79 52 blood pressure: 79/52 blood pressure – is it good or bad?
My Blood Pressure is 79/52
Blood pressure 79/52 – what does it mean?
Your blood pressure reading of 79/52 indicates Hypotension. This means your blood pressure is lower than the usual with values at a systolic (upper) value under 105 mmHg and a diastolic (lower) value of under 60 mmHg.
However, in most cases this is no reason to be concerned. If your blood pressure is only slightly under said values and there are no health impairments a hypotense blood pressure might be alright.
What you should know about a blood pressure of 79/52
Low blood pressure rarely causes any severe symptoms, but some patients experience debilitating side effects. The recommended blood pressure reading for healthy adults is 90 (systolic) over 60 mm Hg (diastolic). Your blood pressure of 79/52 is below the recommended range and considered low blood pressure. Fainting episodes and dizzy spells are two common symptoms associated with dangerously low blood pressure or BP. This condition is known as hypotension and can have life-threatening consequences if left unchecked. Several health-related conditions and life events can cause BP levels to drop. In some cases, an underlying medical condition, surgical disorders, or dehydration might be responsible.
- Poor concentration
- Blurred vision
If a patient experiences extreme hypotension, it can trigger symptoms such as palpitations, confusion, pale skin, and breathing difficulty. It is wise to seek medical attention if this happens because it can result in shock.
How to raise blood pressure quickly?
- Increase aggregate sodium intake. Table salt has a balanced amount of sodium content, which can help boost BP levels instantaneously. However, patients should consult their physician before adding more salt to the diet. High salt consumption can sometimes be dangerous and life-threatening.
- Eat wholesome, well-balanced meals to maintain a healthy diet. Sometimes low BP is triggered by poor eating habits and nutrient deficiencies. A lack of iron, folic acid, and vitamin B- 12 is a leading cause of anemia. If the body is not making an adequate volume of blood, it could lower pressure levels.
- Drink more water. Mild dehydration can lower blood pressure activity, which causes hypotension in extreme cases. Sometimes, sickness involving frequent vomiting, diarrhea, excess sweating, and fever may result in dehydration. In such circumstances, an adequate intake of water to rehydrate the body is necessary. For long-term benefits, those affected must maintain a healthy water drinking habit to stabilize low BP levels.
What are some healthy lifestyle changes to improve low blood pressure long-term?
Controlling low blood pressure naturally can sometimes be challenging, but equally doable with the right self-intervention measures. Numerous studies say regular exercise can have positive effects on cardiovascular health, which in turn can balance low blood pressure. However, individuals should avoid exercising in extreme heat and outdoors, especially during the summer months. Researchers also advise against prolonged rest and spending long hours in the steam room, sauna, or hot tub. Also, compression socks can improve blood flow throughout the body and boost blood pressure levels.
Blood pressure of adults, 2016-2019
Blood pressure has many implications for health and is a leading contributor to disability adjusted life years, a measure of overall burden of disease which combines years of life lost due to ill-health, disability or early death.Note High systolic blood pressure (SBP) and/or high diastolic blood pressure (DBP) can cause damage to blood vessels and can result in cardiovascular disease or events, such as heart attack or stroke, which are among the leading causes of hospitalization and death in Canada. Note Note Hypertension is a leading risk factor for death globally. Canada along with Germany, South Korea, and the United States have the highest rates of hypertension awareness, treatment, and control amongst high income countries.Note
Data table for Chart 1
|20 to 29||30 to 39||40 to 49||50 to 59||60 to 69||70 to 79|
|Normal systolic blood pressure||120||120||120||120||120||120|
|Normal diastolic blood pressure||80||80||80||80||80||80|
|Systolic blood pressure||108||111||112||117||121||124|
|Diastolic blood pressure||69||74||75||77||76||72|
|Systolic blood pressure||102||103||109||119||122||126|
|Diastolic blood pressure||67||68||72||75||73||70|
Results from the 2016-2019Note Canadian Health Measures Survey (CHMS) indicate that Canadian adults aged 20 to 79 had a measured average resting blood pressure of 114/72 mmHg. For both males and females, average resting blood pressure increased significantly with age (Chart 1). The average resting blood pressure for males aged 20 to 29 was 108/69 mmHg, compared with 124/72 mmHg for males aged 70 to 79. The average resting blood pressure for females aged 20 to 29 was 102/69 mmHg, compared with 126/70 mmHg for females aged 70 to 79. Average resting systolic blood pressure tended to be significantly higher for males in younger age groups (aged 20 to 49) but significantly lower for males in the oldest age group (aged 70 to 79) compared with females in those same age groups. It is important to note that structural changes in large arteries observed in systolic hypertension are similar to those caused by ageing making it difficult to ascertain whether arterial changes are due to disease.Note
Data table for Chart 2
|Normal||Elevated||Stage 1||Stage 2, taking medications or diagnosed|
|Males||54.8||4.9Note E: Use with caution||15.3||25.1|
|20 to 39||82.6||3.1Note E: Use with caution||10.7||3.7Note E: Use with caution|
|40 to 59||56. 2||3.5Note E: Use with caution||17.9||22.4|
|60 to 79||28.9||8.5||11.3||51.3|
Among Canadian adults aged 20 to 79, 23% reported they had been diagnosed with hypertension by a health-care professional, were taking anti-hypertensive medication, or had high measured blood pressure equivalent to stage 2 hypertension. This proportion increased significantly with age such that just over half of (51%) of adults aged 60 to 79 had stage 2 hypertension compared to 22% of adults aged 40 to 59 (Chart 2). In comparison, only 14% of Canadian adults aged 20 to 79 had a measured blood pressure equivalent to stage 1 hypertension, with significantly more adults (18%) aged 40 to 59 meeting this criteria than adults aged 20 to 39 and adults aged 60 to 79 (both 11%) (Chart 2).
Data table for Chart 3
|Treated by medication and controlled||50.9|
|Treated by medication, not controlled||16. 7|
|Aware of their condition, not treated||3.8Note E: Use with caution|
|Unaware of their condition||28.6|
Over half of Canadian adults with stage 2 hypertension were aware of their condition and were controlling it through medication use (Chart 3). Approximately 29% of Canadian adults with stage 2 hypertension were unaware of their condition (Chart 3). The proportion of adults who were aware of their condition and treated by medication, but the condition was not controlled (i.e. reported taking medication for high blood pressure yet had a measured blood pressure greater than or equal to 140/90 mmHg) was 17%, and another 4% were aware of their condition but not treated.
Nearly 74% were unaware of having stage 1 hypertension. The proportion of adults who were aware of having stage 1 hypertension and treated by medication, but not controlled (i. e. reported taking medication for high blood pressure yet had a measured blood pressure greater than or equal to 130/80 mmHg) was 22%. Another 5% were aware of having stage 1 hypertension but were not treated (data not shown).
Data table for Chart 4
|20 to 39||Note F: too unreliable to be published||7. 3Note E: Use with caution|
|40 to 59||13||28Note E: Use with caution|
|60 to 79||34||58|
An important risk factor for hypertension is being overweight or living with obesity.Note Results from the CHMS show that measured hypertension was more than two times as likely to occur among adults who were overweight or living with obesity, compared with their normal-weight counterparts.
Stage 2 hypertension was prevalent in 31% of Canadian adults who were classified as being overweight or living with obesity, compared with 11% of those who were normal weight. Adults who are overweight or living with obesity aged 60 to 79 had the highest prevalence of hypertension (58%), while adults aged 20 to 39 had the lowest, regardless of weight status (Chart 4).
Stage 1 hypertension was prevalent in 25% of Canadian adults who were classified as being overweight or living with obesity, compared with 9% of those who were normal weight (data not shown). Overweight or adults with obesity aged 40 to 59 had the highest prevalence of stage 1 hypertension (30%), compared with the 20 to 39 year olds (18%) and 60 to 79 year olds (24%) (data not shown).
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About blood pressure
Blood pressure (BP) is a measure of the force of blood against the artery walls, and is expressed as systolic blood pressure (SBP)/diastolic blood pressure (DBP) in millimetres of mercury (e.g., 120/80 mmHg). The systolic pressure (top number) is the pressure when the heart contracts and pushes the blood out, and the diastolic pressure (bottom number) is the lowest pressure when the heart relaxes between beats.
In 2017, the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines recommended new thresholds which divide the 2003 guideline’s pre-hypertension into elevated and stage 1 hypertension.Note A person is considered to have elevated hypertension if they have a mean measured SBP between 120-129 and a mean measured DBP below 80, while a mean SBP between 130-139 or a mean DBP between 80-89 mmHg is classified as stage 1 hypertension. A mean measured SBP greater or equal to 140 or a DBP greater or equal to 90 is now defined as stage 2 hypertension. For the purpose of this analysis, respondents who were diagnosed with hypertension by a health care professional or reported anti-hypertensive medication use in the past month were grouped in stage 2.
The CHMS measured resting blood pressure using an automated device (BPTru™) following a five minute rest period. The BPTru™ recorded six measurements, one minute apart. The average SBP and DBP were calculated using the last five of the six measurements. Respondents were also asked to report if they have ever been diagnosed with high blood pressure by a health care professional or if they have taken medication for high blood pressure in the past month.
The criteria for blood pressure classification used in this analysis for adults are as follows:
|Normal||Mean SBP/DBP < 120/80 mmHg|
|Mean SBP 120-129 mmHg and DBP <80 mmHg|
|Stage 1 hypertension
|Mean SBP 130-139 mmHg or mean DBP 80-89 mmHg|
|Stage 2 hypertension
|Mean SBP ≥ 140 mmHg OR
Mean DBP ≥ 90 mmHg OR
Self-reported use of medication for high blood pressure within the past month OR
Self-reported having been diagnosed with hypertension by a health-care professional
End of text box
The Canadian Health Measures Survey (CHMS) is a two-step survey. The first step is a personal interview at the respondent’s household. The second step is a visit to the CHMS mobile clinic where physical measurements and blood and urine samples are taken.
The 2016-2019 reference period refers to combined results from Cycle 5 (2016 and 2017) and Cycle 6 (2018 and 2019) of the CHMS.
The target population for the CHMS consists of persons 3 to 79 years of age living in the 10 provinces. The observed population excludes: persons living in the three territories; persons living on reserves and other Aboriginal settlements in the provinces; full-time members of the Canadian Forces; the institutionalized population and residents of certain remote regions. Altogether these exclusions represent approximately 3% of the target population.
Survey weight and bootstrap weight files and instructions are available for combining Cycle 6 Canadian Health Measures Survey data (where possible) with equivalent data from Cycles 1 to 5.
Canadian Health Measures Survey data related to this Health Fact Sheet are available in data tables 13-10-0319-01, 13-10-0373-01, 13-10-0326-01 and 13-10-0384-01.
- Footnote 1.
GBD 2015. Risk factors collaborators. Global, regional, and national comparative risk assessment of 79 behavioral, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the global burden or disease study 2015. The Lancet; 388:1659-1724.
Return to note 1 referrer
- Footnote 2.
Statistics Canada. 2015. “Trends in mortality rates, 2000 to 2012”. Health Fact Sheets. Statistics Canada catalogue no. 82-625-X. http://www.statcan.gc.ca/pub/82-625-x/2015001/article/14297-eng.htm.
Return to note 2 referrer
- Footnote 3.
Public Health Agency of Canada. 2013. “Leading causes of hospitalizations, Canada, 2009/10, males and females combined, counts (age-specific hospitalization rate per 100,000)” http://www.phac-aspc.gc.ca/publicat/lcd-pcd97/table2-eng.php.
Return to note 3 referrer
- Footnote 4.
NCD Risk Factor Collaboration (NCD-RisC). Long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries: an analysis of 123 nationally representative surveys. The Lancet. Aug 24;394(10199):639-651. doi: 10.1016/S0140-6736(19)31145-6. Epub 2019 Jul 18. PMID: 31327564; PMCID: PMC6717084.
Return to note 4 referrer
- Footnote 5.
Blood pressure data from Cycle 5 (2016 and 2017) and Cycle 6 (2018 and 2019) of the CHMS were combined for this fact sheet.
Return to note 5 referrer
- Footnote 6.
