Isolated systolic hypertension: Should I take Amlodipine?

Thanks very much Laroxe for your help with this problem. I agree that a very slow and careful introduction is the way to go and see just how well Amlodipine is tolerated by my system. I am pretty fit overall except that recently I have also been coping on and off with pulsatile tinnitus which can be a nuisance. I used to get ectopic heartbeats quite a lot but this was solved when I took extra Vitamin B12.

Regards

Martin

Thanks for these tips, I will certainly get my doctor to look closely at the next blood test results

Regards

Martin

Thanks very much Miss Woosie for your post. You mention that, in clinical trials, both Ace Inhibitors and CCBs were effective at lowering systolic and pulse pressure, thus reducing overall risk.

My main question about going on to medication has been whether or not the diastolic pressure, after taking medication, is usually reduced at a much lesser rate than the systolic pressure? Do the clinical trials give any indication of how much the diastolic pressure of people has reduced in proportion to their systolic pressure?

For example, if before going on to medication, BP is 180 / 70 (pulse pressure 110), do you think it’s possible after medication to get a BP of say, 140 / 60 (pulse pressure 80)?

If, as has been suggested in this thread, the pulse pressure may remain the same after going on medication as before, with the example above, the BP after medication would be 140 / 30 (pulse pressure 110), which would be an unacceptable situation for me.

I somehow doubt whether the diastolic pressure in this example would actually go as low as 30, but I’m interested to know if this is a possibility?

I realise that I may be able to tolerate a lower diastolic without any symptoms and that I won't know until I try, but I am just as concerned about a low diastolic pressure as I am about a high systolic pressure, because this is much more of a possibility with isolated systolic hypertension than it is with "normal" hypertension!

Regards

Martin

cursoenarm.net/UPTODATE/contents/mobipreview.htm?25/6/25711

If you copy and paste the above into  google search there's a lot of info there with references to a lot of clinical trials and meta analysis etc

On the left side menu there are links to other associated topics.

You may also find this useful.

pathways.nice.org.uk/pathways/hypertension.

Care should always be excercised when looking at the results of isolated clinical trials and the rule of thumb when reviewing literature is that articles musn't be any older than 10 years. 16 years ago, many of the newer antihypertensive meds weren't around, we weren't doing thngs like coronary artery stenting and stroke was viewed as a disease that couldn't be treated acutely. The first ever National Clinical Guidelines for Stroke were published in 2000 and we're now on edition 4 (2015) The National Stroke Strategy wasn't published until 2007.  A lot has changed since 2000.

Thanks very much for these links, they are very helpful. I guess a patient who has no medical training shouldn't really be delving into complex research that is designed for medical professionals who have the benefit of years of experience and who can compare the results of lots of patients and who benefit from going to medical conferences etc!

Nevertheless, I have learned a lot from doing this and from reading everyone's posts on this forum. In particular, I wasn't fully aware of the dangers of low diastolic pressures and if I go on to medication I will be watching this aspect very closely.

I'm still not really sure how low a doctor may allow a patient's diastolic pressure to fall when the main aim is to reduce systolic pressure. A starting diastolic pressure of 65-70 is already quite low, but I guess it may be worth risking this going down to 50-60 if not too many side effects are experienced?

Regards

Martin

If it's of any interest Martin, my diastolic rarely goes much above 60 and is often a lot lower than that, and I don't get any ill-effects from it. I was having dizzy spells (and a nasty fall on an escalator as a result) a year or so ago, but my GP ordered an MRI, and it was ascertained that this was due to a neck problem - arthritis etc. I also got a pinched cervical nerve at the same time. Some postural exercises from a physio, plus my stopping wearing my shoulder bag diagonally across my body cleared all this up. (At 72 I now wear a trendy little backpack like a teenager and don't care how daft it looks!)

I'm not in the market for amlodipine or similar at the moment, as my systolic rarely goes above 145 and I'm happy with that (ditto my GP) whatever the received wisdom might be. However, I don't think you should worry too much about trying the minimum dose. And if it causes side-effects you can simply stop it and ask what else your doctor has to offer. You don't get withdrawal effects from stopping this kind of medication.

