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Your blood pressure is an important signifier of your overall health. If it’s too high or too low, it could be a sign that something is off with your health, and it can lead to serious conditions. Cardiologist Luke Laffin, MD outlines the steps you can take to lower your blood pressure and to keep it within a healthy range.

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Combating High Blood Pressure with Luke Laffin, MD

Podcast Transcript

Speaker 1: There's so much health advice out there, lots of different voices and opinions, but who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts. We ask them tough intimate health questions, so you get the answers you need. This is the Health Essentials Podcast brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

Kate Kaput: Hi, and thank you for joining us for this episode of the Health Essentials Podcast. My name is Kate Kaput, and I'll be today's host.

We are about to talk to cardiologist Dr. Luke Laffin about hypertension, which is also known as high blood pressure. Your blood pressure is an important signifier of your overall health. If it's too high or too low, it could be a sign that something is off with your health, and it could lead to other serious conditions. Dr. Laffin is here with us today to talk about hypertension, to explain it to us and to talk about the steps that you can take to lower your blood pressure and to keep it within a healthy range. Dr. Laffin, thanks so much for being here with us today.

Dr. Luke Laffin: Great. Thanks for having me, Kate.

Kate Kaput: I always like to start by asking our guests to tell us a little bit about themselves. So, tell us kind of what kind of work you do here at the Cleveland Clinic and what sort of patients you typically see.

Dr. Luke Laffin: Yeah. I'm a preventive cardiologist. And so I take care of a variety of patients. One of my other titles is I'm co-director of the Center for Blood Pressure Disorders. So, I see a lot of individuals with difficult-to-control hypertension and sometimes so-called resistant hypertension, as well as a variety of other preventive cardiology patients.

Kate Kaput: Perfect. So let's just jump right into it. What is hypertension? And sort of, how do you explain this concept to the average person or patient who doesn't have a lot of existing medical knowledge in this area? What are we talking about here?

Dr. Luke Laffin: Well, so hypertension is really chronically elevated blood pressures. We can all have sporadically elevated blood pressures for whatever reason, but hypertension is chronically elevated blood pressures. And elevated blood pressure is really just the force within that is exerted on the inside of the blood vessel. The top number is when the heart is pumping, called the systolic blood pressure, and the bottom number is the diastolic blood pressure, when the heart is relaxed. And the reason why we call hypertension or chronically elevated blood pressures, we call it a medical condition is because chronically elevated blood pressures increase our risk for things like strokes, heart attacks, heart failure and kidney disease.

Kate Kaput: And so tell us a little bit more about those blood pressure numbers. What do each of them mean? Right? It's one number over another number. What do they mean, and what range should they be in?

Dr. Luke Laffin: So, that top number is called the systolic blood pressure, and a normal systolic blood pressure is anywhere between about 90 millimeters of mercury up to 120 millimeters of mercury. That's really optimal blood pressure. OK? Once we get up between 120 and 130 for the systolic blood pressure, that's elevated blood pressure. OK? Doesn't quite meet the threshold for hypertension, and then anything above 130 — at least based on the most recent American Heart Association blood pressure guidelines — is technically hypertension.

The diastolic blood pressure similarly has those delineations. OK? So, anything over 90 is hypertension. Between 80 and 90 is also sort of a lesser degree of hypertension, so-called stage 1 hypertension. And then once we get to below 50, 55, that's when it's probably too low. So, anything between 55 and 80 is pretty normal.

Kate Kaput: And you mentioned this a little bit earlier, but is it normal for your blood pressure to change throughout the day? And sort of what causes normal fluctuations in blood pressure?

Dr. Luke Laffin: So, it's very normal to have some fluctuation throughout the day, and there's lots of reasons. It really depends on lifestyle why blood pressure changes a lot during the day, but there's also underlying circadian variation or 24-hour variation in blood pressure. What is normal is a 10 to 20% decrease in blood pressure as we sleep at night. It's called nocturnal dipping. Then, starting around about 3 a.m. or so, there is a sharp, upward rise. The technical term for that is “the early morning blood pressure surge.” And in most individuals, we get this elevated blood pressure, or a peak in blood pressure, shortly after we wake up, sort of in that 6 a.m. to 11 a.m. range. Then, typically, there's a dip in the middle of the day and then another peak usually around dinner time or so. So, that's the normal variation that we see in everyone. Now, some people are going to have more exaggerated variation, but we see that.