Pinto E. (2007). Blood pressure and ageing. Postgraduate medical journal, 83(976), 109–114. https://doi.org/10.1136/pgmj.2006.048371. (Accessed February 8, 2021).
Return to note 6 referrer
- Footnote 7.
Chobanian, A.V., Bakris, G.L., Black, H.R., et al. 2003. “Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure”. Hypertension; 42: 1206-52.
Return to note 7 referrer
- Footnote 8.
Whelton PK, Carey RM, Aronow WS, et al. 2017. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension ; HYP. 0000000000000065. Available at: https://doi.org/10.1161/HYP.0000000000000065. (Accessed December 29, 2020.)
Return to note 8 referrer
Older Adults and Hypertension: Beyond the 2017 Guideline for Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
Epidemiology of Hypertension in Older Adults
Hypertension is one of the primary modifiable risk factors for cardiovascular (CV) disease and its prevalence and severity both increase with age. According to the US National Health and Nutrition Examination Survey (NHANES), 70% of adults ≥65 years have hypertension.1 This number will continue to rise as our population ages as 15% of the US population was ≥65 years old in 2014 and this is expected to increase to 20% by 2050.2
Despite having the highest prevalence of hypertension and greatest risk for CV morbidity and mortality, older adults are frequently undertreated for elevated blood pressure (BP). This group has been traditionally excluded or underrepresented in clinical trials due to concerns regarding frailty, fall risk, poor renal function, abnormal hemodynamic adaptation, and higher risk for autonomic dysfunction, cognitive impairment, and polypharmacy. With advancing age, the gap between chronological and biological age widens and chronological age may be a poor surrogate for biological age.3 Furthermore, chronological age cutoffs used to identify older patients across guidelines are inconsistent and BP treatment targets remain controversial.
Hypertension Guidelines Reviewed
Hypertension guidelines published by several major medical societies highlight the challenges of managing BP in older patients. In January 2017, the American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) released guidelines for BP management in adults ≥60 years. Pharmacotherapy is recommended for persistently elevated systolic BP (SBP) ≥150 mmHg to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) (Table 1). 4
Table 1: A Comparison of Blood Pressure Thresholds and Targets between ACC/AHA, ACP/AAFP, and ESC/ESH Guidelines
|ACC/AHA 2017||ACP/AAFP 2017||ESC/ESH 2018|
|Definition of Older Patients||≥65 years||≥60 years||Elderly 65-79 years
Very Old ≥80 years
|BP Threshold for Initiation of Pharmacotherapy||≥130/80 mmHg||SBP ≥150 mmHg||Elderly ≥140/90 mmHg
Very Old ≥160/90 mmHg
|Blood Pressure Target||<130/80 mmHg||SBP <150 mmHg||SBP 130-139 mmHg
In November 2017, the American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline introduced new definitions for BP management (Table 1). Blood pressure is now categorized as normal, elevated, and stage 1 or 2 hypertension. Normal BP is defined as <120/80 mmHg while elevated BP is 120-129/< 80 mmHg. Stage 1 hypertension is defined as SBP 130-139 mmHg and/or diastolic BP (DBP) 80-89 mmHg. Stage 2 hypertension is defined as SBP ≥140 mmHg and/or DBP ≥ 90 mmHg. Based primarily on results from the Systolic Blood Pressure Intervention Trial (SPRINT), for most adults ≥65 years old, a more aggressive SBP target <130 mmHg is recommended.5-7 However, the ACC/AHA guideline advises clinical judgement and patient preference to determine BP targets in older patients with limited life expectancy and multiple co-morbidities. It acknowledges the lack of randomized controlled trials (RCTs) for patients with history of frequent falls, advanced cognitive impairment, and those living in nursing homes or skilled nursing facilities.8
The 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) BP guideline categorizes older adults in two subgroups; ‘elderly’ refers to patients between the ages of 65 and 79 years while ‘very old’ refers to those ≥80 years (Table 1). The guideline recommends that pharmacologic treatment should be offered to all older patients with an SBP of ≥160 mmHg. A lower therapeutic target of SBP 130-139 and DBP 70-79 mmHg can also be considered in ‘elderly’ (those ≥65 years, but not >80 years) patients. Pharmacologic therapy may also be considered in fit individuals >80 years with an initial SBP ≥160 mmHg and/or DBP ≥90 mmHg while targeting a BP of 130-139/70-79 mmHg.9 These decisions should be based on clinical assessment of biological age and a thorough review of comorbidities. Treatment side effects must be closely monitored, particularly for those who are frail.
Even though the definitions and treatment thresholds differ between the American and European guidelines, both acknowledge the importance of BP treatment in older adults to lower atherosclerotic cardiovascular disease (ASCVD) risk but recommend a cautious approach and close monitoring of these patients. The hypertension treatment goals for older patients according to American and European guidelines are listed in Table 1.
Hypertension Management in Older Adults with History of Coronary Artery Disease (CAD)
The 2017 ACC/AHA guideline recommends a target BP of <130/80 mmHg for older patients (age ≥65) with stable ischemic heart disease (SIHD).8 Notably, the DBP target only achieved level of evidence (LOE) C (limited data, meta-analysis) and was based solely on expert opinion. Furthermore, less intensive BP thresholds for older patients with SIHD were not systematically addressed. The guideline encourages clinical judgment and patient preference to guide BP management in this group, particularly when there is a high burden of comorbidities and reduced life expectancy.8 BP treatment thresholds for older adults with CAD remain controversial due to a lack of RCTs.
In SPRINT, older patients (age ≥75) assigned to intensive BP lowering achieved a greater reduction in the primary CV endpoint (nonfatal myocardial infarction (MI), acute coronary syndrome not resulting in an MI, nonfatal stroke, nonfatal acute decompensated heart failure, and CV mortality) compared to younger subjects [hazard ratio (HR) 0. 66 vs 0.8].10 A subsequent analysis of this subgroup was published in 2016, but did not examine whether patients with CAD derived additional benefit from intensive BP lowering.5 The rate of all reported serious adverse events (SAEs) was similar between the intensive and standard treatment arms. However, the analysis did not report SAEs that were possibly or directly linked to the intervention that might have shown higher event rates in the intensive treatment group. In a secondary analysis from SPRINT, patients ≥75 years with a history of CV disease had a greater risk of the composite CV outcome (MI, non-MI acute coronary syndrome, stroke, acute decompensated heart failure, and CV mortality) at lower DBP (<55 mm Hg) compared to patients ˂75 years.11 Comparatively, in patients without CV disease, low DBP was associated with a higher hazard of the composite CV outcome regardless of age. Taken together, these findings suggest that age and history of CV disease should be integrated into clinical decision-making.
Many studies of hypertensive older patients suggest a “J-shaped” curve with elevated CV risk associated with low systolic and diastolic BPs. Prior to the 2017 guideline update, the 2015 ACC/AHA BP recommendations for CAD patients >80 years old encouraged avoiding a SBP <130 mmHg and/or DBP <65 mmHg.12 The rationale for these recommendations came from observational studies that found an association between low systolic and diastolic BPs and increased CV risk. INternational VErapamil SR Trandolapril STudy (INVEST) included a substantial number of very old hypertensive patients with stable CAD.13,14 Among the 22,576 patients enrolled, 2180 were >80 years old. Patients with stable CAD and hypertension were randomized to either verapamil- or atenolol-based treatment strategies. Trandolapril, with or without hydrochlorothiazide, was added to achieve BP targets <140/90 mmHg or <130/85 mmHg for patients with diabetes or renal insufficiency, respectively. No difference was observed in the primary outcome (first occurrence of all-cause death, nonfatal MI, or nonfatal stroke) between the two treatment arms.13 In this age-based subgroup analysis, higher primary event rates were linked to increasing age. The SBP at the HR nadir also increased with age and was highest for subjects >80 years old (140 mmHg, Figure 1). Patients aged 70-80 years had a slightly lower SBP nadir (135 mmHg), while the two youngest age groups each had a much lower SBP (110 mmHg) at their respective nadirs. The DBP at the HR nadir was similar for all age groups (75 mmHg) except for the very old (age>80), for whom it was <70 mmHg (Figure 1).
Figure 1: Adjusted hazard ratio as a function of age, systolic and diastolic blood pressure. Reference systolic and diastolic blood pressure for hazard ratio: 140 and 90mmHg, respectively. Blood pressures are the on-treatment average of all post baseline recordings. The quadratic terms for both systolic and diastolic blood pressures were statistically significant in all age groups (all P <0.001, except for diastolic blood pressure in 60-70-year-olds for whom P<0.006). Figure reproduced from Denardo, et al. 2010 with permission from the publishers.13
Figure 1: Adjusted hazard ratio as a function of age, systolic and diastolic blood pressure. Reference systolic and diastolic blood pressure for hazard ratio: 140 and 90mmHg, respectively. Blood pressures are the on-treatment average of all post baseline recordings. The quadratic terms for both systolic and diastolic blood pressures were statistically significant in all age groups (all P <0.001, except for diastolic blood pressure in 60-70-year-olds for whom P<0.006). Figure reproduced from Denardo, et al. 2010 with permission from the publishers.13
More recently, data from the prospective longitudinal registry of 32,703 hypertensive patients with stable CAD (CLARIFY) was published.15 Systolic and diastolic BPs before each CV event were averaged and categorized into 10 mmHg increments. The primary outcome was a composite of CV death, MI, or stroke. Using the 120-129 mmHg SBP and 70-79 mmHg DBP subgroups as a reference, multivariable adjusted Cox proportional hazards models were applied to calculate estimated HRs.15 After a median follow-up of 5 years, SBP ≥140 mmHg and DBP ≥80 mmHg were each associated with an increased risk of CV events. SBP <120 mmHg (adjusted HR 1.56) and DBP <70 mmHg (adjusted HR 1.41 for DBP of 60-69mmHg and 2.01 for DBP of less than 60 mmHg) were also linked to an increased risk for the primary endpoint. In the subgroup analysis of patients >75 years old, SBP < 120 mmHg (HR 1.47) and DBP <60 mmHg (HR 1.64) was associated with an increased risk of CV events.15
A current analysis from SPRINT explored the impact of baseline DBP on the primary CV outcome based on SBP intervention.16 This study confirmed a “U-shaped” association between DBP and CV risk. However, regardless of initial DBP, intensive SBP lowering was associated with lower CV event rates.16 Even in the lowest DBP quintile (<68 mmHg, mean 61 mmHg), a 22% lower risk of the primary CV outcome was observed, although it did not achieve statistical significance (HR 0.78, CI 0.57, 1.07).16 While the analysis did not evaluate trends based on age classifications, the average for this quintile was 74.7 years.16
The current guidelines recommend aggressive BP lowering for older patients, including those with SIHD. The evidence for intensive SBP and DBP treatment in this population is inconclusive. To date, prospective randomized trials to define appropriate thresholds have not been performed. Until more conclusive data is published, individualized targets based on comorbidities, quality of life, and patient preferences should be applied when making a BP treatment plan in this group.
Hypertension Management in Older Adults with History of Atrial Fibrillation and Stroke
Hypertension is the most common comorbidity among older patients with atrial fibrillation and both are associated with an increased risk of stroke. In the landmark ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events) trial of nearly 18,000 older patients (mean age 70 years) with nonvalvular atrial fibrillation, 88% had a history of hypertension requiring medical treatment.17 Interestingly, any elevated office systolic BP (≥140 mmHg) or diastolic BP (≥90 mmHg) reading during the trial duration was associated with a 53% increased risk of ischemic stroke (HR 1.53, 95% CI 1.25-1.86) and 85% increased risk of hemorrhagic stroke (HR 1.85, 95% CI 1.26-2.72).17 These findings highlight the importance of BP control among older patients with concomitant hypertension and nonvalvular atrial fibrillation.
