Strokes and heart attacks tend to occur early in the morning. Blood pressure tends to be high then, too. So it would make sense to take your medication in the morning when it would do the most good. But many doctors don’t talk about the best time to take blood-pressure medication.
Even when they do, “medicines don’t affect everybody the same,” says Dr. Sheps. The rate at which your body absorbs medications may be different from your neighbor’s. “And some mediations need to be given on an empty stomach;’ he says.
But you can double-check the timing yourself, with a home monitor. “Take one reading in the morning after you get up and get ready for the day-but before breakfast;’ says Dr. Sheps. “Sit down for five minutes-read the paper or watch the news-and take your blood pressure seated. Take it again at the end of the day. Use the same sequence ofletting your body settle down for five minutes. This tells you when your peaks and valleys are-in the morning or evening. Then your physician can adjust the timing of your medication.

There’s a tendency among physicians to just add blood-pressure medications when one isn’t working adequately, rather than to try substituting them;’ says Dr. Pickering. “Some medications really just don’t work on particular patients. In those people it would make more sense to substitute something that does work, not pile one drug on top of another.”
Part of the problem, he says, is that trying to find out whether a medication is working involves taking lots of blood-pressure measurements. But if you get only three readings at a doctor’s visit and you have only one visit every few weeks, it’s difficult to get enough data to make a good decision on medication. If you’re trying a series of drugs to see which is best, it’s cumbersome and expensive to do it by going to the doctor every week.
One thing a patient can do, Dr. Pickering says, is self-monitor blood pressure. “It’s economical and easy to tell if medication seems to be working by using a home monitor. Then you can phone in or fax in your readings. The doctor can get a feel for whether the stuff is working. It’s a valuable way to assess medication.”

“This is a common problem-physicians often don’t initiate therapy in patients with mild hypertension. They wait until the hypertension is worse. But this waiting game is considered a major public health concern by all the experts in this area;’ says William B. White, M.D., chief, section of hypertension at University of Connecticut Health Center, Farmington. The fact is, even mild hypertension increases your risk of stroke and heart attack. Stage 1 (mild) hypertension means that your systolic reading is between 140 and 159. And your diastolic pressure is between 90 and 99.

Dr. White thinks what happens is that doctors just fail to see mild hypertension as a significant problem in the vigorous person sitting across from them. “They think, ‘O.K., this person is 40 and pretty healthy otherwise with a blood pressure of 140/90;” says Dr. White. “And they think that this isn’t very serious. The patient thinks he or she is healthy because they don’t have something bad enough to get medicine for. But mildly elevated blood pressure is likely to become even higher over time. So the patient resurfaces five years later when his or her blood pressure is 160/110. During that interval, some damage has occurred, such as cardiac changes associated with blood-pressure elevation or some kidney problems.”
Dr. Gifford believes in very early intervention-when blood pressure is high-normal, 130-139/85-89. “But doctors don’t tend to make much fuss if blood pressure is 135 over 85. The message doesn’t come across that it might be risky. And that’s the time to get to it. There’s really good evidence you can prevent high blood pressure then, before it gets worse,” he says. Unless blood pressure is high-over 160/105, says Dr. Gifford-or it’s complicated by a condition like diabetes, prompt treatment of choice means initiating lifestyle changes. “Lifestyle changes are very important;’ says Dr. Gavras. “Your doctor should educate you to eat less sodium and lose weight and exercise with activities like walking. Just by decreasing sodium intake and losing weight, one-third of those with hypertension can control their blood pressure. But doctors seem more at ease with drugs than with eating or exercise regimens, says Dr. White. “We have a lot harder time educating patients about lifestyle changes. It’s hard to implement because physicians don’t have the time or the background information on how to educate patients during the short encounter they have with them,” he says. So when doctors finally nab blood pressure at Stage 1, they often do so with medication. “When a doctor doesn’t have time, it’s easy to just say to the patient, ‘you have high blood pressure-I’ll give you a prescription,’” says Dr. Sheps. If you find yourself in that position and your blood pressure is mild and uncomplicated, Dr. Sheps says: “Then it’s all right for you to say, ‘I’ve been reading that I might be able to help my blood pressure by losing TO pounds, and I’d like to try that first. Is it O.K.? If it doesn’t work in three months, I’ll consider medication.’”