And then to your other question about what makes it change, well, exercising, blood pressure increases as we exercise, but is significantly lower following exercise. That's normal. We have a meal that's real high in sodium or salt. That raises blood pressure transiently in most individuals. If we're in pain, if we're in a stressful situation, the normal physiologic response is to lower blood pressure, or — excuse me — to increase blood pressure. And then if we're dehydrated or something like that, then blood pressure tends to be lower. So, those are some of the more common reasons for changes in blood pressure throughout the day.

Kate Kaput: So, all kinds of, sort of standard things that you do during a day. Another one that I'd like for you to explain to us real quickly is “white coat syndrome.” What is that? And kind of how does that impact what your blood pressure is, or what your doctor thinks might be going on with your blood pressure?

Dr. Luke Laffin: Yeah. That's a really important thing to understand, and I think that we're increasingly understanding the impact of white coat hypertension, white coat syndrome, whatever you want to call it, particularly in this age of home blood pressure monitoring, which is highly recommended. So, the simple way to think about it is up to 40% of individuals have very different in-office and out-of-office blood pressures. OK? And so that's a discordance between in-office and out-of-office.

We can have people with really good-looking pressures in the office and really high at home. That's called “masked hypertension.” And then to your point, people with high pressures in the office, but well controlled outside of the office, that's called “white coat hypertension” or “white coat effect” in those individuals that have underlying hypertension already.

And we don't know the underlying mechanisms of these elevated blood pressures just when you're in a clinical setting. So, be it seeing a doctor before an operation or any type of procedure, we know people as they get older tend to be a little bit more prone to it. It doesn't matter. I've had other physicians that have a white coat effect. It doesn't matter if you're well acclimated to healthcare settings. Oftentimes, I'll have nurses come in and say, "Oh, why do I have this? I'm not nervous or anything." Well, you don't have to feel nervous. It's still just a white coat effect.

And white coat hypertension unto itself isn't dangerous, if you're measuring your blood pressure at home. The way that it increases cardiovascular risk and what we have to be cognizant of is that if every time your blood pressure is high when you see your doctor and you're not measuring at home, or don't have some marker of out-of-office blood pressures, we know that most people, as they age, ultimately develop hypertension. So, we don't want to just wave it off. We need to do some type of out-of-office blood pressure monitoring.

Kate Kaput: That makes a lot of sense. And I'm actually one of those 40% of people. That was happening to me for a while, and my doctor said, “You know what? Let's get you a home blood pressure monitor.” And every time I took it at home, it was totally fine. So, I think that's really interesting. Our bodies do all kinds of things kind of without our realizing it.

So let's talk, though, again, about chronic high blood pressure, about hypertension. Talk to us a little bit about what are some of the causes of hypertension. What are the underlying elements that are at play here?

Dr. Luke Laffin: So, there's certain modifiable elements, and then there's certain non-modifiable elements that we talk about. OK? So as I alluded to earlier, aging is a big component in hypertension, and that has to do with stiffening of the larger blood vessels within our body. So, there's typically a rise in people eating a typical Western diet, rise in blood pressure starting around 18, 20 years of age, and there's a rise in both systolic and diastolic blood pressure. And then, once you get to about 50, 55 years of age, there's a little bit of a divergence due to that stiffening. So, systolic blood pressure takes a higher slope up. Diastolic starts to go down a little bit. And that's why systolic blood pressure most predicts cardiovascular risk in elderly individuals. So, that's one component of it.

Genetics play a role. OK? If your parents had hypertension early in life, you probably will as well. OK? And it's a polygenetic — polygenic, excuse me — condition, in that, there's not one specific gene in the vast majority of individuals that contributes to hypertension. So, there's multiple contributors.

And then, so those are the major non-modifiable risk factors. And then there's some very modifiable ones, OK? If you're overweight or obese, we know that excess weight increases blood pressure. If you're sedentary, so you're not physically active, that also can increase blood pressure. So, we need to be active. When we think about dietary patterns, a heart healthy diet tends to be helpful in these scenarios. And the biggest dietary factor that we think about is excessive consumption of dietary sodium, salt. That definitely increases blood pressure. That's a really important thing that we can get back to and talk to if you want.

