China has become the country with the highest number of hypertensive patients in the world. The number of hypertensive patients in China is around 300 million, which means one out of every four people is a hypertensive patient. As a very common chronic disease, once diagnosed, it is generally assumed that medication needs to be taken for a lifetime.
However, the daily need for medication has caused significant psychological stress to some hypertensive patients. In the era of the internet, news about “medication side effects harming the liver and kidneys” is frequently seen, leading many to believe that once their blood pressure is lowered, they can reduce or stop the medication. Recently, there was such a case in the clinic with an elderly lady.
Aunt Liu, 62 years old, was diagnosed with hypertension when she retired at 55, and she is now considered a moderate to severe case. Initially, she resisted taking antihypertensive medication for a year, thinking that hypertension was common, and the saying “medicine is three parts poison” implied significant side effects with long-term use. However, Aunt Liu later started feeling palpitations and drowsiness, and under the repeated advice of her children, she began taking antihypertensive medication.
For the past few years, everything had been fine until the beginning of the year when she went for a blood pressure check-up and found that her blood pressure had dropped slightly. She started thinking that she couldn’t keep taking the antihypertensive medication like this. However, Aunt Liu also had some knowledge about medications and knew that she couldn’t suddenly stop taking the medication, so she began taking half the dose every day.
For the first few days, she kept monitoring her blood pressure, fearing any issues. She found that her blood pressure was stable, so she relaxed and planned to stop the medication after a while. However, before she could stop the medication, she was hospitalized due to vomiting and fainting.
The reason Aunt Liu was hospitalized was because she had changed the dosage of the medication without consulting, leading to abnormal fluctuations in blood pressure, causing tiny hemorrhages in the brain. Fortunately, she sought medical attention promptly; otherwise, the consequences could have been unimaginable. Today, let’s talk about blood pressure and antihypertensive medication.
What exactly is blood pressure? In professional terms, blood pressure refers to the lateral pressure that blood exerts on the inner walls of blood vessels as it flows continuously through the vessels. It is this pressure that enables the dynamic flow of blood in the blood vessels. It can be classified into venous blood pressure, arterial blood pressure, and capillary blood pressure based on the different names of blood vessels in the human body, with the commonly measured one in hospitals being arterial blood pressure.
When the arteries are elastic and recoil during cardiac diastole, the pressure generated is known as diastolic pressure, where the blood pressure in the arteries is at its lowest, referred to as low pressure; and when the arteries feel the contraction of the heart and receive the lateral pressure from the ventricle, it is known as systolic pressure, which is the maximum pressure exerted on the artery walls during the mid-stage of the heart’s contraction, known as high pressure.
In clinical practice, the normal blood pressure range is defined as systolic pressure of over 140mmHg and less than 90mmHg, and diastolic pressure over 90mmHg and less than 60mmHg. For adults over 18 years old, in the absence of any medications affecting blood pressure fluctuations, when the blood pressure exceeds the critical value, it is diagnosed as hypertension; conversely, when it falls below the critical value, it is diagnosed as hypotension, with variations across different age groups.
For hypertensive patients, it is further classified into three levels based on the systolic pressure:
– Mild hypertension (Grade 1): when the systolic pressure is above 140mmHg and less than 160mmHg
– Moderate hypertension (Grade 2): when the systolic pressure is above 160mmHg and less than 180mmHg
– Severe hypertension (Grade 3): when the systolic pressure is at or above 180mmHg
Moreover, it is particularly noteworthy that within the normal blood pressure range, some individuals may have systolic pressure between 120mmHg and 139mmHg, which, though not considered as hypertension clinically, research findings have indicated a 64% probability of developing hypertension within ten years in this group.
As we all know, cardiovascular and cerebrovascular diseases are the leading causes of death in China, accounting for four percent of the total population. Among these, hypertension is the primary factor leading to cardiovascular and cerebrovascular diseases. Now, let’s delve into the hazards of hypertension.