Thanks for your reply, yes I guess it's fairly unlikely that there would be "mathematical equalness" in the drop in systolic and diastolic, and I am hoping that systolic pressure will drop a lot more than diastolic pressure if I decide to go on medication. Considering that my diastolic pressure is already around 65, I have been influenced quite a lot by statements such as this one which I found on internet:

"In people with isolated systolic hypertension, treatment may lower diastolic pressure too much, potentially increasing the risk of a heart attack or stroke. So if you have isolated systolic hypertension, your doctor may recommend that your diastolic pressure not be reduced to less than 70 mm Hg in trying to reach your target systolic pressure."

This statement is quite specific that if you lower your diastolic pressure too much, you can actually increase the risk of a heart attack or stroke (Mayo Clinic).

Regards

Martin

 

Hi Martin, Thanks for finding that article again. I'd seen it once but couldn't put my finger on it in a recent search.

I know different doctors have different views on this subject. A couple of years ago I was hospitalised for 36hrs following an accident. The nurses had been telling me my BP at each check, and it was a fairly steady 145/65 throughout my stay. Incidentally, this was the first time I'd been aware that my BP had been at this kind of level. I didn't have a home monitor in those days, and it had been 120/80 at my six-monthly GP visits for years. (I have an autoimmune condition that needs regular monitoring, hence twice-yearly visits.)

The junior doctor who did my discharge examination on the last day handed me a prescription and a note for my GP. I immediately noticed that, in addition to the expected antibiotic, the scrip included amlodipine, though he hadn't mentioned what it was for. When I queried this, he said that a systolic of 145 was very dangerous, and I'd have to stay on medication for life. I'd just started hearing about ISH and high PP in those days (before knowing I had it!) so queried the possible effect on my low diastolic. He looked taken aback and was clearly lost for words, but I don't know whether this was because he'd never heard of ISH or whether he just wasn't used to being interrogated by grey-haired little old ladies sitting bolt upright up in bed. He mumbled something about it being vital that I take it and made a quick exit.

I scratched out the amlodipine and just filled the antibiotic prescription, then saw my GP a few days later. In the event, that was the day I recorded my highest-ever PP of 110 (160/50) but he said it might have been down to the shock of the accident etc. At the end of the consultation it was 145/60. He said he'd prescribe amlodipine if I wanted him to, but he really didn't recommend it, as taking my diastolic under 60 would be just as dangerous as leaving the systolic at 140+ in his opinion. In spite of being much older than the hospital doctor, he seemed fully genned up on the risks of raised PP. Instead, he suggested getting a home monitor, and upped the frequency of my visits to four-monthly.

I realise my BP in general is several notches lower than yours - the systolic has never gone above 150 since I started regular monitoring and is usually in the 140-145 range, except after brisk walking, when it's lower. During this period, the diastolic has varied between 40 and a very occasional 70, but I haven't felt any ill-effects. (And to be honest, I suspect my monitor is recording generally on the low side.)

I think that when researching the current medical take on any condition it's always worth making an effort to find articles and studies reflecting opposing views, and then making one's own mind up - hopefully with the support of a GP who's prepared to enter into dialogue. (Though I realise that not all of them are, and also that UK residents have very little input to the choice of GP.)

Hi Lily, thanks very much for sharing this information with us, it’s been very helpful. Although there is a lot of information on internet about treating hypertension in the elderly, much of it doesn’t seem to cover the specific needs of patients with isolated systolic hypertension (ISH). As you have mentioned, even some doctors assume that medication that’s suitable for patients with “normal” hypertension must also be appropriate for patients with ISH, and they don’t seem to be aware that the possibility of very low diastolic pressure must also be closely considered.

I agree that you need to research the situation yourself and not just follow “blindly” the advice of your doctor. My GP has an extremely good reputation, but even so, I usually do my own research as well. For example, one article I found on pulse pressure warns that some medications for high blood pressure may actually increase the pulse pressure and the risk of heart disease. This shows that ISH patients on BP medication need to monitor their BPs even more closely than some other patients who have “normal” hypertension, because diastolic pressures can fall to unacceptably low levels. Nevertheless, it’s probably been very unwise of me not to have followed my doctor’s advice during the last 8 years, which has been to try Amlodipine and closely monitor the results.

