"I Feel Fine—Why Should I Worry About My Blood Pressure?"

Raj’s story is a cautionary tale in the ongoing battle against hypertension, a condition often dubbed the “silent killer.” With no warning signs, it creeps into lives unnoticed, only to emerge later with devastating consequences such as heart attacks, strokes, and kidney damage.

The Cardiologist’s Perspective

“As a cardiologist, I encounter patients like Raj all too often—seemingly healthy individuals blindsided by a diagnosis they neither feel nor believe. High blood pressure is particularly prevalent in South Asian communities, where genetic predisposition and dietary habits play a significant role. The most troubling aspect? Many, like Raj, fail to act because they feel fine, believing good health is synonymous with feeling good. Here’s what makes cases like Raj’s so concerning:

Lack of Symptoms: High blood pressure rarely causes noticeable symptoms until it’s too late. By the time patients feel something, irreversible damage to their heart or blood vessels may have already occurred.

Missed Opportunities: Routine health checks are an excellent chance to catch hypertension early, but if patients don’t act on these findings, we lose precious time to intervene.

Long-Term Risks: Uncontrolled blood pressure dramatically increases the risk of life-threatening conditions like heart attacks, strokes, and heart failure”.

Raj’s Dilemma

It’s easy to understand why people like Raj might ignore high blood pressure.

“I feel fine, so it can’t be serious.” 

We often equate good health with feeling good. Without symptoms, it’s hard to believe there’s an issue.

People like Raj struggle to reconcile the idea of a health condition with no symptoms who doesn’t want to be unnecessarily “medicalised”.

“I don’t want to depend on pills for the rest of my life.” 

The idea of taking daily medication can feel daunting or unnecessary. The idea of lifelong treatment can feel daunting and unnecessary to most - there is a fear of side-effects and the stigma of taking tablets at a relatively young age.

“Maybe the reading was wrong.” 

Many people are sceptical of a single high blood pressure reading, especially if it’s unexpected and are often dismissed as due to stress or life circumstances. Although we shouldn’t base our assessment just on one measurement, especially something as variable as blood pressure, equally Raj shouldn’t dismiss this out of hand.

The Hidden Danger of Doing Nothing

Hypertension quietly erodes the body’s health, leading to serious complications like heart disease and kidney failure. The absence of symptoms doesn’t equate to the absence of risk.

How We Address This:

1. Reassurance Through Tests:

   • Blood Pressure Monitoring: this is the cornerstone to managing blood pressure and is covered in more detail below. Essentially don’t rely on a few one-off measurements taken at home when you’re not feeling great.

   • Advanced Screening: For higher-risk patients, blood and imaging tests like echocardiograms, eye or kidney assessments can reveal early damage, underlining the need for intervention.

2. Calculating global risk

   Blood pressure is not the only factor responsible for cardiovascular diease - age, male gender, weight, cholesterol, diabetes, smoking and family history all need to be considered. Frequently we will estimate a 10 year risk score based on these factors, which estimates your risk of having a heart attack, stroke or death based on studies of large populations who have been followed-up in research studies.

3. Empathy and Education:

   • Getting the balance right with patients like Raj is crucial - whilst there is certainly no imminent or even medium-term risk to him, we are trying to delay onset of serious complications 10-20 years down the line.

Overcoming Misconceptions

While it’s true that one high blood pressure reading doesn’t always confirm hypertension, ignoring it risks missing an opportunity for early treatment.

Averaging out

Average blood pressure values give a better indication of what your organs are being exposed to over a period of time. You could be seeing quite high spikes during the day time, but as soon as you put your monitor away, you have no idea what is happening to your blood pressure, and quite often it is dropping down nicely. This is obviously the situation at night when we are asleep when blood pressure usually falls significantly and will help lower your 24-hour average. This is what matters to the body.

Therefore, the best methods to get an idea of our overall blood pressure load are:

• Ambulatory Blood Pressure Monitoring (ABPM): This is the gold-standard test for blood pressure and can even be obtained at local pharmacies on the NHS in the UK. A device worn for 24 hours to capture a comprehensive average of readings. It’s like a typcial home machine cuff connected to a smaller box that can be worn around your neck or clipped to your waist. It will check your BP automatically and randomly throughout the day and night (around 30-40 measurements in total!). An average blood pressure of > 130/80 suggests hypertension.

• Home Monitoring: Regular measurements over a week provide a more accurate picture of blood pressure patterns. This requires careful compliance with instructions , namely measuring a set time points in the day, taking 3 measurements 3 minutes apart, and recording the final one. An average of the final readings greater than 135/85 indicates hypertension here.

There can often be a huge discrepancy between one-off measurements (that are typically posted on facebook and reddit forums 😀 ), and the methods above - usually average readings are much lower. This means either that you don’t have hypertension after all, or it is not as severe as suspected.

Raj’s follow-up

“As well as a some routine blood tests of kidney function and an ECG (electrical recording of heart), I decided to arrange a 24 hour ambulatory blood pressure monitor for Raj. This showed an average of 133/85 - which confirmed mild (grade 1) hypertension. Whilst not normal, these values certainly felt less worrying and more manageable to Raj. From my perspective it also meant we had more time to play with to get these numbers under control using lifestyle interventions given that Raj was reluctant to start taking tablets”….

Having a plan

The fear of taking daily medication can be a significant barrier for many patients. However, not everyone with high blood pressure requires medication immediately. And in Raj’s case we have room to try….

Lifestyle First

For mildly elevated blood pressure, lifestyle changes such as reducing salt intake, increasing physical activity, and managing weight are often effective. Each of these interventions can be as effective in lowering blood pressure as taking a blood pressure medication. Together the impact of these lifestyle measures can be additive, especially if your weight also drops as a consequence e.g. from cutting alcohol or from exercise.

“I negotiated a 6 month time window with Raj to implement this with specific advice on exercise, diet, alcohol and whatever weight-loss methods work for the patient. The results were impressive with a significantly improved home average blood pressure reading of 127/83”.

“If he had been either unable to implement the lifestyle advice or had tried but not realised any improvement in his readings then mentally he was prepared for considering taking medications which we had discussed previously”.

The taboo of medication

Many patients seem quite scared by the thought of taking medications and I think this boils down to two factors: possible side effects and belief that once started they will never be stopped.

Blood pressure medications certainly are associated with side effects. But the good news is that there are 10 main classes of anti-hypertensives and we can usually find at least 1 or 2 to suit most people. Very few of the blood pressure medications can “damage” the body and usually any harm is reversed quickly after withdrawal.

The good news is that increasingly, doctors are reviewing long-term blood pressure medication prescriptions particularly if the patient has made significant lifestyle adjustments, such as losing weight or stopping drinking. The clue that medications are no longer needed may be very low readings or feeling faint when standing.

Final thoughts

If you’re wondering whether your blood pressure requires treatment, remember that a single high reading isn’t necessarily cause for alarm. Instead, it’s about looking at patterns and considering your overall health. Don’t hesitate to consult a healthcare professional to discuss a tailored plan—it’s often these small, proactive steps that prevent bigger issues down the road.

The more you know about your health, the more control you gain over it. With a little guidance and the right tools, blood pressure management can be straightforward and empowering. If you’re ready to take action, start with one small habit. Every change counts.

Take control of your health journey—your heart, eyes, kidneys, and arteries will thank you!