When blood pressure rises, it can exacerbate atherosclerosis, damage blood vessel walls leading to bleeding, and trigger organ damage in the heart, brain, kidneys, retina, and more. Uncontrolled high blood pressure can result in arrhythmia, coronary heart disease, cerebral hemorrhage, stroke, renal impairment, kidney failure, retinal hemorrhage, and even blindness, among various severe conditions.
High blood pressure poses significant risks. However, low blood pressure is also problematic, easily causing symptoms such as dizziness and fainting, especially in the middle-aged and elderly population. Compared to younger individuals, the elderly have weaker self-regulation abilities, making them less tolerant to low blood pressure. The frailties of low blood pressure can lead to insufficient cardiac perfusion, triggering acute severe conditions like angina pectoris and ischemic stroke.
Given the substantial risks associated with both high and low blood pressure, is it sufficient to control blood pressure within the normal range using medication and then stop or reduce the dosage? Let the doctor tell you!
In daily life, paying close attention to one’s blood pressure dynamics, like Aunt Liu in the case, and deciding to change medication dosage independently upon observing low blood pressure is not advisable. Conversely, patients who believe they have excellent blood pressure control, unlike those who neglect their health status and poorly manage their blood pressure, are a source of concern for medical professionals.
In clinical treatment, adhering to regular medication schedules is a crucial aspect. Intermittent medication not only fails to benefit the condition but may worsen it. The latest hypertension guidelines recommend the following blood pressure reduction targets:
– For general adults, the blood pressure target should be below 140/90mmHg
– For patients with diabetes, coronary heart disease, kidney disease, the target should be below 130/80mmHg
– Elderly patients should avoid excessively lowering blood pressure to prevent inadequate blood supply; the target should be below 150/90mmHg
– For middle-aged and young hypertensive patients, blood pressure should be maintained below 120/80mmHg
During antihypertensive medication, if the patient’s blood pressure remains within the normal range, there is no need to reduce the dosage. If a patient notices a significant improvement in their condition, they should promptly contact their doctor for advice and make dosage adjustments under medical guidance.
Under what circumstances can medication dosage be reduced? In clinical practice, the following situations are generally considered for dosage reduction:
– Secondary hypertension patients, including patients with conditions like renal parenchymal hypertension, monogenic hereditary hypertension, primary aldosteronism, endocrine hypertension, drug-induced hypertension, who, when the primary condition is cured, may consider adjusting the hypertension medication dosage due to the gradual recovery of elevated blood pressure post-treatment.
– Mild hypertensive patients, such as young and middle-aged individuals with hypertension for less than 5 years who only require a single antihypertensive medication, and during regular blood pressure monitoring, exhibit a stable blood pressure within the normal range without any complications (e.g., diabetes, kidney damage, retinal changes, coronary heart disease), may, under the guidance of a doctor, reduce the dosage and gradually discontinue the medication.
– Patients whose blood pressure returns to the normal range during the summer season may, under medical guidance, adjust medication dosage if blood pressure remains stable throughout the day, and no other discomfort is experienced for over 30 days.
Additionally, if a patient’s blood pressure drops below the normal range or experiences a drastic, rapid decline, accompanied by symptoms of hypotension like dizziness, fatigue, and visual disturbances during oral antihypertensive therapy, prompt medical attention is required. Under the doctor’s advice, reducing the antihypertensive medication dosage is recommended until adverse symptoms disappear, followed by gradual dosage increment.
In clinical settings, dosage reduction plans are generally tailored based on the type of antihypertensive medication the patient is using. Understanding that blood pressure is essentially pressure and fluctuates due to various factors like cardiac perfusion, peripheral vascular resistance, vascular wall elasticity, heart rate, vessel diameter, treatment for most patients, combining two or three classes of medications for hypertension control is usually necessary.
For instance, using calcium channel blockers (e.g., nifedipine antihypertensive drugs) + beta-blockers (e.g., metoprolol antihypertensive drugs) + angiotensin receptor blockers (e.g., losartan antihypertensive drugs) concurrently for hypertension control can lead to an excessive drop in blood pressure due to overlapping effects. When experiencing low blood pressure, modifying the medication regimen would depend on individual factors and the specific medication.