Hypertension management is also the most important intervention for secondary prevention of stroke.18 BP reduction among all-comers with a prior history of stroke lowered the risk of a recurrent event in clinical trials, but the evidence in older patients is scarce.19 Moreover, there is concern that long-term antihypertensive treatment may compromise cerebral perfusion in post-stroke older patients (≥70 years) with carotid disease.20 The 2014 American Heart Association/American Stroke Association guideline for stroke prevention acknowledges that a target BP level for those with history of stroke or transient ischemic attack is uncertain. It recommends that BP goals should be individualized and that it is reasonable to target SBP <140mmHg and DBP <90 mmHg (class of recommendation IIa and LOE B).18 Consistent with the 2014 guideline, the 2017 ACC/AHA hypertension guideline recommends antihypertensive treatment for patients with a history of stroke with a BP of 140/90 mmHg or higher (Class I, LOE B-R), but also suggests that a BP goal of <130/80 mmHg may be reasonable (class IIb, LOE B-R).8
Masked and White Coat Hypertension in Older Adults
Masked hypertension (MH) is the presence of out-of-office hypertension in the setting of in-office normotension. White coat hypertension (WCH) refers to in-office hypertension in the setting of normotension on ambulatory BP (ABPM) or home BP (HBPM) monitoring.21,22 Both MH and WCH are frequently observed in older patients and carry different prognostic significance.
An analysis from the SHEAF (Self measurement of blood pressure at Home in the Elderly: Assessment and Follow-up) study revealed that among 4,939 elderly French adults (mean age 70 years) with treated hypertension, MH was present in 9.3% participants and associated with a two-fold increased risk of CV events (HR 2.06, 95% CI 1.22-3.47) during 3.2 years of follow-up.23 This risk was similar in magnitude to what was observed among subjects with uncontrolled hypertension, i.e. elevated BP in both office and home (HR 1.96, 95% CI 1.27-3.02).23 Conversely, participants with WCH (13.3% of the cohort) had ASCVD risk that was similar to those with normal in office and home BPs (HR 1.18, 95% CI 0.67-2.10).23 Pierdomenico and colleagues recently reported similar findings from an Italian cohort of 1191 older patients (mean age 68 years) with treated hypertension who underwent ABPM.24 MH was observed in 12% of the cohort and was independently associated with a 60% higher risk of CV events (HR 1.60, 95% CI 1.12-2.29) during 9.1 years of follow-up.24 WCH was observed more frequently (19% of the cohort) but was not associated with an increased CV event risk (HR 1.09, 95% CI 0.74-1.60).24 In a registry-based, multicenter study conducted in Spain, ambulatory and clinic BP measurements were compared with regard to their predictive ability for all-cause and CV mortality. In this cohort of nearly 64,000 patients, ambulatory BP measurements were found to be a stronger predictor of all-cause and CV mortality.25 MH was associated with an increased risk of all-cause and CV mortality and an even greater risk of death than sustained hypertension.25
These studies highlight the increased CV risk associated with MH and the relative uncertainty of the CV risk associated with WCH among older patients with treated hypertension. The threshold to use HBPM or ABPM should be low in older adults given the potential prognostic implications of these two phenotypes. Recently, the Centers for Medicare Services approved additional coverage for ABPM in the older adult population. The Antihypertensive Treatment in Masked Hypertension for Target Organ Protection (ANTI-MASK) trial is a randomized, placebo-controlled trial seeking to evaluate the effects of allisartan isoproxil 80 mg once daily with a primary endpoint of improvement in the rate of target organ damage (left ventricular hypertrophy, large arterial stiffness, and microalbuminuria). The trial aims to recruit 300 adults with a history of MH, but the recruitment status of the trial is unclear.26
The MASked-unconTrolled hypERtension Management Based on Office BP or on Out-of-office (Ambulatory) BP Measurement (MASTER) trial is currently recruiting patients to compare office BP vs. 24-hour ABPM to guide management of MH.27 Primary endpoints include change in left ventricular mass and microalbuminuria. Findings from these trials should provide some insights for monitoring and treatment of patients with MH.
Special Considerations to Achieving Target Blood Pressure in Older Adults: Side Effects of Pharmacotherapy, Comorbidities, and Orthostatic Hypotension
A recent evaluation of the National Health and Nutrition Examination Survey database revealed that nearly 50% of hypertensive US adults ≥ 80 years of age have uncontrolled hypertension.28 Treatment of elevated BP in older adults to guideline-recommended systolic BP goal of <130mmHg is challenging due to the increased risk of medication side effects and drug-drug interactions. Antihypertensive agents like immediate release nifedipine and peripheral alpha1-antagonists (doxazosin, prazosin, and terazosin) are associated with a heightened risk of orthostatic hypotension while central alpha2-agonists like clonidine, guanfacine, and methyldopa can lead to significant central nervous system side effects in older adults.29 Concomitant use of peripheral alpha1-antagonists with loop diuretics in older women increases the risk of urinary incontinence. Renin angiotensin system antagonists (ACE-inhibitors, ARBs, or aliskiren) and potassium sparing diuretics like amiloride or triamterene can lead to an increased risk of hyperkalemia.29 However, when used with caution, the three first-line agents for hypertension management, including diuretics, ACE-inhibitors and calcium channel blockers, have excellent safety profiles and are generally well tolerated by older adults.
A high degree of heterogeneity in clinical comorbidities, cognitive impairment, and variable life expectancy further add to the complexity of hypertension management in this patient population. Among older patients with multiple clinical comorbidities, high frailty, or advanced cognitive impairment, an accurate assessment of prognosis, risk tolerance, and treatment goals is of paramount importance. Such patients typically reside in nursing homes and assisting living facilities; a population that is not represented in large RCTs and therefore have no demonstrated safety data for intensive BP lowering.5,30 Additionally, older patients may develop orthostatic hypotension with initiation of multiple antihypertensive agents.31 Careful initiation of a single agent followed by sequential titration of the dose and addition of other agents can decrease the risk of adverse outcomes with intensive BP lowering. Along these lines, the 2017 ACC/AHA BP guideline recommends that for older adults (≥65 years of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs (class IIa, LOE C expert opinion).8
Hypertension is highly prevalent and frequently undertreated in older adults. Management of hypertension in this heterogenous population, including those with established CAD, atrial fibrillation, and stroke, requires a comprehensive assessment and shared decision making between clinician and patient that focuses on patient preferences, medical comorbidities, life expectancy, treatment goals, and an appropriate balance between risks and benefits.
- Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics–2015 update: a report from the American Heart Association. Circulation 2015;131:e29-322.
- Colby SL, Ortman JM.Projections of the Size and Composition of the U.S. Population (2014 to 2060). (US Census Bureau website). 2015. https://census.gov/library/publications/2015/demo/p25-1143.html. Accessed August 18, 2019.
- Volpe M, Battistoni A, Rubattu S, Tocci G. Hypertension in the elderly: which are the blood pressure threshold values? Eur Heart J Suppl 2019;21:B105-B106.
- Qaseem A, Wilt TJ, Rich R, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice gGuideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017;166:430-37.
- Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA 2016;315:2673-82.
- Gangavati A, Hajjar I, Quach L, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc 2011;59:383-89.
- Margolis KL, Palermo L, Vittinghoff E, et al. Intensive blood pressure control, falls, and fractures in patients with type 2 diabetes: the ACCORD trial. J Gen Intern Med 2014;29:1599-1606.
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- Williams B, Mancia G, Spiering W, et al. [2018 ESC/ESH Guidelines for the management of arterial hypertension]. J Hypertens 2018;36:1953-2041.
- Group SR, Wright JT Jr., Williamson JD, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-16.
- Khan NA, Rabkin SW, Zhao Y, et al. Effect of lowering diastolic pressure in patients with and without cardiovascular disease: analysis of the SPRINT (Systolic Blood Pressure Intervention Trial). Hypertension 2018;71:840-47.
- Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Soc Hypertens 2015;9:453-98.
- Denardo SJ, Gong Y, Nichols WW, et al. Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. Am J Med 2010;123:719-26.
- Pepine CJ, Handberg EM, Cooper-DeHoff RM, et al. A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. JAMA 2003;290:2805-16.
- Vidal-Petiot E, Ford I, Greenlaw N, et al. Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study. Lancet 2016;388:2142-52.
- Beddhu S, Chertow GM, Cheung AK, et al. Influence of baseline diastolic blood pressure on effects of intensive compared with standard blood pressure control. Circulation 2018;137:134-43.
- Rao MP, Halvorsen S, Wojdyla D, et al. Blood pressure control and risk of stroke or systemic embolism in patients with atrial fibrillation: results from the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) Trial. J Am Heart Assoc 2015;4:pii: e002015
- Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45:2160-236.
- Liu L, Wang Z, Gong L, et al. Blood pressure reduction for the secondary prevention of stroke: a Chinese trial and a systematic review of the literature. Hypertens Res 2009;32:1032-40.
- Boan AD, Lackland DT, Ovbiagele B. Lowering of blood pressure for recurrent stroke prevention. Stroke 2014;45:2506-13.
- Franklin SS, O’Brien E, Staessen JA. Masked hypertension: understanding its complexity. Eur Heart J 2017;38:1112-18.
- Franklin SS, Thijs L, Hansen TW, O’Brien E, Staessen JA. White-coat hypertension: new insights from recent studies. Hypertension 2013;62:982-87.
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- Bromfield SG, Bowling CB, Tanner RM, et al. Trends in hypertension prevalence, awareness, treatment, and control among US adults 80 years and older, 1988-2010. J Clin Hypertens (Greenwich) 2014;16:270-76.
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Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Statins, Acute Heart Failure, Hypertension
Keywords: Primary Prevention, Secondary Prevention, Acute Coronary Syndrome, Aging, American Heart Association, Amiloride, Amides, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Atenolol, Atrial Fibrillation, Biphenyl Compounds, Blood Pressure, Blood Pressure Determination, Calcium Channel Blockers, Cardiovascular Diseases, Brain Ischemia, Cerebrovascular Circulation, Clonidine, Coronary Artery Disease, Comorbidity, Cohort Studies, Diabetes Mellitus, Diastole, Diuretics, Diuretics, Potassium Sparing, Doxazosin, Drug Interactions, Expert Testimony, Follow-Up Studies, Frail Elderly, Fumarates, Goals, Guanfacine, Heart Failure, Hemodynamics, Hydrochlorothiazide, Hyperkalemia, Hypertension, Hypertrophy, Left Ventricular, Hypotension, Orthostatic, Imidazoles, Indoles, Ischemic Attack, Transient, Life Expectancy, Masked Hypertension, Medicare, Methyldopa, Morbidity, Myocardial Infarction, Nifedipine, Nursing Homes, Nutrition Surveys, Patient Preference, Physicians, Family, Phenotype, Polypharmacy, Prazosin, Prevalence, Proportional Hazards Models, Prognosis, Prospective Studies, Pyridones, Pyrazoles, Quality of Life, Registries, Renal Insufficiency, Renin-Angiotensin System, Risk Assessment, Risk Factors, Secondary Prevention, Skilled Nursing Facilities, Societies, Medical, Sodium Potassium Chloride Symporter Inhibitors, Stroke, Triamterene, Vascular Stiffness, Verapamil, White Coat Hypertension
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Physical countermeasures to increase orthostatic tolerance – Wieling – 2015 – Journal of Internal Medicine
Standing upright challenges the cardiovascular system as the pull of gravity displaces about 70% of the circulating blood volume to below heart level, much of it to the compliant veins of the dependent limbs and the pelvic organs. In patients with autonomic failure due to neurodegenerative diseases, the normal cardiovascular adjustments to this challenge are impaired, and symptomatic orthostatic hypotension becomes a common risk on standing or even sitting quietly. These patients learn to sway and shift, so that the pumping action of the muscles can be utilized to counter gravitational displacement of blood by squeezing venous blood from the legs upward. Augmentation of venous return in the upright posture can also be achieved by deliberate tensing of lower limb and abdominal muscles 1, 2, as depicted in Fig. 1.
Effect of whole-body muscle tensing on central blood volume and increased venous pooling in patients with decreased intramuscular pressure. Left, mechanical factors play an important role in promoting venous return in the upright posture. Whole-body muscle tensing increases central blood volume, i.e. the amount of blood available for the heart to pump. Right, intramuscular pressure in normal ‘non-fainters’ during quite standing (left) and in patients with tendency to faint (right).
From 2; reproduced with permission.
