Questions and Answers

This Q&A resource highlights questions I often get in my practice and on my social media channels. I hope you find my tips and guidance on each topic helpful.

Blood Pressure

• What causes high blood pressure?

In any individual, hypertension is related to one or more factors. Genetics contributes about 40-50%,  related mostly to kidneys, which in many is related to salt sensitivity.  Health habits also contribute 40%, (e.g. weight, salt intake, diet, lack of exercise). In others, perhaps 10-15%, hypertension is driven by the sympathetic nervous system. Several factors can contribute to the latter, but I suspect in most it is linked to a mind-body origin. My clinical experience and research strongly suggest the role of repressed emotions in many.

• What blood pressure level is now considered to be too high and require medication?

If systolic BP is above 140/, almost all should be treated. If usual SBP is above 130, most would treat, although in elderly patients I am cautious, and often accept a SBP in the 130s.

• Which blood pressure medications are the most effective ones?

ACE inhibitors, angiotensin antagonists (ARBs) diuretics and calcium channel blockers are all equally effective. The art of medicine though is individualizing treatment by identifying which drug or combination is most likely to be effective in a given individual (see my book Hypertension and You).

• How do I correctly check my blood pressure at home? 

An arm cuff is better than a wrist cuff. Sit down, put your cuff on, sit quietly for 5 min, then take 3 readings about a minute apart. Most patients and physicians overlook the 5 min wait, resulting in readings that are higher than the resting BP, often leading to overtreatment.

• How can I best advocate for myself when it comes to concerns about the side effects of blood pressure medication? 

Don’t get bent out of shape over the long list of side effects that are listed for every drug. If you think you are having side effects, tell your physician.  My book, Hypertension and You, carefully discusses the side effects.

Mind-Body Connection

• Based on your experience as a physician, what is your view of the mind-body connection?

Decades of mind-body research focused on the day-to-day stress and emotional distress we experience have led to little progress in understanding or treating hypertension, and for that matter, many other conditions as well. I am most focused on our most powerful emotions, often related to events from the past, which ironically, many are completely unaware of by virtue of having repressed those emotions. See my new book Hidden Within Us.

• Are there medical conditions that are linked to a history of abuse or trauma?

There is a very long list of medical conditions concerning which research has shown an association with a history of abuse or trauma. A shortlist includes hypertension, colitis, autoimmune diseases, fibromyalgia, migraine, and many, many others.

• If I have come to realize that I may have repressed emotions related to past trauma and think it might be impacting my body, how can I verify this? 

That is an area that medical research has barely explored. A history of trauma, with repression of severe emotions related to it, certainly raises suspicion of a link but is not proof per se of cause and effect. Hidden Within Us explores this.

• What healing options are available in the treatment of medical disorders with a mind-body connection?

Depends. Functional disorders such as tension headaches, irritable bowel and others that are linked to perceived emotional distress, can benefit from relaxation techniques, psychotherapy, and antidepressant medication. Disorders linked to repressed emotions can benefit from gaining awareness, which is possible in some but not others, and from medications (see Hidden Within Us).

• What resources are available to help me learn more about medical disorders with a mind-body connection?

There are innumerable books on the mind-body connection as it relates to the emotional distress we are aware of. Those traditional beliefs have not led to a major impact on the understanding or treatment of medical disorders. Few books explore the role of repressed emotions. The books of Dr. John Sarno were pioneering in this regard. My recent book Hidden Within Us, is the first to further explore this understanding

Hypertension

• What are the main risk factors for hypertension?  

Genetics (family history), weight, salt intake and genetically determined salt-sensitivity

• How much of an effect will reduction of salt intake have on my blood pressure?

On average 5-10 mm.  The effect is greater in salt-sensitive individuals, and less in those whose hypertension is not salt-sensitive. Salt sensitivity is more common in people of color and in older individuals), and less in others.

• If my blood pressure suddenly increases to 180 or more, am I at risk of a stroke if it is not quickly lowered?

Very unlikely. Remember, BP hits 180 routinely during exercise. Elevated resting BP, even if severe, puts you at risk over months or years, not minutes or hours. It also depends on your history. A BP exceeding 200 is of greater immediate concern in someone whose BP was always normal than in someone with a history of chronically elevated BP.

• Can blood pressure medication lower my blood pressure too much? Is it dangerous?

Yes, it can cause weakness, lightheadedness, even fainting. That is why it is best to monitor your BP at home.

• At what point should I see a specialist in hypertension?

If your BP is not well controlled on 3 or more medications, or if your BP is controlled but you are living with medication side effects. Or if you have severe hypertension (e.g. frequently running above 180.)

• What are the most effective exercises for maintaining healthy blood pressure levels?

That’s an easy question: the type of exercise that someone enjoys, or is willing to do on a regular basis, no matter what kind of exercise, is best.

• Do heart palpitations always develop with long-term hypertension, even if fairly well controlled? 

Usually they do not.

• Why do I always have high blood pressure readings at doctor’s offices? 

About 10-20% of patients with BP elevation at the doctor’s office have a normal BP at home (“white coat” hypertension). In some it can happen even without being aware of feeling nervous. That is why it is worthwhile confirming hypertension with home readings. Also, and this is a major problem, most physicians or their assistant measure the blood pressure right away, rather than allowing the patient to sit quietly for 5 minutes, as recommended by every guideline. This results in BP readings that are higher than a patient’s true resting BP, and often leads to unnecessary medication.

Diuretics

• Can diuretics cause dehydration? 

At a high dose, or in a sensitive patient, or in someone who has a very low sodium intake, yes. Also, I always tell patients: if they are sick and not eating, skip the diuretic.

• Do diuretics lower blood pressure as much as other blood pressure drugs?

At the right dose, yes. However, the widely prescribed diuretic hydrochlorothiazide is usually prescribed at a dose of 25 mg, which in many is less effective than the usual dose of other classes of medications.

• What is the most common use for diuretics?

Hypertension, heart failure

• In whom is a diuretic most likely to be successful in lowering blood pressure?

In patients with salt-sensitive hypertension. Thus they are preferentially effective in black and in elderly patients. Fluid retention in the legs (edema) often is another clue that a diuretic would be effective.

• If a person struggles with anxiety and has what is considered white coat syndrome, should they always use a beta blocker?

If BP is normal at home, no treatment is necessary. In some patients with anxiety and hypertension, a beta-blocker can be a nice fit in tackling both problems.