As a rule of thumb, the following sequence may be followed in dose reduction: first discontinue the angiotensin receptor blockers as they directly block Ang II to produce effects without adversely affecting the heart; then, based on personal circumstances, reduce the other two types of medications. Calcium channel blockers, apart from lowering blood pressure, have strong vasodilation effects, preventing angina pectoris; hence, they are unsuitable to discontinue first in patients with coronary heart disease, atherosclerosis, and other cardiovascular diseases.
Beta-blockers, upon long-term administration, may stimulate the heart upon sudden discontinuation, leading to rebound hypertension and headaches, especially in patients with a low heart rate, making it unsuitable to taper off as the first-line medication.
For patients using all three classes of medications, discontinuing the angiotensin receptor blockers first, then preserving the remaining two classes and monitoring for a month. If the blood pressure remains low, consider discontinuing the calcium channel blockers, followed by continued observation. Individual-specific considerations, taking into account the patient’s medication history, side effects, etc., are essential in providing professional evaluation for dosage adjustment under a doctor’s guidance, avoiding unauthorized dose reduction.
Additionally, for mildly affected patients, doctors may recommend a single antihypertensive medication (e.g., irbesartan tablets, amlodipine besylate tablets). Generally, the antihypertensive effects of a single medication may not be significant. In instances where blood pressure remains low, it could be due to factors like summer season or relatively mild symptoms. In such cases, it is pivotal not to stop the medication independently but gradually taper off under medical guidance.
During dosage reduction or discontinuation, constant monitoring of blood pressure changes and maintaining healthy lifestyle practices to help stabilize blood pressure are essential. Individuals can also incorporate the following behavioral interventions:
1. Adopting a balanced diet with scientific food combinations: Following the principles of eating less but more frequently, avoiding overeating at each meal, having an early and lighter dinner. Opt for nutritious proteins, fresh fruits and vegetables rich in vitamins, and cooking oils containing unsaturated fatty acids. Avoid high-sugar and high-salt diets, reduce daily salt intake (not exceeding 6g/day), abstain from pickled food and consume foods rich in potassium to counterbalance sodium fluctuations due to high-salt diet.
2. Quit smoking and limit alcohol consumption: Long-term smoking increases blood pressure due to the accumulation of harmful substances like nicotine in the bloodstream, which stimulates organs, causing an increase in heart rate, vasoconstriction, and elevated blood pressure. Studies have shown that heavy smoking can lead to hypertension and uncontrolled blood pressure. Excessive alcohol intake can also exacerbate high blood pressure, increasing the risk of severe conditions. Hence, avoiding smoking and drinking is essential.
3. Regular exercise and routine check-ups: Engaging in moderate exercise can enhance overall fitness levels, with options like aerobic activities such as swimming, jogging, yoga, or Tai Chi promoting metabolism, blood circulation, preventing clot formation, increasing blood vessel resilience, and boosting immune defenses against diseases. Maintaining a relaxed, stress-free demeanor reduces the likelihood of anger-induced blood pressure spikes. Regular health check-ups enable early detection and treatment of diseases to prevent complications.
In conclusion, patients with hypertension should vigilantly monitor their blood pressure, ensuring they do not experience excessively low blood pressure. Even if confronted with low blood pressure symptoms like dizziness and blurred vision, patients should refrain from discontinuing or changing medication dosages independently; prompt consultation with the healthcare provider is necessary. For individuals with better blood pressure control, adhering to the prescribed antihypertensive medication dosage is crucial, avoiding the misconception that stopping medication is appropriate because the blood pressure appears normal, as seen in Aunt Liu’s case.
References:
[1] Zhang, Q., & Hao, R. “Clinical Essentials of Drug Treatment for Elderly Hypertension Patients.” Chinese Journal of Geriatrics 31.12(2011): 3.
[2] Zou, C., Wu, B., & Liao, X. “Research Progress on Medication Compliance of Hypertension Treatment.” Progress in Cardiovascular Diseases 1 (2013): 4.
[3] Li, S. R. Matters Needing Attention and Daily Care for Antihypertensive Medication. Heilongjiang Science and Technology Press, 2012.