These clinical observations were the basis for physical countermeasures, which are taught to patients with autonomic failure to combat symptomatic orthostatic hypotension 3-5. Physical counterpressure manoeuvres specifically generate a counterpressure to oppose gravitational venous pooling (e.g. a single bout of lower-body muscle contraction to translocate blood centrally and sustained tensing of the same muscles to prevent subsequent peripheral pooling in the legs and abdomen). More recently, it has been shown that physical counterpressure manoeuvres are also effective interventions in otherwise healthy subjects with episodic orthostatic syncope due to neurally mediated (i.e. vasovagal reactions) 6, 7 or postexercise syncope 8.
In this narrative review, we will primarily consider these physical counterpressure manoeuvres. Secondarily, we will describe the broader category of physical countermeasures that include breathing manoeuvres and other physical methods, to oppose orthostasis. Existing external devices, which operate through some of the same physiological principles as these manoeuvres, will only be discussed for proof of principle.
The defining characteristic of the manoeuvres described in this review is the fact that they can be employed by patients when a faint is imminent. This is in contrast to devices such as bandages and abdominal belts, which require ongoing use to be effective. We will discuss both early studies in patient with primary autonomic failure due to neurodegenerative diseases, as well as more recent experience obtained in patients with neurally mediated syncope. The physiology and pathophysiology of orthostatic blood pressure control and perfusion of the brain are key factors in understanding how physical countermeasures work. These topics have been reviewed extensively 2, 9-12 and will only be discussed here briefly.
Physical counterpressure manoeuvres
It has been reported that intramuscular pressure is related to orthostatic tolerance 2. Henderson et al. demonstrated that intramuscular pressure measured in the relaxed biceps muscle was decreased after prolonged bed rest (38%), following surgery (35%), during voluntary hyperventilation (28%) and in the absence of air movement over the skin (31%) 13, 14. These conditions are strongly associated with decreased orthostatic tolerance and a tendency to faint 2, 15. In addition, intramuscular calf pressure has been shown to be 15–24 and 6–9 mmHg, respectively, in those without and with a tendency to faint during the head-up tilt test using a tilt table with a saddle and suspended legs (Fig. 1) 16.
Although these interesting results from studies performed in the 1930s and early 1940s have never been confirmed, it is highly likely that any increase in muscle tension will function to augment intramuscular pressure. Intramuscular pressure can be thought of as a pressure opposing that within the veins. As such, venous distension is determined by the difference in the opposing pressures on each side of the venous wall (i.e. the venous transmural pressure). Increasing pressure outside the vein will therefore reduce venous distension, displacing blood back towards the heart 2.
During quiet standing, the body behaves more or less as an inverted pendulum that sways about the ankles. The static increase in tone of the antigravity muscles that are involved in maintaining upright posture also function to oppose venous pooling in lower limb veins, thereby protecting central blood volume, i.e. the amount of blood available for the heart to pump 13, 14, 17-19.
It is considered that postural sway during quiet standing is able to compensate for otherwise poor orthostatic tolerance 20, 21. Along these lines, Amberson 22 suggested the possibility of a connection between arterial baroreceptors and skeletal muscle tone, which could serve to increase muscle tensing during orthostasis. Although the precise neural pathway has not been established 2, recent work by Bernardi et al. demonstrated that carotid baroreflex modulation influences postural sway 23.
The first reports of the application of skeletal muscle tensing to prevent fainting reactions were from psychologists interested in the prevention of fainting reactions due to haemophobia. In the 1980s Öst and Sterness reported that ‘applied tension’ could be used as a behavioural method for treatment of this phobia 24, but the physiological mechanisms underlying its effect remained poorly understood due to the lack of haemodynamic measurements. However, the development in the early 1990s of the Penaz-Wesseling volume-clamp method, combined with the computation of stroke volume by pulse wave analysis, commercially available as the Finapres device, enabled clinical researchers to combine the experiences of individual patients with continuous noninvasive measurements of beat-by-beat changes in arterial pressure 25, 26. As a result, the underlying haemodynamics of a wide range of movements that simulated every day activities could be investigated, first in patients with symptomatic orthostatic hypotension due to autonomic failure 1, 3 and in recent years as a countermeasure to avert an impending vasovagal faint. Single case reports were published at first 1, 27-31. Figure 2 shows an example of such work, in which the combination of leg crossing and leg muscle tensing is effective in counteracting an impending vasovagal syncope 32.
Aborting a vasovagal faint by the combination of leg crossing and muscle tensing. Typical vasovagal syncope in a 24-year-old male subject with recurrent syncope during orthostatic stress testing on a tilt table. After crossing of the legs and tensing of leg and abdominal muscles (+) with the patient remaining in the standing position, blood pressure and heart rate quickly recover. The delay in the increase in blood pressure of about five beats is explained by the transit delay of the venous return through the pulmonary circulation. HR, heart rate; BP, blood pressure; bpm, beats/min.
From 32; reproduced with permission.
Further evidence came from a study by Krediet et al., which included 20 patients 6. This work confirmed that the combination of leg crossing and leg muscle tensing depicted in Fig. 2 is highly effective. A rise in blood pressure was observed in all 20 subjects, and the vasovagal reaction was averted in five of these individuals. The remaining 15 subjects were able to postpone the faint by an average of 2.5 min. Patients who could completely abort the faint started the manoeuvre at a significantly higher blood pressure level than those patients who could not (79/51 vs. 61/41 mmHg). In a study focusing on the underlying haemodynamic mechanism, Krediet et al. 33 demonstrated that physical counterpressure manoeuvres such as leg crossing, muscle tensing, squatting and the crash position are effective against vasovagal reactions solely through increases in cardiac output as shown in Fig. 3.
Haemodynamics underlying blood pressure rise induced by muscle tensing. Typical vasovagal syncope in a 21-year-old female subject with recurrent vasovagal syncope during tilt-table testing [head-down tilt (HDT), i.e. supine; head-up tilt (HUT), i.e during orthostatic stress]. Leg crossing combined with muscle tensing (first grey bar) and lower-body muscle tensing without leg crossing (second grey bar) are very effective in aborting vasovagal faints. The haemodynamic effect is mediated by an increase in cardiac output (CO), as systemic vascular resistance (SVR) remains largely unchanged. BP, blood pressure; HR, heart rate; SV, stroke volume. SV,CO and SVR are represented as percentage (%) from baseline i.e. mean values over 2.5–3 min after HUT.
From 33; reproduced with permission.
During the manoeuvres involving muscle tensing, cardiac output increased by a factor of 1.3–1.7 from the low levels during presyncope and was restored to 95–104% of the stable values recorded in the head-up position in the first few minutes of tilt 33. Systemic vascular resistance responses varied, but remained largely unchanged. Because lower-body muscle tensing is accompanied by a threefold increase in leg blood flow 34, a counteracting presumably reflex-mediated vasoconstriction must occur in other parts of the circulation, such as the nonworking muscle, kidney and splanchnic vascular beds.
The rise in cardiac output during muscle tensing is largely attributed to mechanical and not to autonomic effects. The change in cardiac output as produced by leg crossing with muscle tensing is strikingly similar to that which is produced by inflation of an antigravity suit, which is similarly effective at aborting an impending vasovagal faint (see Fig. 4) 35. This reinforces the notion that the physiological effects of muscle tensing are mainly mechanical.
Aborting a vasovagal faint following inflation of antigravity suit to 60 mmHg. Note the progressive fall in intra-arterial pressure (trace labelled ‘Brachial artery’). Blue highlighting indicates the period of inflation. Central venous pressure (CVP) increases immediately after inflation. The increase in blood pressure is delayed by about 3 s due to the transit time from the right to the left ventricle (as in Fig. 3). The increase in blood pressure was solely explained by the increase in cardiac output (increase by a factor of 1.4). ECG, electrocardiogram; Resp., respiration.
From 35; reproduced with permission.
However, an instantaneous increase in heart rate (see Figs 2 and 3) was also observed during muscle tensing. This indicates that autonomic effects are present as well. The instantaneous increase in heart rate at the onset of muscle tensing is a reflex effect produced by a combination of the muscle mechanoreflexes and central command with inhibition of cardiac vagal tone 26. Such chronotropic changes at the onset of exercise are generally associated with concurrent increases in cardiac contractility, which may contribute to the increased cardiac output 33.
It is worth noting that forceful arm tensing manoeuvres, i.e. hand gripping at maximal voluntary force using a rubber ball and arm tensing by gripping one hand with the other and abducting both the arms at the same time 7, 36, 37, are also effective if they are accompanied by whole-body muscle tensing and thereby by an increase in cardiac output. Isometric arm exercises without tensing of large lower-body muscle groups are far less effective and cannot prevent an impending vasovagal faint 6, 38.
Activation of the muscle venous pump of the legs during tiptoeing or walking, in the presence of competent venous valves, pumps blood back to the heart and partially restores cardiac filling pressure. The leg muscle pump can be considered as a ‘second heart’ 2 and is capable of translocating blood against a substantial pressure gradient (e.g. >90 mmHg). Manoeuvres that use skeletal muscle pumping are heel raises (i.e. plantar flexion; rising on the toes using calf muscles to raise heels off the floor) and repeated knee flexion (i.e. marching in place) 4, 16, 39. However, their effects on standing blood pressure in patients with autonomic failure vary. The variable responses may stem from differences in the degree of sympathetic vasomotor failure in these patients 40, 41.
Knowledge that bending forward can mitigate orthostatic hypotension dates back to the 1930s 42 i.e. to the time of the first description of patients with idiopathic orthostatic hypotension in the English literature by Bradbury and Eggleson.
It is a useful manoeuvre for patients with autonomic failure to increase blood pressure in the upright posture, as has been reported by many investigators 1, 41, 43 and is shown in Fig. 5.
Effects of bending forward on blood pressure. Tracing obtained in a 24-year-old female patient with autonomic failure and debilitating orthostatic hypotension. Orthostatic blood pressure response without (upper panel) and with abdominal compression and bending the head (lower panel). Line marked ‘standing’ indicates the duration of the period of standing. Note in the lower panel the increases both in mean arterial pressure and in pulse pressure during abdominal compression and bending the head.
From 1; reproduced with written informed consent of the patient and permission from the publisher.
The beneficial effect of bending forward in patients with autonomic failure can be ascribed to pronounced abdominal compression and to lowering the head to heart level. Abdominal compression squeezes blood from the compliant splanchnic venous pool towards the heart, resulting in an increase in cardiac output and thereby in arterial pressure 44, 45. Additionally, lowering the head to heart level shortens the hydrostatic column between the heart and the brain instantaneously by 25–30 cm corresponding to a hydrostatic pressure increase of 15–20 mmHg in mean blood pressure 11.
In patients prone to vasovagal syncope, bending forward is also reported to be a useful manoeuvre to increase orthostatic tolerance. Treatment of fainting patients traditionally consists of lowering the head between the knees whilst sitting (Fig. 6) 46-49. Likewise, bending forward with hands on knees appears to be a preferred position for many athletes during recover from vigorous physical activity.
Manoeuvres to combat vasovagal syncope. A 32-year-old female patient underwent cardiovascular reflex assessment for recurrent syncope and presyncope of vasovagal origin. A vasovagal reaction with prodromal pallor and sweating occurred whilst the patient was standing in the cardiovascular laboratory. The patient sat down with her head between her knees (crash position) (upper panel). After standing up, the hypotension returned and the patient squatted (middle panel). After standing up from squatting, when hypotension returned again, she was instructed to cross her legs and tense leg, buttock and abdominal muscles (lower panel), which successfully aborted the presyncope. BP, blood pressure.
From 49; reproduced with permission.
The beneficial effect of leg crossing in patients with autonomic failure (Fig. 7) 1, 43, 50, 51 has been attributed to mechanical compression of the veins in the legs, buttocks and abdomen, which displaces gravitationally pooled blood towards the heart and increases thoracic blood volume 39, 52, 53. This results in an increase in cardiac filling pressure, stroke volume and cardiac output, effectively correcting the symptom-causing reductions in systemic arterial pressure and cerebral blood flow.
Physical countermanoeuvres using isometric contractions of the lower limbs and abdominal compression in a patient with autonomic failure. The effects on finger arterial blood pressure (FINAP) of leg crossing in standing and sitting positions, placing a foot on a chair and squatting in a 54-year-old male patient with pure autonomic failure and debilitating orthostatic hypotension. The patient was standing (or sitting) quietly prior to the manoeuvres. Bars indicate the duration of the manoeuvres. Note the increase in blood pressure and pulse pressure during the manoeuvres.
