19:05 EST, 12 May 2014
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19:05 EST, 12 May 2014
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Every week Dr Martin Scurr, a top GP, answers your questions
Can
you explain why I have high blood pressure? I am 66, a size ten, don’t
smoke, rarely drink and exercise regularly. I take 4mg of perindopril,
but it isn’t effective enough. However, instead of looking for a reason
as to why my blood pressure is high, my medication is going to be
increased. Why aren’t more checks done about the cause when a patient is
otherwise healthy?
Eleanor Gamble, by email.
A blood pressure reading consists of two figures – the first is the systolic pressure
Given your situation, I can  see why you are puzzled, and there are probably many readers in a similar position.
Most
people who have high blood pressure have no symptoms, so taking the
one, two or even three medications they’ve been prescribed needs
commitment, not least as they’ll have to do this long term and the pills
may have side-effects, such as gout or ankle swelling.
The obvious
question, as you have put it, is why this has happened to you. What is
needed is a careful explanation, though this isn’t always forthcoming,
so this short tutorial may help.
A blood pressure reading consists of
two figures – the first is the systolic pressure, the pressure in the
arteries when the heart contracts. A normal reading is 120 or lower.
The second figure, the diastolic pressure, is when the heart relaxes – this should be 80 or lower.
If
the reading is consistently above 140 over 90, this is known as
hypertension. The diagnosis should not be made until blood pressure has
been measured after three to six visits over some weeks. This is because
it can be affected by factors such as physical activity, and varies
from minute to minute.
This is why we sometimes arrange for
‘ambulatory’ blood pressure monitoring, using an automatic system to
record measurements every 30 minutes or so, day and night, as the
patient goes about daily life.
Once diagnosed, it’s important to
distinguish between primary, or ‘essential’ hypertension, where there is
no identifiable cause, and secondary hypertension.
The second figure, the diastolic pressure, is when the heart relaxes (posed by model)
This is when
there is an identifiable cause, such as kidney disease, oral
contraceptives and some medicines (eg, non-steroid anti-inflammatory
drugs), hormonal disorders including thyroid problems and obstructive
sleep apnoea (a night-time breathing disorder that affects some
overweight people).
Secondary hypertension is less common, but it
must be excluded with blood tests and other investigations, not least
because it is often ‘curable’. But 90 per cent of  hypertension cases
are unexplained, though we know there are many risk factors such as
obesity, lack of physical activity, genetics (such as hypertension in
one or both parents), a high salt intake and vitamin D deficiency.
Age is another factor – as we get older, blood pressure rises.
The
reason it’s so important for hypertension to be detected, and treated
effectively, is that the adverse effects are so serious.
It’s a
major risk factor for heart disease, more so than smoking, high
cholesterol or diabetes. It’s also the most important risk factor for
stroke and kidney disease.
So, WHEN a patient has been diagnosed with hypertension, it’s vital we  check for heart or kidney damage.
We also need to identify any potential curable causes; this mainly involves blood tests.
Once
all this is done, the patient must be started on a suitable long-term
treatment. This will include reducing their salt intake, Â losing weight
and regular exercise. If the systolic reading is consistently above 140
(150 for those over 60) and the diastolic is over 90, then it means
starting on an anti-hypertensive drug.
The greater the reduction in pressure, the greater the reduction in heart attack or stroke risk.
You
are taking 4mg of perindopril a day. This is an ACE inhibitor, which
helps blood vessels relax. If this is ineffective, the dose can be
increased up to 8mg.
Many patients need a second or even third drug to regulate their blood pressure, and if that’s the case, so be it.
Nothing
matters more than achieving a steady level of suitably lowered blood
pressure for the long term – you must work on it with your doctor.
For
18 months I have suffered from cholinergic urticaria, which means I
don’t sweat, but instead get a painful rash, affecting my back, chest,
arms and ankles, which stops me doing sport. The rash also appears for psychological reasons, such as pressure and embarrassment. I’ve
tried everything from rash creams to acupuncture and antihistamines
prescribed by my GP, but nothing has worked. Are there any other
treatments?
