Hypertension: What It Is; What It Isn't; How to Think About It, to Prevent It, and to Manage It

Suzanne Oparil, MD; George D. Lundberg, MD


December 12, 2007


This feature requires the newest version of Flash. You can download it here.

Dr. Lundberg: Good morning, I'm Dr. George Lundberg, Editor-in-Chief of Medscape General Medicine, and we are in Orlando, Florida, at the convention center, at the American Heart Association. We have the privilege this morning of being able to bring to you, in a Webcast Video Interview, Dr. Suzanne Oparil who is a Professor of Medicine at the University of Alabama, Birmingham, School of Medicine, who came there from the University of Chicago and before that had been trained in Boston and New York, and where else? Places like Columbia, Mass General, etc. And she is an expert, not only in hypertension, where she's the current sitting President of the American Society of Hypertension, but has also been President of the American Heart Association and the Federation for Clinical Research, or thereabouts. Good morning.

Dr. Oparil: Well, thank you very much. After that long introduction I'm afraid to say anything.

Dr. Lundberg: Well, you'd better not be afraid because we're going to talk about your subject, hypertension.

Dr. Oparil: Good.

Dr. Lundberg: What is it?

Dr. Oparil: Hypertension -- nothing in this world is simple anymore. Generally, hypertension is defined as a blood pressure greater than some number. Traditionally it's been greater than 140 over 90; in the old days it was greater than 160 over 100. Now some curveballs have been thrown into the lexicon because the experts are beginning to realize that what we call hypertension is really a syndrome. Elevated blood pressure is a physical sign, but people who have hypertensive disease generally have other things: the expanding girth, obesity, cholesterol abnormalities or dyslipidemia, glucose abnormality. There is a syndrome that is beginning to evolve. We sort of catch it when we measure a person's blood pressure with the cuff, and we find that it's elevated above some number. Then we advocate treatment, both lifestyle modification and medicine. But now we're getting a little bit smarter, and we're beginning to realize that just trying to lower the blood pressure is tunnel vision. We need to attack these other risk factors -- the obesity, the sedentary lifestyle, the too much alcohol, the cigarettes, and so on.

Dr. Lundberg: Hypertension is a number, but you're not willing to give us what it is at the moment. I'm not going to push you to do it because it's a sliding scale, and it must depend upon other things as to whether it matters much for individuals. Is that true?

Dr. Oparil: It's a little bit true, but we don't want to make things so complicated that everyone has to use a computer to figure out whether they're hypertensive or not.

Dr. Lundberg: Yeah, but some people talk about prehypertensive. Isn't that birth?

Dr. Oparil: That's right.

Dr. Lundberg: Birth as a human being -- isn't that prehypertension? Or am I being too general?

Dr. Oparil: Well, prehypertension the way the JNC 7 -- which is the committee that creates the guidelines for hypertension diagnosis, prevention, and management in the US -- prehypertension is defined as a blood pressure of 120-130 mm Hg systolic, over 80-89 diastolic. It is defined this way because it's higher than normal, which we define as 120 over 80 or less, but it's less than 140 over 90, which is the traditional upper limit of normal.

Dr. Lundberg: And that's regardless of what the age of the person might be?

Dr. Oparil: It does not depend on age.

Dr. Lundberg: It's not dependent on age at all. How many readings does that take? Because I've had a little problem with blood pressure for about 40 or 50 years, and I know that my blood pressure goes all over the place depending upon who's taking it; what the circumstances are; what the time of day is; and so forth, and so forth, and so forth. It's not that simple.

Dr. Oparil: And you're still here. That's good, after all that.

Dr. Lundberg: I'm doing fine, thank you. The treatments are pretty good.

Dr. Oparil: In fact, it's been shown in endless epidemiologic studies that systolic blood pressure increases throughout the lifetime, from the time you're born until about 80, 85 years, and then it may plateau. Diastolic goes up until you're about 50 or 55 and then falls. Older people tend to have a very high systolic and a normal diastolic, which, when I was in medical school in the 60s, we were told was just fine, because the diastolic...