From 32; reproduced with written informed consent from the patient and permission from the publisher.
When leg crossing is practiced routinely, standing systolic/diastolic blood pressure can be increased by ~20/10 mmHg in patients with autonomic failure 3, 4, 9, 39, 43. Even such a small rise in upright blood pressure may be clinically important, as it may shift mean arterial pressure from just below to just above the critical level of perfusion of the brain 10. Larger increases of ~30/15 mmHg can be seen when leg crossing is combined with the additional tensing of the leg musculature, thighs and buttocks.
Leg crossing improves orthostatic tolerance in healthy subjects as well as in patients with vasovagal fainting 27, 54-56. When standing for prolonged periods, healthy humans who have a tendency to faint often unknowingly utilize this leg crossing countermeasure (i.e. the ‘cocktail party posture’ serves a physiological purpose).
By sitting down, the orthostatic load due to gravitational displacement of blood is decreased, resulting in increases in venous return, stroke volume and cardiac output and thereby blood pressure is increased 57, 58. Portable chairs have been shown to be quite useful for patients who are severely incapacitated by their orthostatic symptoms 59. We have shown that the beneficial effect of sitting is greater, i.e. blood pressure increases more, when using lower portable chairs 60. A chair height of about 40 cm may be optimal for many patients, being effective in raising blood pressure and yet not so low as to cause difficulty in rising, although this may be more of a concern for patients with neurodegenerative diseases with motor disability 9, 59. Leg crossing can increase seated systolic blood pressure considerably in patients with autonomic failure (Fig. 7) 5, 60, 61, whereas the effects in healthy normotensive subjects (on average <2 mmHg) and patients with hypertension (on average <7 mmHg) are small 62. Cheshire has reported an interesting phenomenon, observed in six patients with autonomic failure, of an urge to produce leg movements in the sitting position; these movements were effective at increasing seated blood pressure. This ‘hypotensive akathisia’ appeared to be habitual and could be transiently suppressed, yet felt irresistible to the patients 5.
Squatting, which is a combination of sitting, bending and increased muscle tone, expresses blood out of the leg venous vessels, thereby rapidly restoring venous return, cardiac filling pressure and cardiac output (Fig. 6) 33, 63, 64. The temporary hindrance to blood flow to the legs caused by physical compression or kinking of blood vessels is thought to increase systemic vascular resistance mechanically as well, but this issue is debated 65. There are two varieties of the squatting posture. In the first, the body is vertical, with the weight resting on the balls of the feet and/or the toes and with the calves strongly pressed against the back surface of the thighs. In the second, the body is inclined forward, with the feet flat on the floor. The latter is reported to have a stronger effect in most subjects 46, but might be considered difficult by the less athletic. It is worth noting that the greater the amount of blood pooled in the lower limbs, the more robust the effect of squatting 46. In patients with autonomic failure, squatting is a useful manoeuvre when syncope is imminent 18 as it increases blood pressure and cerebral blood flow almost instantaneously (Fig. 7). It can produce an increase in systolic and diastolic blood pressure of about 60 mmHg and 35 mmHg, respectively, in these patients 1, 4, 9.
Squatting is also very effective for aborting an imminent vasovagal faint (Fig. 6). Suspension with a double-strop device imitating squatting is used as a position that secures venous return during helicopter rescue transportation 66. A drawback of squatting is that patients may have difficulty in returning to standing from this position. They may experience orthostatic lightheadedness due to a rapid fall in pressure during the transition 67-70. This fall in pressure occurs primarily because of the sudden increase in blood flow to the legs due to vasodilatation of resistance vessels as the result of the brief large muscular effort to stand up from squatting, with widening of the local arterial–venous pressure gradient and removal of the physical hindrance of blood flow to the legs (reactive hyperaemia) as additional factors 69. The accelerative force during standing up from squatting may play an additional role 71. The fall in pressure upon arising from squatting can be exacerbated if the patient strains during the transition thereby decreasing venous return and further reducing stroke volume and cardiac output 11. Muscle tensing, such as clenching the buttocks or immediately walking upon standing, may reduce this problem (Fig. 8) 68, 69.
Effects of lower-body muscle tensing on the fall in blood pressure on standing from squatting after vasovagal fainting. Six consecutive squatting and standing manoeuvres are depicted in a patient with recurrent vasovagal syncope. The patient was studied directly after a tilt-table-induced vasovagal faint. White bars indicate squatting, grey bars indicate standing without lower-body tensing and black bars indicate standing with lower-body muscle tensing. BP, blood pressure.
From ; reproduced with permission.
The beneficial effects of sitting in a knee-chest position 46, 49, 72 or placing one foot on a chair whilst standing 46, 73 are comparable to squatting (Fig. 7). It is clear that lying down (preferably with raised legs) is also a very effective intervention in case of an impending orthostatic faint 74.
Effects of breathing manoeuvres
Although the main focus of this review is the physical counterpressure manoeuvres that directly oppose gravitational venous pooling, it is worth discussing several breathing-related physical countermeasures that appear to indirectly benefit cardiovascular stability in the upright individual via action on the respiratory pump.
Intrathoracic and intra-abdominal pressures demonstrate counterpoised oscillations with breathing, such that intrathoracic pressure decreases during inspiration whilst intra-abdominal pressure increases. This pumps blood towards the heart through the abdominal region during inspiration, as veins in the iliac and femoral veins prevent retrograde flow out of the abdomen when this region is compressed by inspiratory efforts. The negative intrathoracic pressure further facilitates venous return from the abdomen, as well as augmenting return from the upper limbs and head 2. The large oscillations in peripheral venous return to the heart that are generated by this respiratory pump are buffered during normal breathing by the splanchnic circulation, as the hepatic vein is compressed to the point of occlusion by the diaphragm during inspiration, but in turn will release pooled blood during expiration when the vein is decompressed 75. The net result is that preload on the heart is somewhat enhanced during inspiration, but still maintained during expiration with normal breathing. With rib-cage-only breathing, intra-abdominal pressure no longer rises with inspiration, and the primary effect is augmented venous flow into the thorax during inspiration 76.
It appears that humans are ‘wired’ to take advantage of this respiratory pump during orthostatic challenge, as deep inspirations and sighs are common precedents to faints and may serve to augment venous return. Such sighs and gasps may also promote vasoconstriction and venoconstriction in the skin 77. Indeed, recent findings by Lucas et al. suggest that slow deep breathing in the absence of hyperventilation may improve orthostatic tolerance 78.
Negative-pressure breathing and inspiratory resistance
Manipulation of intrathoracic pressure, designed to take advantage of the action of the endogenous respiratory pump, can be affected by changing breathing patterns and breathing resistances. Early work by Weissler et al. demonstrated that negative-pressure breathing (inspiring and expiring against a slight vacuum of 16–19 mmHg) was an effective means to reverse or protect against experimentally induced orthostatic vasovagal syncope 35. More recent refinement of this concept has been the development of an impedance threshold device (ITD) for treatment of severe haemorrhage and as an adjunct to cardiopulmonary resuscitation, CPR. In spontaneously breathing subjects, this commercially available device prevents inspiration until a negative pressure of 7 cmH2O (~5 mmHg) has been generated at the mouth by greater inspiratory effort, and thus creates a more negative intrathoracic pressure during the inspiratory phase, but with minimal effect on expiration.
In healthy subjects, use of an ITD has been shown to increase tolerance to simulated haemorrhage (lower-body negative pressure) 79, increase orthostatic tolerance during free standing 80, reduce orthostatic hypotension during a squat/stand test 81 and increase tolerance to upright tilt following 1 min of all-out sprinting on a cycle ergometer against a high resistance 82, as illustrated in Fig. 9. The use of an ITD also has been shown to be beneficial in subjects with a tendency towards vasovagal syncope) 80. In patients with autonomic failure, use of an ITD augments standing blood pressure by ~8 mmHg 83. The notion that this additional circulatory pump is under volitional control prompted the study of other manoeuvres, without the use of a device, including inspiratory sniffing and inspiration through pursed lips. However, responses across patients were more variable than with the ITD, as the voluntary breathing manoeuvres sometimes resulted in concomitant hypocapnia and hypotension, due to inadvertent hyperventilation. Hypocapnia causes vasodilatation in skeletal muscle and vasoconstriction in the brain and can induce syncope in patients with autonomic failure 84, 85. Thus, voluntary inspiratory sniffing and inspiration through pursed lips can also reduce orthostatic hypotension with the important caveat that hyperventilation must be avoided 83. This highlights the importance of training and feedback in the use of many countermeasures.
Effects of inspiratory resistance on recovery from vigorous exercise. Inspiratory resistance generated by an impedence threshold device (right panel) versus control (left panel) during upright recovery from 1 min of vigorous sprinting on a cycle ergometer against a high resistance in a healthy subject. The subject became symptomatic during control breathing but not when using the device. Note the increase in arterial and pulse pressures as well as cerebral tissue oxygenation index when inspiring against the resistance, and the oscillations in both arterial pressure and stroke volume generated by the enhanced respiratory pump (Lacewell et al. 2013, unpublished data).
It is worth noting that use of inspiratory resistance, either by means of a device or by breathing through pursed lips, may generate additional benefits beyond the primary effects on venous return. Along these lines, it appears that inspiring against resistance resets the operating point of the arterial baroreflex towards higher pressures, akin to what happens during exercise. This may provide an advantage for defending against hypotension. It has also been suggested that inspiratory resistance may increase cerebral blood flow independent of changes in arterial pressure. From animal studies, it is clear that breathing against an inspiratory resistance will lower intracranial pressure 86, which is inversely related to cerebral vascular resistance owing to the Starling resistor effect. In addition, negative intrathoracic pressures may augment cerebral blood flow via a siphon effect, although the presence of a functional cerebral siphon in upright humans remains controversial (as discussed by Lacewell et al. 82). Further refinements related to purposeful slow deep breathing 78 or use of rib-cage-only versus diaphragmatic breathing need to be explored 76.
Physical countermanoeuvres: from single observations and small series to clinical trials
When physical countermanoeuvres were applied in the early small, open-design patient series (n = 19–29) under conditions of daily living, excellent outcomes were reported during long-term follow-up (6–21 months) 6, 7, 36. Next, the multicentre PC trial was performed 87, in which patients were recruited in 15 medical centres worldwide. The PC trial included 223 patients, aged 16–70 years, with recurrent vasovagal syncope (at least three episodes in the past 2 years, or at least one syncopal spell and at least three presyncopal episodes in the past year, and recognizable symptoms). The trial assessed the effect of adding physical counterpressure manoeuvres (either arm tensing or leg crossing) to conventional therapy (explanation of underlying mechanisms of vasovagal syncope, lifestyle modification advice using an information leaflet). There was a 36% relative risk reduction for syncope in the physical counterpressure group versus conventional therapy (Fig. 10). It should be noted that 35% of the patients did not have sufficiently long prodromes to benefit from the manoeuvres. The relative risk reduction of 36% is amongst the largest seen in a randomised controlled trial of any therapy for vasovagal syncope.
Difference in syncope-free survival between patients treated with physical counterpressure manoeuvres (PCM) compared to treatment as usual (conventional) in the PC trial. The Kaplan–Meier curve shows that the 106 patients treated with PCM were significantly less likely to experience a recurrent syncopal episode than the 117 patients treated as usual (32% vs. 51%).
From ; reproduced with permission.
In the study by Croci et al., counterpressure manoeuvres were not effective in patients >65 years of age 36; however, the number of patients involved was small and, under laboratory conditions, the pressor effect of muscle tensing in fit elderly subjects is at least as great as in young subjects 54. Squatting was not part of the counterpressure manoeuvres in the PC trial, but its great effectiveness under laboratory conditions is clear. Thus, an additional large prospective randomized controlled trial is not needed 88.