But other modifiable things, smoking raises blood pressure a little bit. More than a drink or two a day increases blood pressure. And then, we also have this idea of stress. OK? Acutely, stress can raise blood pressure. There's no question about it. But once in a while, that's fine. That's a normal physiologic response. The issue really becomes chronic stressors and how they impact some of these lifestyle factors: if they're changing your diet, if you're not exercising because of it, if you're not sleeping well. Sleep is an increasingly recognized cause for not only elevated blood pressures, but more blood pressure lability, up and down, particularly as we get older. So, all of those factors really play a role.

Kate Kaput: Let's go back to the dietary piece that you mentioned, too much salt in your diet or high sodium diet. Tell us a little bit more about that. Kind of what foods are and aren't recommended? How does salt impact our blood pressure, and what should we be doing there?

Dr. Luke Laffin: Yeah. So it's a little bit contentious about how much salt actually impacts blood pressure in individuals without hypertension. So we're going to restrict our conversation to those people with a known diagnosis of hypertension because all of those where the vast majority of them should be on a low-sodium diet.

That being said, the vast majority of Americans are overdosing on salt on a daily basis. So, the average salt intake — or sodium intake, excuse me — is about three and a half grams or more. And when we talk about blood pressure management, what we really aim is for a low-sodium diet, which is equivalent to less than 2,300 milligrams, so 2.3 grams of sodium a day for individuals to intake.

If you go on the American Heart Association's website, they're going to say less than 1,500 milligrams per day, and that's aspirational goal, and if individuals can get there without changing their diet a radical amount and being miserable, that's fine, but definitely less than 2,300 milligrams is what we recommend.

Most individuals are pretty familiar with the types of foods that are really high in salt. OK. Anything from the deli counter, your ham, sausage, bacon, pickles, soups you don't make yourself, tons of salt in them. When we think about foods that we don't think about having a lot of salt, but actually do, salad dressings, cheese, bread tends to have a lot of salt. A typical example I like to use with my patients is if you go and have a ham and cheese sandwich, that's 1,600 milligrams of sodium. OK? And even if you're getting the low-sodium ham or whatever the case is, you're still getting some. So, it's important to be aware of that.

So, those are some things to really focus on. And then when we think about types of salt, all salt is created equal when it comes to sodium, so sea salt, Himalayan salt, kosher salt — there's a hundred different types of salt. They all have sodium in them, and they all increase blood pressure.

One thing that has recently been shown and will recommend sometimes to those individuals that really have trouble kicking that sodium habit is salt substitutes. So, something which is potassium chloride can be helpful for those individuals. But being mindful of the individuals that use it, that have, for example, chronic kidney disease, too much potassium can be dangerous.

Kate Kaput: That's really helpful. Thank you. I want to move into talking about symptoms. I know that hypertension is often called the silent killer. What does that mean?

Dr. Luke Laffin: It means that we don't know we have it, and it leads to cardiovascular morbidity and mortality, so strokes and heart attacks. The vast majority of people with hypertension don't have any symptoms whatsoever. OK? And it's because, at least for the majority of people, blood pressure doesn't tend to rise acutely. OK? It becomes elevated over many years, and the body can adapt to high blood pressures for long periods of time. OK? But then there's maladaptive features. For example, the heart muscle gets thick, called left ventricular hypertrophy. That's no good. OK? That's surrogate marker for end organ damage. OK? So, the body doesn't like it for decades on end seeing these high blood pressures, and that's why it's called the silent killer.

Kate Kaput: So, it's more of an accumulation over time, not like a sudden and acute health problem where you're going to have sudden symptoms. It's building up in you, and over time, your body is like, this isn't good for us.

Dr. Luke Laffin: Yeah. That's for the vast majority of individuals. So, sometimes, in the hospital, we'll see someone with an acutely elevated blood pressure for whatever reason, OK? Maybe they did some cocaine or something like that, which we know raises blood pressure. OK? They can have some acute abnormality, like heart attack, like a stroke, like an aortic dissection. In those individuals, that elevation is so fast that it causes end organ damage, but again, in the vast majority of individuals, it's built up over time, and that's the conditions that we see — atherosclerosis, heart failure, chronic kidney disease — that are impacted.