Dr. Lundberg: [interposing] Just fine, a hundred plus their age.

Dr. Oparil: Does not count; it's absolutely untrue.

Dr. Lundberg: Forget about that now.

Dr. Oparil: Forget about that; it's absolutely wrong. Because the elevated systolic blood pressure is due to increased stiffness in the aorta and the major conduit vessels, and this is a sign of target organ damage. It's not atherosclerosis. It's fibrosis; it's endothelial dysfunction -- many other things that correlate with a bad prognosis.

Dr. Lundberg: Rather than talking about right now how to take care of obesity, excess alcohol use -- all that kind of stuff: If the doctor makes the diagnosis -- you are not just prehypertensive; you're hypertensive -- is drug medication indicated early on?

Dr. Oparil: I believe it is.

Dr. Lundberg: And what kind? Or does it matter much?

Dr. Oparil: We do believe in lifestyle modification, and we don't want to downgrade that at all. But in fact, I believe most patients and the public are aware of what should be done. They're generally not terribly motivated to do these things, so generally we move very quickly in this country to pharmacologic treatment.

Dr. Lundberg: And are the generic drugs pretty good?

Dr. Oparil: The generic drugs are pretty good.

Dr. Lundberg: Well, are they better than pretty good? Do you have to pay a whole bunch of money for fancy antihypertensive medications, or are some of the cheap ones still pretty good?

Dr. Oparil: It depends on how bad your disease is. Clearly, if the goal is just to lower blood pressure, diuretics, which are pennies a day, are as good as anything else. Where the controversy comes in is that diuretics have adverse metabolic effects, such as hypokalemia; every doctor is aware of that. That tends to predispose to dysglycemia, elevated blood glucose by mechanisms that we don't understand, and then leads to further problems. Since many patients have now what we call the metabolic syndrome, which is associated with impaired glucose tolerance, maybe diuretics are not optimal treatment, although, still, diuretics are recommended by JNC 7 as the number 1 treatment in the US, a point of controversy.

Dr. Lundberg: Sure.

Dr. Oparil: The Europeans say this is wrong, and we should be using drugs that correct metabolic abnormalities.

Dr. Lundberg: Okay. Now let's talk about human behavior: patient behavior and compliance with prescribed medication, physician behavior, and compliance with "We better find this hypertension in my population." Aren't these two both real problems?

Dr. Oparil: Absolutely.

Dr. Lundberg: How are we going to deal with that?

Dr. Oparil: I think first of all we need more research. I'm not a behaviorist; I'm a simple cardiologist. We need behaviorists, and whoever can work in this field, to help us find ways to motivate people to do things that they don't particularly wish to do that they know they should be doing: the weight loss, the increased physical activity, maybe reducing drinking, stopping smoking.

Dr. Lundberg: All that kind of stuff.

Dr. Oparil: All that kind of stuff. Virtually everybody knows that that's important, but getting to think that you, the patient who has all these bad habits, have the strength, the energy to do the things that are needed. Also the belief that they're really going to help, I think there's a cynical attitude on the part of some that they're going to exercise and lose weight and do better, but then it's not going to help them; they're going to have a heart attack anyway. Changing that belief system, I think, is very important.

Dr. Lundberg: We've been talking with Dr. Suzanne Oparil. Thank you so much for being with us today. Dr. Suzanne Oparil from the University of Alabama, Birmingham, and current sitting President of the American Society for Hypertension. She kind of leaves us with the thought that patients ought to take charge of their health; after all it is their health. I'm Dr. George Lundberg, Editor-in-Chief of Medscape General Medicine, signing off from Orlando. Thank you very much, Dr. Oparil, for being with us.

Dr. Oparil: Thank you. I appreciate being here.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: