Peter was one of my favorite patients. He was a forty-six year old Romanian triathlete that competed in all sorts of fitness competitions. He was an avid cyclist, ran two to three miles per day, ate a balanced diet, and swam frequently. He never had any major health concerns except for the occasional knee pain he got from time to time. He had never smoked, drank occasionally, and had a pretty unremarkable family history. The funny thing about Peter was how superstitious he was. He would knock on wood when I would go over his test results. He would carry a rabbit’s foot on his keychain. Prior to his competitions, he would lace up his shoes, unlace them, and then lace them again, believing that it would affect the outcome of his race. There was even one time, where I walked into the visit and noted the smell of burnt vegetation. I found out that he had done a spiritual cleanse with sage. At least that’s what he said.
Over the past three visits, I noticed that his blood pressure had slowly been creeping up. On his initial visit, it was 142/90. It didn’t change after checking it a second time. “It’s just that doctors make me nervous,” he said. I agreed, but asked that he keep a blood pressure log just to keep an eye on things. On his follow up, it was 153/87. Reviewing his BP log, his numbers ranged from 135/70 to 165/94. “I had been under more stress than usual,” he said. He came back three weeks later appearing frustrated. “I just don’t get it,” he said. After training harder and eating better, his repeat blood pressures had not improved.
Essential hypertension is exactly as it sounds, hypertension that is essential or without cause. It means that it’s not from too much sodium or obesity. It’s not because of failing kidneys or thyroid disease. It not from atherosclerotic disease. It means that fate tapped the patient on the shoulder and he got the short straw from the bunch. Blood pressure is a fundamental part of the doctor’s visit. Every patient that comes to the office has their blood pressure taken as part of their vital signs.
Blood pressure is the bread and butter of a primary care practice. What it represents is the interplay between what the heart pumps out (cardiac output) and what the resistance it needs to overcome is (peripheral resistance) in order to circulate blood throughout the body. When the blood pressure is elevated, it can be related to an elevation in peripheral resistance or a decrease in cardiac output. With long standing hypertension, the heart has to work harder and will either compensate by growing larger, like any other muscle, or it will fail. By growing larger, the heart’s chambers will shrink and its oxygen demand will go up. By failing, we’re in heart attack territory.
Peter was doing everything right, yet he still had blood pressure problems. His cholesterol was outstanding and his EKG, kidney and thyroid function were perfect. He was just cursed with it. It was as if by some strange gypsy sorcery that his blood pressure came to be this way. He couldn’t understand why or come to terms with it.
At 140/90, the diagnosis of hypertension can be made. The standards for hypertension are changing and they are finding that cardiac events can occur at even lower thresholds, particularly in the context of comorbid conditions like diabetes or smoking. At 160/100, the threshold for stage two hypertension is reached. These may seem like arbitrary numbers, but the risk of having a cardiac event increases dramatically between the two stages. Regardless of cause, whether its diet, lack of exercise, stress, smoking, or if it’s essential, as in the case of Peter, the risk is present, which is why doctors will treat the condition if it is diagnosed.
We eventually had to place Peter on medication to get his blood pressure controlled. His blood pressure was ultimately a fault in his stars, a hex upon his house, or he was just plain unlucky. Fortunately for him, we have medications that were able to control it to reduce his risk so that he can go about living his life normally.
By: Dr. Juan Borja
Original post: https://yourdoctordad.com/cursed/