Heart and Circulation Problems with High Blood Pressure

Many people with high blood pressure get angina (pain over the front of the chest on exertion), and many people with angina are eventually found to have high blood pressure. Bringing down blood pressure, by whatever means, nearly always reduces the frequency of anginal pain, probably because with lower BP the heart has less work to do. Beta blockers and calcium channel blockers are both usually very effective treatments for angina as well as for high blood pressure. Beta blockers are also very effective in preventing attacks of angina.

All the drugs commonly used to treat or prevent angina also reduce blood pressure.

Due to the disease in the arteries a person may suffer from severe leg pains when they walk for a short distance also. In many ways this leg pain (claudication) resembles angina. It is pain from a muscle when the demand for blood exceeds the supply. As with angina, when the blood pressure falls, this demand is reduced, the blood supply increases, and the amount of exercise one can take before the pain makes one stop increases.

One of the side effects of beta blockers is less good circulation in the feet and hands (many people who take them find that they get cold hands and feet in the winter and always need gloves or thick socks). All studies show that the opposite occurs (except in a few unusual instances) probably because beta blockers only affect the superficial, and not the deeper blood flow. Bringing one’s blood pressure down, whatever the drug used, helps improve the circulation in the legs and reduces the pain.

Evidence that damage has already occurred to the heart or arteries (usually the aorta, neck arteries or leg arteries) makes control of high blood pressure more urgent and occasionally narrows the choice of BP-lowering drugs.

For people who have already had a heart attack (metoprolol, propranolol and timolol) have been shown to reduce the risk of a fatal disturbance of heart rhythm during the next two to three years.

In people who already have extensive heart damage, usually survivors of repeated or severe coronary heart attacks, beta blockers reduce heart output and may precipitate heart failure. This does not mean they should never be used, but they must be used cautiously, particularly in elderly people with a sharp look out for evidence of increasing heart failure (mainly increasing shortness of breath, often with dry cough).

At one time it was thought that calcuim channel blockers were likely to worsen claudication (leg pain from hardening of the leg arteries). We now know that this is not so, but if there is also evidence of heart damage, calcium channel blockers taken in combination with beta blocker may precipitate heart failure.

Heart Failure

Heart failure means that the heart has difficulty in keeping up with its work, of pumping blood around the body. It does not mean that the heart will fail to beat or is about to stop. The main symptoms are tiredness, shortness of breath on slight exertion and often a dry cough with or without wheezing. One of the commonest causes of heart failure is uncontrolled high blood pressure over many years.

People who already have heart failure have a low output of blood from the heart. This will be lower still if one is on beta blockers. However, heart failure brought on by beta blockers rarely occurs in people with high BP treated by GP’s probably because as heart failure advances so does blood pressure fall, meaning that few people in this state will start beta blockers as a treatment for their high BP. Many start them as a treatment for angina, but even for these people, very few seem to get problems from worsening heart failure. For the large majority of people treated for high BP before, it has caused heart failure. Beta blockers seem to be as effective as other BP lowering drugs in preventing this complication.

Patients with severe heart failure treated with diuretics are at a risk of low blood potassium. The main symptom of this is extreme tiredness and muscular weakness.

Fibrillation or Irregular Heart Beat

Fibrillation means independent irregular and uncoordinated movement of the fibres of the heart muscle, so that instead of acting effectively together to squeeze blood through the heart, they tremble or flutter ineffectively, producing shallow, irregular, rapid heartbeats.

There are two types of fibrillations, one more serious than the other. When fibrillation happens in the ventricles (the main chambers of the heart), the result is a cardiac arrest from which one will die within seven minutes, unless someone can stop this process and restart normal rhythm by giving the heart an electric shock.

Another type of fibrillation is atrial fibrillation which is more common, usually but not always in people with heart failure. Normal heart rhythm can be restored either by using drugs or by giving a controlled electric shock, sometimes followed by insertion of a pacemaker to maintain the heart’s normal rhythm. This is rarely necessary. Most people with atrial fibrillation manage well with treatment for heart failure by ACE-inhibitors or diuretics and sometimes digoxin to slow their heart rate and raise their heart output (the amount of blood the heart pumps out to the rest of the body).

High blood pressure can be one of the main causes of heart failure. Paradoxically, the blood pressure tends to fall as the heart fails and rises when heart failure is controlled and the heart output rises. The main consequence of the treatment is that one will need very carefully balanced treatment/ medication to treat heart failure, to make sure that the BP doesn’t go too high again, and usually also to prevent clots forming in the flabby parts of the heart by using anti-coagulants (drugs which stop the blood clotting too quickly) such as warfarin, or warfarin + aspirin which is twice as effective.

Another important problem is that blood pressure is difficult, often impossible, to measure accurately in people with atrial fibrillation, because each heartbeat is so different, some giving a high pressure, others such a low pressure that no pulse wave can be felt. Usually all that is possible is a rough estimate of BP, but this is usually all one needs, because control of blood pressure is seldom the main difficulty in this situation.