Teaching physical countermanoeuvres
The subtle but significant effects of physical counterpressure manoeuvres, such as leg crossing or squatting, on a low standing blood pressure are difficult to monitor by sphygmomanometer. A continuous (ambulatory) noninvasive blood pressure device, such as Finapres 25, 26, enables quantification of their effects in detail. The changes in blood pressure can be demonstrated immediately to a patient by showing the finger blood pressure tracing on a video screen in the doctor’s surgery. This biofeedback will demonstrate to patients the effectiveness of their manoeuvres and will also help to select effective manoeuvres and to relate symptoms to actual blood pressure readings. Patients can thereby practise applying the manoeuvre effectively whilst being coached, possibly by a specialist nurse practioner 4, 32.
Physical countermanoeuvres often need to be modified specifically for individual patients depending on their abilities. They may be hard to perform in patients with multiple system atrophy. In the elderly, crossing the legs and pressing them together may lead to destabilisation, causing them to fall over. However, the buttock-clenching manoeuvre is often possible in the elderly 3. In our experience, this manoeuvre is effective to combat initial orthostatic hypotension.
Patients should be instructed in how to perform muscle tensing without raising intrathoracic pressure, as raising intrathoracic pressure impedes venous return to the heart and may cause blood pressure to drop and lead to lightheadedness in patients with neurogenic orthostatic hypotension 11. Patients should also be advised to avoid deep breathing and consequent hypocapnia during physical manoeuvres, because hypocapnia causes vasodilatation in skeletal muscle and vasoconstriction in the cerebral vessels both in patients with autonomic failure and in those with a tendency to vasovagal fainting 84, 85, 89. Close observation whilst practising the manoeuvres may be useful to alert patients to this habit.
A great advantage of physical countermanoeuvres is that they can be applied instantaneously at the moment of symptomatic low upright pressure. They thereby give the patient the opportunity to regain self-confidence in provocative situations. Gradual exposure to specific provocative conditions may be of use to regain self-confidence. Patients may benefit from practising leg and lower-body muscle tensing whilst standing motionless each morning as part of their daily routine 32. A video demonstrating useful counterpressure manoeuvres and illustrating the direct effect they have on blood pressure is available on the patient website www.stars.org.uk.
We have found the following practical patient recommendations to be helpful (Table 1). First, apply leg crossing or skeletal muscle pumping using heel raises or marching in place as a preventive measure. Leg crossing has the advantage that it can be performed casually without much effort and without drawing attention to oneself. With proper instruction and practice, many patients will begin to automatically apply leg crossing in daily life to prevent the feeling of lightheadedness or faints during quiet standing. Leg crossing can also be used to prevent these symptoms in the sitting position in patients with reflex syncope (Wieling and Krediet, unpublished observations).
Practical patient recommendations for manoeuvres to increase low blood pressure on standing
|Skeletal muscle pumping using heel raises or marching in place|
|Combatting symptomatic orthostatic hypotension|
|Leg muscle or buttock clenching|
|Whole-body muscle tensing, e.g. with arm tensing|
|Skeletal muscle pumping using heel raises or marching in place|
|Slow deep breathing|
|Combatting initial orthostatic hypotension|
|Emergency countermeasure in case of an impending faint|
|Bending over as if to tie shoe laces|
|Sitting with head between the knees (crash position)|
|Lying down with raised legs|
- A video with instructions for patients and additional lifestyle measures for patients with orthostatic intolerance can be found at www.syncopedia.org and www.stars.org.uk, respectively.
Secondly, when leg crossing is insufficient to prevent symptoms, patients can try adding leg muscle tensing and buttock clenching. Whole-body muscle tensing, for example with arm tensing by gripping one hand with the other and abducting both the arms at the same time, can also be used. Buttock clenching is also very effective to combat orthostatic hypotension upon standing (initial orthostatic hypotension).
Finally, squatting, which is the most effective physical manoeuvre to increase blood pressure, can be used as an emergency measure to prevent losing consciousness when fainting symptoms develop rapidly. Likewise, bending over as if to tie shoe laces has similar effects to squatting and is simpler to perform by elderly patients 1, 18. When arising again from the squatted position, patients should immediately sit down or begin lower-body muscle tensing to prevent the return of symptoms (Fig. 8 68).
The beneficial effect of physical countermeasures, based on the keen observations of astute clinicians in the first half of the 20th century, is an excellent example of how therapies that help many patients may be based on clinical observations in small groups or even individual patients 90, 91. In summary, physical countermeasures are simple, inexpensive techniques that have a strong biological rationale based on experiments conducted in the physiology laboratory. These techniques can be applied instantaneously at the moment of symptomatic low upright pressure. Furthermore, they are clinically effective evidence-based interventions without side effects that improve quality of life in patients with orthostatic intolerance.
Conflict of interest statement
There are no conflicts of interest.
Your blood pressure is 125/82. Is this too high?
As some of you may know, a new definition of hypertension (high blood pressure) was recently proposed by the American Heart Association, the American College of Cardiology, and 9 other sponsoring organizations.
According to the new definition, if one’s resting blood pressure (measured properly) is more than 120/80, it should be considered “elevated.” And if one’s BP is more than 130/80, then the person with that blood pressure should receive a diagnosis of hypertension.
Needless to say, the proposed definition has generated a lot of controversy. If all doctors adopted the new definition, that would create millions of new patients overnight, and a third of American adults would be considered to have a chronic disease!
What’s more, anyone with a blood pressure over 120/80 would be advised to have close medical follow-ups: repeat visits every 3-6 months, according to the new guidelines.
If the new definition seems a little extreme to you, you’re not the only one. I also find myself at odds with the document, and other doctors and colleagues are equally skeptical. But how are we to make sense of the new definition? Surely there must be some basis for it?
The answer is yes and no. But before we can judge the recommendation itself, we need to understand better what high blood pressure is and how it can affect us.
Basic facts about the blood pressure
The blood pressure is the force exerted by the blood against the walls of the blood vessels with each heartbeat. As you can imagine, the pressure goes up as the heart squeezes and then falls as the heart relaxes. That’s why the blood pressure is represented by 2 numbers (systolic and diastolic). For example, 118/76 or 150/83.
Image Attribution: OpenStax College via Creative Commons CC BY 3.0
The blood pressure normally changes all the time. Even if you are resting quietly, there will be small pressure changes from beat to beat related to your breathing pattern, your state of alertness, and other factors.
Then, if you start moving, the blood pressure will also change in response to your movements. And the blood pressure changes throughout the day: it is higher when you just wake up (you get a jolt of adrenaline to get you out of your slumber!), it is lower after you eat (blood goes to your gut to help digest), and much lower when you sleep. It is higher when you are more stressed, and lower when you are more relaxed.
As you can see, the blood pressure is not one set of numbers, but a quantity that varies all the time.
Defining “the” blood pressure
Many decades ago, when doctors began to suspect that a high blood pressure could be associated with health complications, they came up with some procedure to standardize the measurement to reduce the inherent variability. One standard procedure is to measure the blood pressure after someone has rested quietly for a few minutes, and to repeat this on 3 occasions and average the 3 numbers.
That’s what is commonly referred to as the blood pressure. But even with this procedure, there are is lot of variability and many pitfalls in measurement that one has to keep in mind.
Lower is better
Now, with this standard way of measuring the BP, doctors and scientists established beyond any doubt that a higher resting blood pressure indicates a higher risk of complications in the future. That’s true for either the top (systolic) or bottom (diastolic) number.
For example, if we take a group of people whose systolic BP is between 101-110 today, the number of individuals among that group who will have heart attacks, strokes, or kidney failure in 10 years will be very low and lower than in a group of people whose systolic BP is between 111-120. In turn, the number of people who will experience complications in that group will be lower than for a group of people with systolic BP 131-140, etc.
In a sense, then, “lower is better” so long as people are otherwise feeling well. Of course, the blood pressure shouldn’t get too low or we could faint! Fortunately, the body usually keeps that from happening, but there are nevertheless some instances where we need to be careful about low blood pressure.
For example, there is one caveat with elderly patient who may paradoxically have a higher risk of heart attacks if their diastolic blood pressure is too low. Otherwise, if we are talking about blood pressure in general, I think it is fair to say that lower is better.
At any rate, the relationship between the blood pressure and the risk of health outcomes can be described according to the graph below, and where the dotted “J” shaped indicates that in some instances a low BP may not necessarily be better:
So, we should have a blood pressure as low as possible, right? And , if so, how low should it be, and what’s considered normal?
Here’s where we can get in trouble.
The lowest point on the curve is not a fixed number that we can identify. The curve gradually increases from the range of normal and there is no identifiable number that says “above this, your risk is too high.” Calling any number “normal” or “abnormal” is tricky.
Because the curve is drawn from large population studies, and the “risk” of complications pertains to groups and not to individuals, is not all that clear that any given BP number imparts the same risk to different people.
For example, for one person a BP of 135 may be too high, but for another it may be just fine. People’s bodies may respond different to a given blood pressure due to genetic predispositions, or because their bodies are healthier in other ways.
So, the numbers picked in the new definition of hypertension (and in the old one, for that matter) are, in a very real way, arbitrary. To say that 120/80 or less is “normal,” and anything above 120/80 is abnormal, is really stretching the meaning of normal and abnormal. The definition attaches to specific numbers a significance they do not have.
Population health versus individual health
The new definition is really a tool for population health, rather than of medical care. The committees that come up with definitions of hypertension are really saying that as a population, it would be best to have an average blood pressure lower than it currently is in the United States.
That may very well be true, but doctors should always be mindful of the individual person they are treating, and not simply thinking about that as statistical data points.
If, on the one hand, we can argue that “lower is better” and that a BP less than 120/80 is more desirable that a BP > 120/80, we should be very mindful of the potential negative consequences of turning that number into a criterion to define normal and abnormal.
Risks of overdiagnosis
There are many potential negative consequences of being too eager to make the diagnosis of hypertension, and these consequences have been well documented in the medical literature over the years:
- For example, imagine walking into the doctor’s office for a routine check-up and walking out with a “label” of hypertension or elevated blood pressure. There can be negative psychological consequences.
- We know that some people can start feeling sick, experience headaches or other symptoms just from being told they have high blood pressure. This is the so called nocebo effect and can lead to sick calls from work and decreased productivity.
- Also, the increased risk of complications from having a mild elevation in the blood pressure must be placed in the context of the patient. Some patients already have many other health problems to deal with. Why add to these problems with a new diagnosis that is unlikely to change the course of things?
- Importantly these days, a label of hypertension can also have serious financial impact on life insurance and health insurance premiums. And once someone is labeled as having an elevated blood pressure, more doctor visits will be expected, and probably more treatments.
- Although blood pressure medicines are generally very safe, complications sometimes occur. This is particularly true for elderly patients whose body can have a hard time adjusting to changes in blood pressure and, as result, may be more prone to falls or faints.
The way forward
So, how do we sort all that out?
I personally think that we should move away from making decisions according to arbitrary cut-off numbers. It is important to be mindful of the relationship between the blood pressure and complication described by the graph above, but it is also important to be mindful and observant of all the specific patient considerations that could bear on how we label patients.
We don’t want to label and treat patients unnecessarily, and we also don’t want to ignore and miss opportunity to intervene and avoid complications. In fact, I think that sometimes adhering rigidly to cut-off numbers can causes people to be under-treated.
Medicine is a fine art. A doctor should be ready to not treat 2 patients with the same blood pressure in the same way, but take into considerations all the necessary factors. A few years ago, Dr. Herbert Fred and I published an article outlining what we consider a sensible approach to the question of hypertension. In some cases, cardiovascular testing can be helpful to help differentiate the patient who needs more intensive intervention from the one who does not.
At any rate, the main point that I would like to make is that definitions of “high blood pressure” based on cut-off numbers are artificial and potentially harmful. Doctors should not treat individual patients on the basis of population health considerations, however well intentioned these might be.
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Your Good Health: 90-year-old experiences fast heartbeat, low blood pressure
Dear Dr. Roach: A couple of weeks ago, I had a sudden fast heartbeat with a very irregular and erratic pulse (approximately 150-161) for about six hours, along with a very low blood pressure, ranging from 74/59 to 79/52.
Dear Dr. Roach: A couple of weeks ago, I had a sudden fast heartbeat with a very irregular and erratic pulse (approximately 150-161) for about six hours, along with a very low blood pressure, ranging from 74/59 to 79/52. I first felt a strange thumping in my neck area. I am treated for high blood pressure with amlodipine, losartan and HCTZ. My BP usually is in the normal range, and I have never had an episode like this. I called my doctor’s office a day later, and he ordered a Holter monitor (I will have it tomorrow). I was feeling some anxiety before this happened, but this has been an entirely new event for me. My other medications include thyroxine. I am 90 years old, in good health, with mild arthritis, alert and oriented. What could possibly cause such an episode?
