)
with you in their original containers when you see your doctor or
nurse for follow-up, so that they know exactly what you are
taking. If your blood pressure doesn’t fall despite apparently
adequate medication, think about your weight or your alcohol
intake. Follow-up visits should be frequent at first, perhaps once
a week until your blood pressure is controlled to under 160/90
mmHg. After that most doctors will want to check your blood
pressure every three months or so; never go longer than six
months without a check.

The end of the beginning

All this (and I mean all) is the least you need to know to take an
intelligent share in responsibility for your future health, not just
as a passive consumer of medical care, but as an active producer
of better health (as everyone should be). However, I hope by now
you are interested enough to want to know more than this. The
rest of this book will tell you a lot more both of what we do know
about high blood pressure and – just as important – what we
don’t know.
 About this book

Most of you reading this will have been told that either you, or
someone in your family, has raised blood pressure. The questions
in this book are those asked by people like you every day; the
answers are intended to help you be as informed as possible
about your own care so that your treatment will be more
successful and you will feel more in control. Remember that no
one involved in this subject (including doctors and nurses) ever
stops learning more about it. In fact, a few of you may read this
book not because of your own health problems, but because
in your work you are concerned with the health problems of
other people.
Because different people have different requirements for
information about high blood pressure, this book has been
designed in a way that means you do not have to read it from
cover to cover unless you wish to do so. The questions are
arranged into chapters and sections, so you may care to dip into
it in sections at a time, or look for the answer to a particular
question by using the table of contents and the index. Cross-
references in the text will lead you to more detailed information
where this might be helpful, and essential information is repeated
wherever it seems to be necessary. Having said all this, the book
begins with a brief general outline of high blood pressure – What
you most need to know in 11 questions. However much you
dip into and skip through the rest of the book, may we ask you
please to read these few pages thoroughly?

xix
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