Too often, high blood pressure gets short shrift in doctors’ offices. And there are two big reasons for this. “Part of the problem is that even though hypertension is extremely common, it’s not generally recognized as a medical specialty. There are no board examinations to qualify as a specialist. And, for most physicians, it’s not their prime interest. So hypertension frequently doesn’t get the professional scrutiny it needs. It’s treated mostly by family practitioners, internists, nephrologists and cardiologists,” says Dr. Pickering.
The other part of the problem is the sheer amount of time hypertension demands. “You have to give patients tender loving “” care. But it’s hard to do on a IS-minute schedule. If you don’t, though, you’re doomed to failure;’ says Ray W. Gifford, Ir., M.D., professor of internal medicine at Ohio State University College
of Medicine and consulting physician in the department of nephrology and hypertension at the Cleveland Clinic Foundation. “One of the most common mistakes is that doctors don’t spend enough time up front convincing patients that the way to reduce their risk of stroke and heart attack is to lower their blood pressure. Then the doctors need to talk to
their patients and make lifestyle changes tempting because people tend to resist them. They have to make sure patients know that those changes are almost sure to bring blood pressure down so they may not need medication.”
“You can’t tell patients to start a low-salt diet and an exercise program and come back in six months. They need to come in three times during those six months to reinforce lifestyle modifications. They need a physician who spends the time to keep evaluating them once they’re on a program.”
But how do you find a dedicated doctor if you can’t look him up in the Yellow Pages under “Hypertension Specialist, Long Hours?” Dr. Pickering has formed the Hypertension Network, which makes use of the Internet to provide people with up-to-date information about hypertension, including question-andanswer forums. It can also provide a list of physicians who have a special interest in treating hypertension. The website address is http://www.bloodpressure.com. Or write to the Hypertension Network at P.O. Box 302, Wingdale, NY 12594. If you don’t want to look for a new physician because you already have a long-time family doctor you like, make an appointment for a heart-to-heart talk with him or her. Come prepared: Write down your questions and refer to them. If you’ve read up on the subject and made notes for discussion, bring them in, too. Tell your doctor your concerns about your blood pressure and its treatment. Let your doctor know you’re willing to take an active role in managing your condition by recording your blood pressure and by making appropriate lifestyle changes.

Prevention Magazine asked five top blood-pressure specialists and found out the five biggest mistakes doctors make in hypertension treatment-and what you can do to prevent them. Doctors Rely on Too Few Blood-Pressure Readings Here’s what happens. “Patients get one high reading. Their doctors put them on medication. They come back; they’re fine; the doctors say the medication has done the trick. But in many cases, if those people had come back even without medication, their pressures would have been fine;’ says Thomas G. Pickering, M.D., professor of medicine at the hypertension center at New York Hospital-Cornell Medical Center in Manhattan and author of Good News About High Blood Pressure (Simon & Schuster, 1996).
That’s because a blood-pressure reading is just one brief snapshot in time. One reading may not at all represent what’s going on most days. Government guidelines for treatment suggest multiple readings during each doctor’s visit.
“Even then, our research has shown that for some people, doctors’ readings are often the least representative of their overall level of blood pressure,” says Dr. Pickering. The reason: About 20 percent of people with high blood pressure suffer from “white-coat hypertension.” Doctors’ offices make them nervous.
Their blood pressure spikes. But they don’t usually need to be medicated. One way to get around that is to ask the doctor’s nurse or technician to take your blood pressure. Another is to take your own blood pressure. There are other reasons for blood-pressure spikes and you have to deal with these, too. And they’re sneaky. Your blood pressure can temporarily jump up-and show a spike on the pressure gauge-because you had a cup of coffee less than a half hour before the test. (It’s the caffeine that’s the culprit, so watch out for other sources, too.) You can also get an unusually high reading if, during a measurement, you talk or have a full bladder. Some over-the-counter medications, especially those with warnings for people with hypertension, may raise your BP, so be sure to tell your doctor if you’re taking any.
Another source of spikes is cuff size. Regardless of who takes your blood pressure, the wrong cuff size on the measuring device-often one too small-can throw your readings off. Say you have large, muscular arms. If you’re measured with a “regular” adult cuff when you need a “large;’ your readings may be falsely high. And misfits do happen. “What you really want is to have your arm fitted with the proper-sized cuff by your physician;’ says Donald J. DiPette, M.D., director of the division of general internal medicine, which includes the hypertension section, at the University of Texas Medical Branch at Galveston. A simple way to do this is to have your doctor measure the distance around the middle of your upper arm and select the size cuff that’s right for you. If your doctor notes your arm measurement in your chart, there’s no need to remeasure at every visit, unless your weight or the size of your muscles has changed significantly. Don’t be shy. You may have to speak up to get good BP measurements. That may mean reminding your doctor or his assistant to take more than one. If your initial readings are high, get another right before you leave-measurements taken at the end of the visit are often lower. Your doctor has to repeat these multiple readings over several visits and then average your results to better estimate your “true” blood pressure.
An alternative to this multiple-visit approach is 24-hour ambulatory monitoring. This involves wearing a small, comfortable monitor that automatically and consistently reads your pressure night and day, while you sleep and even at work-where telephones and deadlines can get your blood boiling. “This is actually the fastest way to get an accurate diagnosis,” says Sheldon G. Sheps, M.D., chief of the hypertension division at the Mayo Clinic in Rochester, Minnesota. “There’s also a big movement for home monitoring;’ says Dr. Pickering. You can buy manual or electronic home units that provide fairly reliable readings. (See “Your Monitor Options” on page 25.) With a home monitor, you can average out various readings taken during the course of a day. Your measures may very well be different in the morning and evening, at work and after exercise. But you’ll be able to get the total picture, especially if you track pressure for a few weeks and average out all the different readings.