A sudden, fast heart rate without exertion can be caused by anxiety or fright; however, that doesn’t sound like what happened to you. Your report sounds very much as though you had an episode of atrial fibrillation. The atria are the top chambers of the heart, which fill with blood passively from the veins of the body (on the right side) or the lungs (on the left), and contract to fill the ventricles. The right atrium also normally provides the electrical stimulation for the heart. In atrial fibrillation, instead of, say, 60 beats a minute, the atria may put out a thousand impulses a minute.
The heart cannot possibly respond to all those impulses (there is a safeguard built into the electrical system), so the heart rate becomes highly irregular and variable. The rate may be normal, but more frequently it is too fast. One of the goals in atrial fibrillation is to control the heart rate, to protect the heart from going too fast. A rate of 160 in a 90-year-old is not safe, and the fact that your blood pressure went down is concerning: I would have considered admitting you to the hospital in this situation, and certainly would have recommended that you be seen and get an EKG at the time.
People with atrial fibrillation also are at risk for blood clots forming in the heart, and these can travel to the brain, causing a stroke. The other major goal of treating atrial fibrillation is to reduce stroke risk. This requires anticoagulation.
There are other possible causes for fast heart rates, but the erratic nature makes me think atrial fibrillation is the diagnosis. Please let me know the results of your heart monitor.
Dear Dr. Roach: You recently wrote that 1,200 calories a day is not enough for most people, but 1,200 calories will support a 120-pound person. Most diets recommend 2,000 calories. That is enough for a 200-pound person! And we wonder why we have so many obese people in our country? The answer is portion control!
I must disagree with your numbers. According to the Office of Disease Prevention and Health Promotion, a sedentary adult woman of 126 pounds requires 1,600 to 2,000 calories to maintain her weight. People with normal or high levels of activity will require more. Estimates of how many calories are actually consumed vary, but most estimates are that the average intake is close to 3,500 calories per adult per day.
I agree with you that portion control is key, but telling a person that 1,200 calories is adequate to maintain weight is not supported by the data.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
ECHI – European Core Health Indicators
The European Core Health Indicators (ECHI), formerly known as European Community Health Indicators are the result of a long-term cooperation between the EU Member States and the European Commission. Three ECHI projects (1998-2001, 2001-2004, 2005-2008) funded under the EU Health Programmes established the first lists of ECHI indicators, aiming to create a comparable health information and knowledge system to monitor health at EU level.
Under the Second Programme of Community Action in the Field of Health 2008-2013, the EU funded the Joint Action (JA) on European Community Health Indicators Monitoring (ECHIM). The JA ECHIM built on previous achievements and developed more precise definitions of the indicators and continued the implementation of the indicators in the Member States. One of the aims of the ECHIM was to consolidate and expand the ECHI indicator system towards a sustainable health monitoring system in Europe supporting the EU Health Strategy. The work was carried out in close collaboration with Member States, the European Commission, Eurostat, WHO, OECD and other international organisations. The JA ended in June 2012 and the main result was a shortlist of 88 health indicators classified by policy areas.
In May 2013, the Expert Group on Health Information agreed to rename the ECHI to European Core Health Indicators.
Definitions and data collection are in place for nearly 60 out of 88 ECHI indicators. The indicators under development still need further refinement before being accessible in the ECHI data tool. ECHI indicators are grouped below under five main chapters. To access data and metadata, click on the indicator to go to the ECHI data tool. This tool allows presenting selected indicators in different layouts: line chart, bar chart, map or table.
Indicators are at the crossroads of policy questions and data sets. They reflect a policy interest as well as a selected set of possibilities in terms of what can be calculated. For these reasons, the European Commission also presents other European health indicators that are not part of the ECHI system but are still useful to health stakeholders (see below). Intended indicators below are also directly accessible through the ECHI data tool.
Where considered useful or appropriate, stratification by gender and age is applied. Breakdowns by socio-economic or regional level are provided when available.
Demography and socio-economic situation
Determinants of health
Health interventions: health services
Health interventions: health promotion
85. Policies on environmental tobacco smoke (ETS) exposure (D)
86. Policies on healthy nutrition (D)
87. Policies and practices on healthy lifestyles (D)
88. Integrated programmes in setting, including workplace, schools, hospital (D)
90,000 What is normal blood pressure at what age?
Blood pressure is a purely individual indicator and depends on many factors. And, nevertheless, there is a certain average medical norm. That is why deviations from the accepted indicators allow the doctor to suspect malfunctions in the body’s systems. However, the indicators change depending on the time of day and on the age of the person.
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Normal pressure in an adult should be determined only at rest, since any stress (both physical and emotional) has a huge impact on his performance.The human body independently controls blood pressure, and with a moderate load, its indicators rise by about 20 mm Hg. This is due to the fact that the muscles and organs involved in the work require a better blood supply.
According to the “Newest Reference Book of Necessary Knowledge”, normal blood pressure in newborns is 70 mm Hg. Normal blood pressure in a child who is one year old: boys – 96/66 (upper / lower), girls – 95/65. Reported by poradamamu.in.ua
Normal blood pressure in a 10-year-old child: 103/69 in boys and 103/70 in girls.
Normal blood pressure in young people 20 years old: in boys – 123/76, in girls – 116/72.
Normal blood pressure for those who are about 30 years old: for men – 126/79, for young women – 120/75.
In a middle-aged person: in 40-year-old men 129/81, in 40-year-old women 127/80.
For fifty-year-old men and women: Pressure is considered normal for men 135/83 and for women 137/84.
For elderly people:
The following pressure is considered normal: for 60-year-old men 142/85, for women of the same age 144/85.
For seniors who have turned 70 years old: normal pressure is 145/82 for men and 159/85 for women. What is the normal blood pressure of an old or elderly person? For 80-year-old people, pressure 147/82 and 157/83 for men and women, respectively, is considered normal. For elderly ninety-year-old grandfathers, the normal pressure is 145/78, and for grandmothers of the same age – 150/79 mm. rt. pillar. Blood pressure consists of two numbers, the upper number is the renal pressure, the lower number is the heart pressure.
How to measure pressure?
There is a special device for measuring blood pressure – a tonometer. At home, it is most convenient to use an automatic or semi-automatic device.
To obtain correct results, the following recommendations must be observed:
- Before measuring pressure, you must completely eliminate physical activity;
- No smoking;
- measuring blood pressure immediately after eating will also give incorrect results;
- measure blood pressure while sitting in a comfortable chair;
- the back must be supported;
- The hand on which the measurement is taken must be located at the level of the heart, i.e.e. pressure is measured while sitting at the table;
- when measuring pressure, you must remain motionless and not talk;
- readings are taken from both hands (measuring interval 10 minutes)
What to do if the pressure is high (help):
1. Pour hot water with a temperature of 37-40 ° C into a basin or a bucket and immerse your feet in the water. While the water cools down – it will take about 20 minutes – the pressure will drop by 15-20 mm. If a person has varicose veins on the legs, you can lower your elbows into the water.
2. Dill seeds reduce blood pressure. You need to steam them with boiling water, taking 2 tbsp. spoons for 0.5 liters of boiling water, drink 1-2 teaspoons at a pressure of up to 200 mm and 3-4 tsp. at higher pressure.
3. Add 1 tsp to kefir. cinnamon, drink this drink in 1 glass for 3 months. The pressure should stabilize. There is one very simple and incredibly effective recipe for traditional medicine that will help bring blood pressure back to normal, well, at least for a couple of years.And besides, it doesn’t cost a dime. So the composition of the broth: take 5 tablespoons of pine needles, 2 tablespoons of rose hips and 2 tablespoons of onion husks. Pour all this with 1 liter of cold water, bring to a boil and cook over low heat, covered for 10 minutes. Let it brew and strain. You can add a little water. Drink it all in 2 days. The course of such treatment is 4 months. Improvement can come within 5 days – the headaches will go away, and after a month you can try to gradually cancel antihypertensive drugs.The stool will become regular, which means that the intestines and liver are also cleansed. This broth has immuno-strengthening properties, is a prophylactic agent against influenza. It has a good diuretic effect. It will help with painful bleeding of the gums.
90,000 What does blood pressure mean 100 to 60 mm Hg. and what if it fell?
Every second person experienced a decrease in blood pressure. More often, a similar phenomenon occurs in adolescents and during pregnancy, but there are exceptions.Do I need to panic if the pressure is 100 to 60 – what does this mean and in what cases should I see a doctor?
Qualified doctors will help you answer these questions.
Blood pressure: concept, norm
One of the most important indicators is blood pressure. But in modern medicine, only one type of it is most often measured – blood pressure, or blood pressure. According to its indicators, one can judge the state of the vessels and the general health of the patient.
To determine blood pressure, doctors record 2 types of it:
- systolic – the upper value, showing the level of pressure during the contraction of the heart muscle;
- diastolic – the lower indicator indicating the state of the vessels during relaxation of the heart.
There are no strict guidelines for blood pressure. However, 120/80 indicators are recognized as the benchmark for people over 17 years old. But this is just a convention. So, many doctors consider a pressure of 100 to 60 acceptable, provided that the subject feels normal, vigorous and active. Such indicators can also be a symptom of serious pathologies that require immediate medical attention.
Read about the variety of blood pressure and pulse monitors here.
What does it mean if blood pressure dropped to 100 by 60 mm Hg. Art.?
A decrease in indicators to such a level in most cases is considered a variant of the norm. After all, the pulse pressure is within acceptable limits. But for some patients, these numbers are abnormal.Therefore, if suddenly there was a decrease in values and a pressure of 100 to 60, what should be done to ask the doctor. In this case, it is worth considering the presence of dangerous factors that can provoke hypotension:
- inflammation of internal organs;
- various ailments of the cardiovascular profile;
- previous head injury;
- serious allergic reaction;
- blood diseases;
- violations of vascular elasticity;
Be careful: lowering blood pressure during pregnancy is especially dangerous! Therefore, if the expectant mother has a pressure of 100 to 60, what does this mean – the doctor should find out! After all, such indicators indicate a deterioration in blood circulation, which can lead to hypoxia and miscarriage.
In some situations, a decrease in indicators was provoked by relatively safe reasons:
- lack of a balanced work and rest regime;
- alcohol consumption;
- active sports.
90,036 stressful situations;
90 036 taking certain medications (antidepressants, diuretics, drugs for hypertension, etc.)etc.)
If the pressure is 100 to 60, it is better to focus on the accompanying symptoms. Hypotension is often accompanied by weakness, nausea (up to vomiting), headache, fainting. Such signs require the attention of doctors, especially if you have previously been injured.
Note: if the pressure is 100 to 60 – what is it – will help to understand the pulse. After all, heart rate (HR) is considered an important diagnostic sign for hypotension.
If the pulse is normal
Lack of compensation for low blood pressure by increased work of the heart usually occurs during a period of active growth in adolescents, during acclimatization, or in individuals for whom hypotension is a natural state. But there are also exceptions.
Normal adult heart rate ranges from 60–90 beats per minute. A decrease or increase in performance can both indicate the presence of problems, and be the result of stress, overwork, etc.Therefore, if the pressure is 100 to 60 at a pulse of 60, what does this mean is a moot point. In most cases, such indicators are the norm. But if you do not feel well, you should see a doctor.
Many people mistakenly believe that tachycardia with a decrease in blood pressure is a pathology. But it is not always the case. In most cases, an increase in heart rate is normal. For example, during pregnancy, an accelerated heartbeat is a consequence of an increase in blood volume, etc.But if the pressure is 100 to 60, the pulse is 100, what does this mean – the accompanying symptoms will help to understand:
- nausea and vomiting – typical for heat strokes, overheating;
- fever is a sign of an inflammatory process;
- severe headache – may indicate hemorrhage;
- weakness, fainting – profuse blood loss, shock.