Kate Kaput: Got it. So, I mean, there are some symptoms that people can have that I'd like to talk about, or at least some symptoms that people tend to associate with high blood pressure. A lot of people who think that having headaches is related to high blood pressure, or dizziness or fatigue, what can you tell us about some of those symptoms or possible symptoms? Are they symptoms at all?

Dr. Luke Laffin: They definitely can be. I mean, everyone's a little bit different, so I would never discount someone's symptoms saying it's not due to high blood pressure. But to cut to some of the specifics, so headaches is tough because it becomes a really a chicken-and-the-egg issue. Are you having headaches because of high blood pressure, or is the headache causing your blood pressure to become more elevated, the pain from it? OK? Because I mean, if I was to hit my knee or something, or have a knee injury, my blood pressure would go up. That's fine. Same with a headache, similar.

So, it's difficult, not necessarily difficult, but it's really important to tease that out. And so in a lot of individuals that I see, I'll say, "Well, you know what? I want to see what your blood pressure is when you're not having headaches, so we get a baseline." It's not appropriate to just check blood pressure when you're having symptoms. We want to see what it is on a standard basis when you're feeling well. OK? So that's what I think about headaches.

The thing about headaches, too, low blood pressure can cause headaches, as well. OK? People can just feel lethargic and tired. So, there's that. Other symptoms that you talked about, so dizziness, for example. Dizziness is sort of a tough one, too, because especially when we think about it from a cardiovascular perspective, we put it into one of two buckets. Is it really a room spinning dizziness, or is it a lightheadedness? The room spinning, which is more associated with vertiginous or vertigo symptoms, that would be very unlikely to be caused by any type of blood pressure issues. OK? It's more of an inner ear issue for most people.

But lightheadedness, OK, so that is oftentimes not caused by high blood pressures, but by changes in blood pressure. OK? So going from a high blood pressure to a very low blood pressure, particularly positional, that can definitely result in lightheadedness, people feeling unsteady, even sometimes frank syncope, so passing out. So, we can definitely see that in individuals. It's usually not just the elevated blood pressure, but it's the change associated with it.

Kate Kaput: When you say positional, do you mean you're laying down, you get up really quickly, that creates a change in blood pressure that can also create that sort of lightheadedness, dizzy feeling?

Dr. Luke Laffin: Yeah, exactly. In someone that's completely healthy and normal, we have sensors in our body that react to these changes in positions. OK? They vasoconstrict, and they send enough blood flow to our brain based on these changes in position. But if we're lying down, or let's say even we're out gardening on our knees, for example, for a long period of time, and then we stand up quickly, everyone's had this, where they feel a little bit lightheaded and dizzy. OK? I'm sure you've had it, Kate. I've had it. I had it this past week. OK?

And sometimes, and that's just less blood flow going to the brain. It takes the body a little bit more time to get acclimated. And it doesn't mean that there's some major problem, and the biggest way around that is making sure that you're hydrated and things like that. But some people can have this to an extreme extent or to a multiple-times-a-day extent, and that's where blood pressure medication changes, et cetera, need to be talked about with their doctors.

Kate Kaput: And what about fatigue or tiredness? Again, is it one of those chicken-and-the-egg things? One can cause the other or vice versa? Do those go together? Does tiredness play any sort of a role in blood pressure?

Dr. Luke Laffin: Yeah. It's pretty difficult to find any major link between feeling fatigued and elevated blood pressure. If blood pressure's too low, clearly, we can be tired. There's no question about that, and the data is much stronger.

The issue with fatigue or feeling tired is that it's oftentimes multifactorial, and so those individuals that are tired usually aren't doing a lot of exercise. They might have undiagnosed sleep apnea. OK? They might be obese. And all those are risk factors for hypertension, too. So, how we separate or tease them out is important to talk about.

