What can I do for uncontrolled hypertension?

I have had high blood pressure which will not come normal. On Carvedilol 3.125 and Lisinopril 20mg. It fluctuates around 158/106. Sometimes I get a whirling feeling in my head. I had 2 strokes in 2008. Recovered. I went to ER and was told Lisinopril was the problem. Don’ t believe it is. I am 60, F, overweight and diabetic. Fearful of another stroke or a heart attack. Please advise as I am wanting help.

Submitted by Cathye from Savannah, Georgia on 09/12/2014

by Deborah E. Meyers, MD

Dear Cathye,
I am going to try to respond to your query, which raises a number of issues. You say that you have poorly controlled hypertension despite being on a reasonable dose of Lisinopril, which is a member class of drugs called ACE inhibitors. You are also on a tiny dose of a medication called Carvedilol, which is a member of a class of drugs called beta-blockers. You have already suffered several strokes.

Blood pressure control is essential in the management of a patient with other risk factors including diabetes and obesity. You are right to be concerned, but I also want to be clear that this is a long-term problem and requires long term monitoring and management by a doctor that can be your partner. The worst place to get any kind of chronic disease care is in the emergency department of a hospital. This chronic care needs to be delivered by a family medicine or an internal medicine doctor. When you are started on new medications (or more medications) someone needs to make sure that the medications have the desired effect and make sure that you have no untoward side effects over time. An emergency department is simply not designed to provide this individualized care plan and follow up.

The next question is what should your blood pressure target be? The current recommendations from the JNC-8 (Joint National Committee Panel) is that medication should be started if the systolic blood pressure is greater than or equal to 150 and should be maintained to be less than 150/90 in persons 60 years or older. This recommendation has stirred some heated arguments in the medical literature and some data suggests even lower blood pressures are better. So your medications need to be adjusted at least to the new targets, but more importantly you need to also combine medications with some serious lifestyle modification. People think high blood pressure is only about medication, but that simply is not true. Diet and exercise play a key role in helping you manage your health.

A study called the Diabetes Prevention Program Study found that even a modest weight loss of 12 pounds prevented odds of progression from pre-diabetes to diabetes by 50%. The important message here is that diet is critical to your ongoing diabetes control and management of your blood pressure. You need to be on a low salt diet (<1500 mgs daily) and start to rethink your diet seriously.

Here are some tips:

Avoid drastic changes- implement change gradually
Start reading labels- you will be shocked how much salt is contained in commercially prepared food
Start by eliminating the easy stuff- sodas, sugary drinks – switch to flavored waters and artificially sweetened drinks. Fruit juices are sugary- just a few sips or better still- use a small amount of fruit juice to flavor some fizzy water.
Watch those carbohydrates- start by reducing portions (nothing more than a small fist) and go for whole grains when you are able
Limit consumption of processed and salty meats including sausages, hot dogs and luncheon meats. Instead fish, lean poultry (not fried and skin off) beans and nuts.
Low fat dairy options are great
Lots of veggies- should fill 2/3 of your plate.
Finally, exercise is key. You need to move to improve. Regular and preferably daily exercise with a cardio component (walking, biking, swimming, exercise classes where you get your heart rate up) is a critical part of diabetes and hypertension treatment.

Start with finding and locating a GP/ family practice specialist or an internal medicine doctor to manage your diabetes and blood pressure. See if you can find a doctor that you like and is interested in you. But even the best doctors cannot fix your lifestyle without your involvement and commitment. Think long and hard about how to introduce gradual and sustainable healthy eating and exercise into your daily life.

For the “whooshing in your ears” it is hard to say what that may be. A more detailed history and exam is required to sort that issue out but your doctor can refer you for a neurologic or another specialist if required.

Finally, it is hard to change your lifestyle but it is worth the time and trouble to do it. Don’t give up because this is the best investment in your future that you can possibly make.