If during pregnancy the pressure is 100 to 60, the pulse is 100, only a qualified doctor can determine what to do.It is possible to determine the severity of the condition of the expectant mother by the intensity of signs of toxicosis. If his symptoms worsen (severe vomiting, the appearance of edema in the upper parts of the body, photopsia, etc.), you should undergo additional examination!
Do not focus only on blood pressure and heart rate indicators: it is important to take into account additional symptoms. If your health has noticeably deteriorated, and low blood pressure is not the norm, it is better to consult a doctor.
Is this condition dangerous?
If the blood pressure is 100 to 60, what this means should be found out, taking into account the person’s well-being.Modern doctors recognize that such indicators are not critical and in most cases are considered the norm.
But to assess the patient’s status, it is important to take into account not only the current values, but also such moments:
- Results of previous surveys. If earlier blood pressure was 120 to 80, and then suddenly dropped, it is worth conducting additional research.
- The presence of concomitant symptoms. If a patient complains of nausea, fever, frequent fainting, dizziness, migraine or feeling unwell, you should make sure that there are no serious health problems.
- A detailed analysis of the circumstances of the drop in indicators: the presence of injuries, taking medications, stressful situations, travel – everything matters for the diagnosis.
If you feel unwell and your blood pressure suddenly drops to 100 to 60, what to do will be determined by the doctor. After all, abrupt deviations from the norm are a dangerous sign that requires the attention of professionals.
What to do, how to raise?
If the decrease in blood pressure occurred abruptly, provoked by trauma, or is accompanied by such severe symptoms as severe migraine, loss of consciousness, impaired coordination of movements, pain in the heart, you should immediately consult a doctor.When the signs of malaise are insignificant or absent altogether, it is worth taking the following measures:
- drink a cup of green tea or coffee;
- eat bread with honey, lightly sprinkled with cinnamon;
- take a contrast shower;
- to perform breathing exercises;
- in the cold season, it is permissible to dissolve a pinch of salt;
- in the heat it is worth drinking clean water, since a decrease in indicators can be caused by dehydration;
- take specialized medications (Strofantin, Norepinephrine, etc.)but only if approved by your doctor.
Be careful: do not take pharmacy drugs without permission.
Interesting information about self-massage with hypotension can be found in the following video:
- When the pressure is 100 to 60, how to raise – the doctor will determine!
- If a decrease in blood pressure is not accompanied by dangerous symptoms and causes only mild discomfort, then you can use the means at hand.
- If an attack was preceded by an injury or your health has deteriorated sharply – contact your doctor. After all, such symptoms can indicate dangerous pathologies that require urgent medical attention.
GBUZ TO “KBSMP” Tver. – The first signs of a stroke and actions when the first signs of acute cerebrovascular accident occur
The first signs of a stroke and actions when the first signs of stroke occur
Stroke is hemorrhagic (cerebral hemorrhage) and ischemic (necrosis of brain cells, also called cerebral infarction).
Signs of hemorrhagic stroke are:
- Acute headache, confusion or fainting.
- Sudden vomiting, drooling.
- Hearing and vision impairment.
- Paralysis of half of the body, distortion of facial expressions.
Signs of ischemic stroke include:
- Feeling of weakness and numbness in the limbs, which gradually increases.
- Confusion of speech, distortion of words, impaired coordination of movements.
- Decreased visual acuity.
- Skewed face.
In both cases, a stroke develops in a matter of minutes. The signs of a hemorrhagic stroke are brighter. As a rule, the patient cannot answer questions. With an ischemic stroke, the patient first feels a slight discomfort, and here it is necessary to conduct several simple tests: ask to smile, raise your hands, read the line in small print.If a patient has one corner of his mouth left, it is difficult for him to move his limbs, vision problems have begun, an ambulance must be called. Ischemic stroke is more common, accounting for about 85% of cases.
Stroke is an emergency, so in no case should you hesitate, but you must immediately call an ambulance.
While you are waiting for an ambulance to arrive, there are a few simple rules that can significantly help a patient with a stroke:
It is imperative to make sure that the patient can breathe.If you find a breathing disorder, it is necessary to clear the airways by laying the patient on his side and clearing the oral cavity.
It is important, if possible, to measure the level of blood pressure and glucose. The recorded indicators must be recorded and reported to the doctors upon arrival.
If the patient fainted and ended up on the floor, you can move him to a more comfortable position. The widespread belief that a patient with a stroke cannot be moved is a myth!
It is especially important to understand when the stroke occurred.Especially if the patient has already been found with signs of a stroke. Try to understand when the patient was last seen without a stroke.
Do not immediately begin to lower blood pressure in a patient. High blood pressure in the first hours of a stroke is a necessary norm due to the adaptation of the brain.
In no case should you give water or feed the patient. This can only aggravate his condition.
Normal blood pressure numbers
Pressure standards by age are determined by the following indicators:
Up to 30
30 – 40
40 – 50
50 – 60
Older than 70
Dear residents of the cityUfa and the Republic of Bashkortostan!
GBUZ Republican Narcological Dispensary No. 1 of the Ministry of Health of the Republic of Belarus informs about work on holidays and weekends:
1. Provision of medical care in stationary conditions:
from 04.11.2021 to 07.11.2021 around the clock.
2. Provision of medical care in stationary conditions:
from 04.11.2021 to 07.11.2021 weekends.
3. Office for issuing medical opinions (certificates):
03.11.2021 works until 15:45. November 4, 5, 6, 7 are public holidays non-working days. Since November 8, the office for issuing medical certificates (certificates) has been working as usual.
Hot line phone +7 (347) 266-03-88. Administration of GBUZ RND No. 1 of the Ministry of Health of the Republic of Belarus.
Hotline of the Ministry of Health of the Republic of Belarus:
– on issues of medical care for the adult population +7 (347) 218-00-53;
– on issues of drug supply: +7 (347) 218-00-76;
– on wages: +7 (347) 218-00-83
– on issues of medical care for children and obstetrics: +7 (347) 218-00-48
on weekdays from 9.00 a.m. to 6 p.m .;
on non-working holidays call forwarding to the phone
GBUZ RSSMP and CMK: +7 (347) 287-81-84.
Dear residents of Ufa and the Republic of Bashkortostan!
From 09/28/2021 office for the issuance of medical reports (certificates) at the address Ufa st. Suvorov 79 is temporarily closed for technical reasons.
Reception of visitors is carried out at the address Ufa, st.50 years of the USSR, d.43 strictly by appointment (phone number 266-40-05; Vatsap – 89177935202)
visitors who made an appointment from 09/28/2021 can contact the address Ufa, st. 50 years of the USSR, 43 according to the recorded time.
We apologize for the inconvenience caused!
Dear residents of Ufa and the Republic of Bashkortostan!
In order to increase the availability of specialized medical care to the population, the State Budgetary Healthcare Institution Republican Narcological Dispensary No. 1 of the Ministry of Health of the Republic of Bashkortostan informs you that from January 18, 2021, a psychiatrist-narcologist’s office will be additionally opened at the address: St.Ufa st. Lenin, 95 (transport stop “Permskaya”).
For residents of all districts of the city of Ufa and the Republic of Bashkortostan, nonresident citizens with a certificate from the main place of registration for obtaining a medical opinion from a psychiatrist-narcologist (certificate) for weapons (form 003).
day off: Saturday, Sunday
And also the offices continue their work at the addresses: g.Ufa, st. 50 years of the USSR, 43, Ufa, st. Suvorov, 79, Ufa, st. Brothers Kadomtsevs, 8.
We ask you to use personal protective equipment (masks, gloves). Maintain a safe distance of 1.5-2 meters. If you have signs of a respiratory infection, refrain from visiting a psychiatrist-narcologist
Dear visitors !
In order to increase the availability of specialized medical care to the population of the city ofUfa, the issuance of medical opinions (certificates) during medical examinations by a psychiatrist – narcologist is carried out at the addresses:
|Address||Service||Types of medical reports||Reception schedule||Phone number for appointment|
street 50 years of the USSR, 43
(view on Yandex maps)
– Management of vehicles – Employment, civil service
Daily: from 08.00 to 17.00
lunch from 13.00 to 13.30
Saturday: 08.00 to 15.00
Day off: Sunday
8 (347) 266-40-05
8 (927) 924-05-44
Recording by message via WhatsApp is carried out by phone number: +7 (917) 793-52-02
ALL DISTRICTS OF UFA AND RB
+ Nonresident citizens: 90,023 with a certificate from a narcologist from the main place of registration.
– foreign citizens
st. Suvorov, 79
(look at Yandex maps)
Districts: Ordzhonikidze Kalininsky
Daily: from 08.30 to 17.00
Lunch from 13.00 to 13.30
Weekends: Saturday, Sunday
8 (347) 266-40-05
8 (927) 924-05-44
Recording by message via WhatsApp is carried out by phone number: +7 (917) 793-52-02
8 Br.Kadomtsevykh str.
(view on Yandex maps)
– Vehicle management – Employment, civil service
– Military Medical Commission
Daily: from 08.30 to 17.00
Lunch from 13.00 to 13.30
Weekends: Saturday, Sunday
95 Lenin str.
(view on Yandex maps)
Daily: 08.30 to 17.00
Lunch from 13.00 to 13.30
Weekends: Saturday, Sunday
ALL AREAS OF THE CITYUFA and RB
+ Nonresident citizens: with
there is a certificate from a narcologist from the main place of registration.
Blood Pressure – Health IQ
Increasing or decreasing blood pressure is a widespread problem that cannot be ignored or taken for granted.
Increasing or decreasing blood pressure is a widespread problem that cannot be ignored or taken for granted.Usually, we detect these changes during daily monitoring, after which we mandatorily prescribe an ultrasound examination of the heart, which helps us determine how long and seriously these changes affected the cardiovascular system.
To a greater extent, patients suffering from high blood pressure complain about changes in blood pressure and, often, these cases are detected in a patient by chance.
An increase in blood pressure can appear against the background of emotional overload and stress, which can be regarded as a psychosomatic manifestation.Such episodes can be both long-term and single, which are stopped on their own and in the future do not manifest themselves in any way. However, isolated crises are very rare and, mainly, at a young age. As a rule, the older the patient, the more alarming the reported cases of increased blood pressure.
Methods of treatment.
First of all, we must change the patient’s lifestyle. Every cardiologist will recommend reconsidering your lifestyle, regardless of whether the patient is prescribed drug therapy.Probably, you will have to change a lot of the established and familiar: the time of falling asleep, and the time of awakening, and the drinking regimen. It will be necessary to limit the consumption of certain foods. In short, a lot of things will have to be avoided, especially in the first stage of treatment. It is very often difficult for patients to increase their physical activity, as they think they are already reaching their maximum. Patients are ready to take any medication, follow any diet, but just not increase their physical activity.In our clinic, we prescribe a particular type of physical activity to patients based on indicators such as simple body weight and fitness. If the patient’s body weight is very high, it will be difficult for him to even take unnecessary steps. In this case, we will consider the exercises performed while lying down, we can talk about swimming, for example, in any case, we will in one way or another increase the amount of physical exercise. Of course, we take into account the individual parameters of the patient and write out the optimal feasible load.
It is important to effectively select the type of physical activity based on the survey results. For example, hypertensive patients need rather aerobic exercise, and the patient himself would prefer a gym. We are not saying that this or that type of exercise is bad: we only indicate the need to select a program, taking into account the physical characteristics of the patient. As we get to know the patient, we can recommend both the acceptable heart rate limit (HR) and the type of training, for example, continuously increasing or stepping.
Indicators above 140/90 are considered hypertension and require examination.
As a rule, high blood pressure is accompanied by the prescription of medications, and depending on the type of increase in blood pressure, these drugs are very different and are used in different regimens and combinations. Factors such as sugar levels, blood lipids, and electrolyte metabolism are taken into account.All this leaves an imprint on the choice of antihypertensive drug.
Indicators below 100/60 are considered hypotension and also require examination.
On the one hand, there are constitutionally adapted patients in whom low blood pressure manifested itself from adolescence and is very well tolerated. It is bad when low blood pressure has arisen suddenly. Such sharp changes must be diagnosed in time: this may be a sign of acute heart failure.Such cases usually do not occur at a young age. Although statistics show that today, heart attacks also occur in relatively young people. A sudden drop in pressure also occurs with arrhythmias.