The one thing that I always sort of think about when we talk about these symptoms of high blood pressure or hypertension is that it's easy to attribute symptoms to blood pressure because "You know what, I can just check my blood pressure at home." OK? "Oh, it's a little abnormal. Oh, it must be the blood pressure," but not necessarily. That's why it's warranted to have an in-depth discussion, and oftentimes, we will with patients to say, is it really these symptoms that are being driven by your blood pressure? Is it vice versa? Or are they completely unrelated? You still have to treat your blood pressure, but we ought to look into these other factors as well.

Kate Kaput: So, like so much of health, it's really about figuring out all the various pieces and sorting out the puzzle that is our bodies.

Dr. Luke Laffin: Yeah. Unfortunately or fortunately, it keeps me in business, I guess. Yeah.

Kate Kaput: I was going to say, that's what we have doctors like you for luckily, people who thrive on figuring out the answers to those puzzles.

So, you've mentioned this a little bit in some of your other responses, but tell us more about what can happen if high blood pressure is left untreated. Right? What other conditions and diseases can it lead to or is it associated with?

Dr. Luke Laffin: Yeah. So the big four are strokes, heart attacks, heart failure and kidney disease — and there's overwhelming amounts of data to show that uncontrolled hypertension leads to these outcomes. And again, these happen over many years, but there's clearly risks associated with them. So, probably the most sensitive to blood pressure reductions is a reduction in stroke. So, if you reduce your blood pressure, that's going to give you the biggest benefit in terms of reducing your risk of stroke in the future.

Kate Kaput: So, let's move then right into talking about some natural ways to lower your blood pressure. I know that medication is an option. Before we start talking about medication, let's talk about some of those things that you can do to change some of your risk factors. So, what are your top recommendations for folks who are trying to keep an eye on their blood pressure?

Dr. Luke Laffin: The way that I think about it when I talk to my patients is hypertension is really 70% lifestyle, 30% medications. So most individuals with hypertension, if you look at the data, need two to three blood pressure medicines. OK? But that has to be in the background of, as you stated, sort of natural ways or lifestyle modification, because if you're not doing that, you're really behind the eight ball and going to be challenged to control blood pressure, even on multiple medicines.

So, the top things that we think about, and these are highly endorsed by the American College of Cardiology, American Heart Association and essentially every other hypertension society within the world, are less salt. So, we talked about that, right? Decreasing the salt consumption. OK? Increasing potassium consumption. So, potassium is the inverse of sodium. OK? So, too much sodium increases blood pressure. Too little potassium increases blood pressure. So, trying to get yourself some bananas, tomatoes. Those foods that are rich in potassium can be helpful.

There are more specific dietary patterns that can be helpful. The most commonly studied is the DASH diet, which is an acronym for dietary approaches to stopping hypertension, and that can be done in combination with a low-sodium diet. So, that's really more of a balanced diet, rich in fresh fruits and vegetables, whole grains, et cetera. So, that can be really helpful, particularly working with a dietician or nutritionist to drill down on the basics.

Getting to a healthy weight is helpful. There's no question about that. Oftentimes, I'll tell my patients, the fat cells that we get around the middle, those spare tires, for example, those are metabolically active cells. So, they're secreting all kinds of hormones, et cetera, which ultimately raise blood pressure.

Alcohol raises blood pressure as well. So, the general recommendation is in men, no more than two alcoholic drinks a day, and women, no more than one. Smoking can raise blood pressure a little bit. And then less well studied, but still increasingly important, or at least we're finding it's increasingly important, is getting six to eight hours of uninterrupted sleep at night. So, if people are doing that plus exercising regularly, 150 minutes a day — excuse me, a week of moderate intensity, aerobic, physical activity — they're going to be in good shape.

Kate Kaput: Great. And you talked a little bit about salt and potassium. Are there any recommended vitamins and supplements that can help? Or should you really be focusing on dietary elements?

Dr. Luke Laffin: Yeah. You should really be focusing on dietary elements more than anything else. Now, if you look online, there's small studies of variety of different things, OK, that if you see them, they're probably not going to hurt you. Might be a little bit helpful, but we're not talking major decreases in terms of blood pressure. So, I do not typically recommend any vitamins or supplements for individuals.

If they really want to avoid medicines, we do as much as we can with lifestyle. And then, if you're going to take something and pay for something, you might as well take something that's FDA-approved and actually has some data for cardiovascular risk reduction and blood pressure reduction.