Mantas Stonkus, Medway, Kent.
The word urticaria is
derived from the Latin word for stinging nettle, urtica, and is the term
for a skin condition with different types and causes. It describes what
looks like nettle rash, which is fiercely itchy.
Cholinergic
urticaria is one of the so-called physical urticarias, when the rash or
skin wheals are triggered by physical factors, such as pressure on the
skin, for instance from a watch.
It can also be triggered by a
change in body temperature – referred to as generalised heat urticaria –
caused by the patient’s emotional state, exercise or a hot bath or
shower.
Write to Dr Scurr
To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London
W8 5TT or email [email protected] – including contact details.
Dr Scurr cannot enter into personal correspondence.
His replies cannot
apply to individual cases and should be taken in a general context.
Always consult your own GP with any health worries.
The rash starts with an eruption of multiple tiny wheals typically on the body and neck; these start to itch and tingle.
The
wheals can be anything from pinprick size to an area bigger than your
hand, usually resolving within hours, though some people suffer from it
chronically for months or even years.
Antihistamines in high doses
can work, and I’d suggest asking your GP if you were given cetirizine at
double the normal dose, ie, 10mg twice daily.
Another effective
drug is the antihistamine ketotifen – the anti-allergy dose is 1mg, but
this type of urticaria may need 4mg or more daily, though this can cause
unacceptable sleepiness.
The steroid danazol and the monoclonal
antibody drug, omalizumab, have also been shown to be useful. These
would be prescribed under the guidance of a dermatologist or allergy
expert. Your GP may agree to refer you.
The condition usually abates
– 70 per cent of those affected have recovered by the tenth year. It’s
not entirely good news, but reason for optimism.
The drugs should not be taken by those suffering anxiety, agitation or tension
By the way… Drugs won’t help students pass exams
Over
the past year or so, an increasing number of university students have
come to me asking for a prescription for stimulant drugs – either
methylphenidate, a drug typically prescribed for ADHD (the tradenames
are Concerta, Medikinet or Ritalin), or amphetamine in some shape or
form.
There is a widely held belief that these drugs help increase
concentration and therefore academic performance. And this pernicious
culture is ever widening, as I have had schoolchildren requesting them,
too.
The story is always the same. A friend gave them a few tablets
to try and now that the pupil or student has tasted the benefits of the
forbidden fruit, a supply is needed.
The first point I make is that
to provide a prescription drug for someone else to use is a criminal
offence: the friend is effectively setting himself up as a medical
practitioner – by diagnosing and prescribing – and as a pharmacist by
dispensing. It is best not to collude in this.
Second, while these
drugs might appear an easy and helpful and attractive aid to study –
they can trigger a sense of euphoria and confidence – the adverse
effects include nervousness, insomnia, palpitations and mood and
behavioural disturbances.
The drugs are also ‘contraindicated’, in
other words, should not be taken by those suffering anxiety, agitation
or tension. And these are all hallmarks of those who have exams
approaching and who are inadequately prepared.
Taking a stimulant
intended and prescribed for patients diagnosed with attention deficit
hyperactivity disorder is not going to make up for lack of study and due
application – it will only provide, at best, an illusion of
productivity when attempting some last-minute cramming, or perhaps, make
pre-exam anxiety worse. I explain all this to young patients, who glaze
over with boredom, radiating a sense of having heard it all before.
But
then I catch their attention: I point out that the prescription of a
controlled drug, potentially addictive, is subject to very strict
regulation. The details will remain on their medical records for all
time.
Would anyone appoint a person who needs a drug to help them
concentrate and perform if they are applying to medical school or to
train as a pilot, investment banker or barrister? Probably not.
The
message to get across is that these medicines are for the treatment of a
serious disorder, where there has been a diagnosis by experts, with
continuous ongoing careful assessment and monitoring. There is no such
thing as a ‘smart drug’.
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