Joint Pain and Arthritis

Basically, there are two kinds of arthritis-Non-inflammatory and Inflammatory. Non-inflammatory arthritis, otherwise known as Osteoarthritis, Ostia-arthrosis or Degenerative arthritis, usually affects the large joints in the shoulder, hip, knee or ankle, and is caused by wear and tear damage to these joints. As we get older, we nearly all have some arthritis of this type, but how severe it is and how much pain it causes varies from person to person. Inflammatory forms of arthritis (rheumatoid arthritis, ankylosis pancarditis and some other rare disorders) can affect almost any joint. As the name implies the problem here is inflammation and swelling of the joints rather than one of injury or wear and tear.

Both of these forms of arthritis can be treated with so-called ‘pain killers’, an odd name, as everyone who has ever suffered from them knows, that these pains seldom die. The three main types of pain killers are NSAIDS (which stands for non-steroidal anti-steroidal anti-inflammatory drugs), paracetamol and aspirin. Almost all the NSAIDs raise the blood pressure by an average of 5-10 mm Hg, roughly the same as the reduction produced by most blood pressure lowering drugs. Roughly 40 percent of all people needing BP- lowering drugs also suffer from chronic rheumatic pains for which NSAIDs are often prescribed. Paracetamol has no harmful interactions with any drugs used to reduce blood pressure, and can be used safely in kidney failure, pregnancy and even during breastfeeding.

Aspirin does have a major and very prolonged effect on the blood, making it less “sticky” and so less liable to clot. Due to this, it is therefore very widely (and correctly) used to prevent coronary heart attacks and strokes in people at high risk, especially those who have already had one heart attack, small stroke or transient ischaemic attack. Aspirin has no effect on blood pressure, no significant interaction with BP-lowering drugs and is safe in all but severe kidney failure.

There is also a bewildering variety of more powerful pain­relieving drugs available on prescription, all related more or less closely to morphine, but less powerful and less addictive. For example paracetamol-codeine. None of these has any effect on blood pressure nor any significant interaction with BP-lowering drugs, but they often cause other unpleasant minor side effects such as constipation, nausea and minor depression, which may make them unsatisfactory for regular daily use.

Severe rheumatoid arthritis is treated with steroid tablets. These steroid tablets are the corticosteroids. They are necessary and effective for severe, acute attacks of rheumatoid arthritis, particularly in the first few months after the onset of the disease, if this is very severe. In these circumstances they may not only relieve pain but also reduce long-term joint damage. Although they raise BP by causing sodium and water retention and thus increasing the volume of blood in the body, this is almost always a price worth paying, even for people with severe high blood pressure. In any case, people whose problems are so severe will usually be under the care of a hospital specialist, whose job it is to make a balanced decision on their treatment in the light of all the available evidence.

Ankylosing Spondylitis

Spondylitis means inflammation of the small joints connecting the ‘wing’ on either side of the vertebrae. Most back pains probably originate either from these joints or from pressure on nerve roots as they emerge from the spinal cord between the vertebrae. It has two entirely different causes: simple spondylitis and ankylosing spondylitis.

Joint changes caused by simple spondylitis are common and can be seen on x-rays. Simple spondylitis is mainly wear and tear damage to the spindlier joints, similar to osteal arthritis (or ostia arthrosis) in other joints. Inflammation plays little or no part in causing the pain, so NSAIDs are seldom effective in relieving it. For people who also have high blood pressure, they seldom give enough relief to justify their harmful effect in raising blood pressure.

Ankylosing spondylitis is an eventually serious disorder that runs strongly in families. It usually starts in young people in their 20s and it may not be properly diagnosed for a long time. People with ankylosing spondylitis generally have severe back pain typically relieved by movement and worse when they are at rest, often dramatically relieved by NSAIDs. Joints tend to eventually fuse together by bridges of bone, producing the typical ‘bamboo spine’ and sometimes forward curvature of the upper spine like a question mark. People with ankylosing spondylitis absolutely depend on NSAIDs. They also need treatment for high blood pressure. This contradiction must simply be accepted as inevitable.

Gout

Gout happens when the body fails to get rid of one of its waste products, a substance called uric acid. Usually the kidneys remove uric acid from the blood, then get rid of it in the urine, but in those people who produce too much of it, it can accumulate as crystals in the joints. The result is an attack of gout, with very severe pain, swelling, redness and tenderness in one or more joints. Untreated this can last for several days and is very disabling. It usually affects the small joints, most commonly but not always in the big toe. It is a very common problem and often runs in families.

The level of uric acid in the body is raised by alcohol, by some foods and by the thiozide diuretics used for treating high BP. Acute attacks of gouts cause severe pain, which can usually be brought to an end quickly with one or two day’s treatment with one of the NSAIDs, usually indomethacin. These courses of NSAID treatment are too short to have any significant effect on control of blood pressure. Probenecid (Benemid) is an alternative and equally effective treatment for acute gout which has no effect on blood pressure. Both indomethacin and probenecid help the kidneys to get rid of uric acid. Allopurinol (Hamarin, Zyloric), taken regularly to prevent attacks of gout rather than to treat them, has no effect on blood pressure. People who get repeated attacks of gout even on low doses of thiazide diuretics often need to take allopurinol regularly to prevent them. Thiazides are so effective for controlling high blood pressure, both by their own effect and by increasing the effect of other BP-lowering drugs, that it is often difficult to stop taking them without loss of control.

Though many total abstainers suffer from gout, and it is not a reliable indicator of alcohol problems, there is no doubt at all that in people who are prone to it a little beer or spirits is a common cause of acute attack.