Kate Kaput: So, let's move into talking about medication then. When is it time to consider medication with your doctor? Kind of what does that conversation with the doctor look like? What are some of the options? Walk us through that process.

Dr. Luke Laffin: So, the first question becomes is what's your overall cardiovascular risk? OK? So, in folks that have had a stroke or heart attack, they're clearly at higher cardiovascular risk, or they have multiple other risk factors. They're elderly. They have high cholesterol. Maybe they smoke. OK? Those patients, we want to be a little bit more aggressive about starting medicines and getting them to lower blood pressure targets.

For those individuals that maybe hanging out, let's say their blood pressure's 135/85, OK, so technically, they're stage 1 hypertension, but they shouldn't be ... and this could be someone I see in my office or our primary care doctor sees. They're 40 years old. They just noticed it's been creeping up. OK? The right answer isn't, "Here's a pill. Start taking it." OK? The right answer is focus on some of those lifestyle factors, and then give it three to six months, OK, and see where we are. And that's what the guidelines recommend for stage 1 hypertension.

When blood pressures are consistently greater than 140/90, even with these significant lifestyle changes, that's the time when we really start thinking about adding medications in these individuals, because generally medications, particularly at lower doses, are very well tolerated and very effective, and they're generic. They're really easy to get, and we see results within about 10 to 14 days. So, those are the times when it's really comes to consider medications in these individuals.

Sometimes, people will ask me, ‘Can I ever get off of medicines?” Sometimes, OK? Usually, the people that ask me that, though, are the ones that are normal weight, exercise every day and eat really healthy. OK? And in those individuals, if they're already on medicines, the likelihood of getting off medicines is pretty low. But in the individual that maybe they have a lot of extra weight that they're carrying around, don't do a lot of physical activity, are having McDonald's every day, in those folks, yeah, we can, but it's going to take some work on their part and on my part to do that. So, that is the time that we really consider medication.

And one thing that I always tell my patients, and I think a lot of folks at Cleveland Clinic will agree with this, is that I'm not wed to any medication doses. OK? Any certain medications and medication doses. If we can reduce in the future, that's fine. I'm more than happy to do that. The goal is to get the blood pressure controlled on the least medicines possible, and I think most people are open to that discretion.

Kate Kaput: I think that's a good point. And I think worth reiterating, like you said, that it's not just that the medication is a cure-all. The medication really has to accompany those lifestyle changes, that healthy lifestyle, and sort of putting all of it together, not just taking a pill and hoping that all is well.

Dr. Luke Laffin: Yep. And you can do that for certain things, like cholesterol, not so much for hypertension though, unfortunately.

Kate Kaput: And I think heart health, in general, is one that is really lifestyle-focused. Got to put some effort into this one.

Dr. Luke Laffin: Yep.

Kate Kaput: How do you track your blood pressure? We talked a little bit about doing in your doctor's office, about getting a blood pressure monitor for home. Walk us through some of those options. When's the best time to take your blood pressure medication or your blood pressure reading? What should people be doing to figure out what their blood pressure is?

Dr. Luke Laffin: So, when we talk about out-of-office blood pressure monitoring, particularly self-monitoring of blood pressure or home blood pressure monitoring, the first thing that is really important is that someone gets themselves a blood pressure machine and cuff that is well validated. OK? So, using the little app on your smartphone, where it measures it from your thumb, that doesn't work, OK? Or your Apple Watch or whatever. OK?

The best validated blood pressure devices can be found on a website called validatebp.org, and it's a non-commercial website that's sponsored by the American Medical Association and American Heart Association. And it lists about 15 to 20 of the best validated cuffs. You can't buy it on there, but it'll give you a list. And this is not ... you don't have to pay a hundred dollars for one of these blood pressure cuffs. I think the least expensive on there, it's about $30, $35. It's going to give you just as accurate blood pressure reading as the $100 ones. It just doesn't give the bells and whistles, Bluetooth, et cetera. So that's the first thing. Make sure you have a valid machine.

You got to make sure you have the right size cuff. OK? And there's things online that'll show you that. I think we probably have it on our website as well, just saying, if you have a big arm, you need a bigger cuff, OK? Because if your cuff is too small, that artificially inflates blood pressure readings. You'll think that you're not controlling it, but you probably are. Similarly, if your arm's really small and you're using a big cuff, a cuff that's too big, you're going to get artificially low blood pressure readings. So, we got to make sure that's accurate.