Regards

Martin

 

Martin, I'm very reluctant to accept any medical intervention lightly (as you may have gathered from some of my posts!) but I have to say that if my BP was regularly at the kind of values you've mentioned I would be inclined to give amlodipine a go. But only at the lowest possible dose for at least the first three months, to make sure I wasn't getting any side-effects. I'd then take it in equally small increments from there, if necessary, also at three-month intervals, as side-effects can be slow to manifest. Personally, I wouldn't necessarily aim for the "gold standard" of 120 systolic, but - as you've said above - would be happy with something below 140.

I don't have one myself but I believe you can get pill cutters at most pharmacies that make it easy to cut up tablets. I'm assuming amlodipine doesn't come with a slow-release coating that would make this inadvisable.

I hasten to add that I'm not entirely adverse to medication. For example, I happily take L-thyroxine for an underactive thyroid and recently - and reluctantly - started to use a steroid inhaler for my late-onset asthma, after my GP did another spirometer test and warned me that in spite of being a lifelong non-smoker, I was at real risk of developing COPD at some time in the future, as my lung capacity was declining over time due to chronic inflammation. Being me, I compromise on this one by using it once a day instead of the prescribed twice! However, if at the end of a four-month trial my lung capacity continues to decline, I'll give in and use it twice a day (four months being the interval at which I see my doctor for check-ups). 

I believe in a discerning, but pragmatic, approach to medical matters!

Hi Lily, thanks a lot for this very good advice. I think these days people in their 70's are quite happy to achieve a systolic pressure of 145, provided that the diastolic pressure isn't too much below 70. My prescription is for 2.5mg tabs so I doubt whether I would need to cut these up to a smaller dose, but I could take 1 tab every 2 days. I agree with your advice to go on the lowest possible dose for the first three months. I haven't decided finally yet about whether or not to go on to Amlodipine.

Regards

Martin

Just a further note about researching medical articles on isolated systolic hypertension (ISH). I recently came across an article by Norman M Kaplan which said that: "In the Rotterdam Study involving 2351 elderly hypertensives, the risk of stroke was significantly higher in those given antihypertensive drugs whose diastolic blood pressure was <65 mm Hg compared with those who had a diastolic blood pressure between 65 and 74 mm Hg.

So this emphasises again that diastolic pressure in people with ISH shouldn't be allowed to go much less than 65 and mine is already close to that on average.

Kaplan also said that  "ISH is the most common form of hypertension in those older than 65 years. Because this segment of the population is expanding so rapidly, ISH will soon be the most prevalent form of hypertension."

Although this article was published about 16 years ago, I think it's still quite valuable.

Regards

Martin

 

Actually Martin, I think it's generally better to cut any tabs in half rather than take them on alternate days - unless you're doing so on the advice of your doctor. Most drugs work better if you can achieve a steady blood level.

Ah, I hadn't seen that article about the Rotterdam study, but it goes along with my gut feeling that it's best not to mess about with the BP of the elderly unless it's seriously high!

This bit of info you found on the net worries me, as my diastolic BP has been around 60 all my life!  Currently it is still around 60 but my systolic has risen from around 90 to around 150 over the past 10 years.  I worry about whether or not to start medication as the only one I found mentiopned on the net that seemed to be good at reducing systolic without diastolic is not available anywhere that I've tried so far (Rasilez - generic Aliskiren fumarate) and cost a fortune when it was around.  

Isolated systolic hypertension (high systolic/low diastolic) is common in older people, though you don't mention your age. I have the same thing. A couple of years ago, I too recorded 150/60 in my doctor's office. I queried this, but he said he wasn't worried about it. In the past year or so the diastolic has started creeping up as well, but he still doesn't want to put me on medication - and I wouldn't want to take it.

Various studies over the years have indicated an increased risk of stroke and heart attack in ISH, but I'm happy to take the risk for the time being. I figure we've all got to die of something.