And then in terms of timing, we recommend typically in the morning and then in the evening as well, because of those peaks, like I talked about earlier. And when someone where we've made changes to their medicines or significant lifestyle changes, three to five times a week, typically in the morning and a couple times in the evening, is good. But if someone has really stable blood pressure, the data would suggest once a week, once every couple weeks is probably fine to do it, to keep track and let your doctor know.

Kate Kaput: And what about sometimes, you go to a drug store and they have those blood pressure cuffs for you where you can kind of do it yourself. You just stand on the platform thing and stick your arm in there. Are those readings worthwhile? Are they typically accurate?

Dr. Luke Laffin: It's very variable, right? It's very variable. So, if you haven't ever had your blood pressure checked, I think it's fine to do that as just a screening mechanism. Probably anyone listening to this podcast probably has checked their blood pressure or is thinking about it. But I think it's better than nothing, but it's questionable accuracy in that scenario.

The other thing that you had said, standing there, that's the other thing. Make sure you're sitting and doing all the proper things, right? So, sitting for five minutes before you do it, your bladder's got to be empty because full bladder raises blood pressure 10 to 15 points. You can't have had smoked or had getting caffeine 30 minutes before. All those are really important to make sure that you're truly getting an accurate blood pressure.

Sometimes, people ask me, "Well, what about my blood pressure when I just sit down? Isn't that physiologic?" The counter to that is that in all the studies that we've done with hypertension and these treatment targets, OK, there's a very standardized process that goes into measuring blood pressure. And so that's what we ask our patients to do. Maybe not quite as rigorous, but similar mechanisms so that we can use similar thresholds to treat hypertension.

Kate Kaput: That makes sense. So, follow some of these specific steps to get the most accurate kind of baseline of your blood pressure. Is there anything that we haven't discussed today that you think is important for your average listener to know about hypertension?

Dr. Luke Laffin: I think the only thing that it adds on, sort of, when is it time to consider medication, is that if blood pressure is significantly elevated, so over 140/90. Most cardiovascular societies around the world recommend actually starting with two medicines rather than one, if we're doing it, and the reason for that is that two medicines at low to medium doses are actually more effective than one medicine at a high dose and tend to have less side effects because of their synergistic mechanisms of action. So, if your doctor is starting you on what we call fixed-dose combination therapy, so one medicine with two — excuse me, one pill with two medicines in it — that's proper and the right thing to do. And oftentimes, it's not done. So, it's something to talk to your doctor about.

Kate Kaput: Good to know. And speaking of talking to your doctor, how do you kind of start the conversation with your primary care physician about your blood pressure? When is it time to see a cardiologist? Anything that people should know on that front?

Dr. Luke Laffin: So, always happy to see anyone in the preventive cardiology department. That being said, OK, if someone has resistant hypertension, which is blood pressure that's not controlled on three or more medicines, that's the time to see a hypertension specialist, OK? Within our Center for Blood Pressure Disorders is a great place to start. Those are the folks that we like to see, and that we have not only do we get back to the basics and look for other weird causes of elevated blood pressure, but also, we can talk to them about clinical trials, about new medicines or new devices for blood pressure and really give them that expert opinion.

Kate Kaput: Perfect. Anything else from you, Dr. Laffin, on this topic?

Dr. Luke Laffin: No. That's it.

Kate Kaput: All right. Great. Thank you so much for being here with us today and for speaking with us on this important topic. We hope that it's helpful to people.

To all of our listeners, to learn more about heart health at Cleveland Clinic, please visit clevelandclinic.org/heart. Again, that's clevelandclinic.org/heart. Or to make an appointment, call 1.800.659.7822. Thank you so much for joining us today.

Speaker 1: Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts, or visit clevelandclinic.org/hepodcast. You can also follow us on Facebook, Twitter and Instagram for the latest health tips, news and information.

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Tune in for practical health advice from Cleveland Clinic experts. What's really the healthiest diet for you? How can you safely recover after a heart attack? Can you boost your immune system?

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