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Advice for Perplexing Heart Questions

New York (Feb 14, 2011)

What blood pressure numbers should patients aim for?

From Holly S. Andersen, M.D.

Holly S. Andersen, M.D.
Holly S. Andersen, M.D.

Optimal blood pressure is 120/80 mm Hg or less. For patients with high blood pressure (or hypertension), the goal is to lower blood pressure to at least 140/85 mm Hg, but the lower the better. Lifestyle changes that lower blood pressure are good for the whole body. These changes include increasing aerobic activity, losing weight, eating foods that are low in salt, avoiding excessive alcohol, and getting a good night's sleep. If lifestyle changes are not enough, partner with your doctor to find a medicine that is right for you.

One thing to be careful of is that many home blood pressure monitors overestimate blood pressure, particularly the bottom number (diastolic pressure). Wrong information is worse than no information. For people who monitor blood pressure at home with an arm cuff, it is important to get the device calibrated to make sure that the readings are correct.

High blood pressure is a powerful risk factor for stroke, heart attack, and kidney disease. Know your blood pressure and if it is too high, work with your doctor to lower it. There is no excuse for not having a good blood pressure.

Holly S. Andersen, M.D. is the Director of Education and Outreach at the Ronald O. Perelman Heart Institute at NewYork-Presbyterian/Weill Cornell Medical Center and an Associate Professor of Clinical Medicine at Weill Cornell Medical College.

How can patients make sure they get accurate blood pressure readings?

From Keith LaScalea, M.D.

Keith LaScalea, M.D.
Keith LaScalea, M.D.

Patients should give themselves enough time to get to their appointment so that they are not rushed. It is best to arrive early to allow for a few minutes to sit quietly and stress free. When blood pressure is measured, the patient should sit in a chair with both feet on the ground and with arms at heart level. Your physician should check your blood pressure with an appropriate sized cuff. If a person who is obese or extremely muscular is monitored using a standard sized cuff, the blood pressure will be overestimated. Ideally, if there is enough time, the physician should check the blood pressure two or three times and take the average of the results.

Many things can affect a blood pressure reading including:

  • Alcohol
  • Smoking
  • Extreme stress
  • High levels of caffeine
  • Sleep deprivation

It is important not to smoke cigarettes for at least an hour before having your blood pressure taken. Smoking can cause vasoconstriction (a narrowing of blood vessels), which causes blood pressure to increase. Also, patients should not exceed one to two alcoholic beverages the night before their appointment and should get a good night's sleep.

For patients who experience white coat hypertension (high blood pressure only when tested in a clinical setting), I ask my patients to monitor their blood pressure at home at various times of the day and night. I advise them to sit quietly for a few minutes, take their blood pressure three times, and average the results. In many cases, home testing offers a more accurate assessment than what is measured in a doctor's office. The more measurements that a patient takes, the better I am able to assess if the patient really has high blood pressure or if it is white coat hypertension. Patients measuring their blood pressure at home should use an arm cuff rather than a wrist or finger cuff as these are not as reliable.

Keith LaScalea, M.D. is an Assistant Attending Physician at NewYork-Presbyterian/Weill Cornell Medical Center and an Assistant Professor of Medicine at Weill Cornell Medical College

What cholesterol levels should patients aim for?

From Lori Mosca, M.D., M.P.H., Ph.D.

Lori Mosca, M.D., M.P.H., Ph.D.
Lori Mosca, M.D., M.P.H.,

Cholesterol levels are one of the most established risk factors for heart disease and also one of the most treatable and preventable. Ideally your total cholesterol level should be <200 mg/dL, but there is more to the story. Total cholesterol is made up of the good, the bad, and the ugly cholesterol levels.

If the good cholesterol (high-density lipoprotein or HDL) level is <40 mg/dL you are at increased risk for a heart attack or stroke. Think of it as H is for healthy and we want HDL levels higher. The target HDL level is >40 mg/dL in men and >50 mg/dL in women. The reason for this gender difference is that after puberty females tend to have HDL levels that are about 10 points higher than men and this difference is maintained throughout adulthood. Ideally, a level of ≥60 mg/dL is good for both men and women as this is considered a protective level. The best way to raise your HDL level is through lifestyle – getting regular exercise, maintaining a healthy weight, not smoking, and eating a healthy diet (not eating too many carbohydrates and replacing bad fats with good fats like those found in olive oil).

With the bad cholesterol (low density lipoprotein or LDL), L is for lousy and we want it lower. For both men and women, the LDL should be <100 mg/dL. However, if you already have or are at high risk of heart or other vascular disease, your LDL should be <70 mg/dL. Lifestyle changes should be the first line of therapy for patients who are not considered at high risk for heart disease. The most important approach is to reduce the amount of saturated or bad fats in your diet. Eating a diet rich in fiber also can help lower your LDL levels. For patients with heart disease, cholesterol-lowering drugs such as stains have shown strong benefits. The benefits of these medications are less clear for low risk patients, especially women.

The ugly cholesterol is triglycerides. This cholesterol level reflects the amount of fat in your blood and it varies significantly based on your diet. The good news is that triglyceride levels can be lowered quickly by exercise and diet (avoiding too much sugar, fat, and alcohol). The optimal level of triglycerides is <150 mg/dL for both men and women. Sometimes cholesterol levels are elevated due to genetic or medical conditions, but for most patients elevated levels are related to poor lifestyle choices. There are many other special cholesterol levels that your doctor may measure but the good, the bad, and the ugly are the most common, the most researched, and fortunately can often be improved with healthy lifestyle choices.

Lori Mosca, M.D., M.P.H., Ph.D. is the Director of Preventive Cardiology at NewYork-Presbyterian/Columbia University Medical Center and a Professor of Medicine at Columbia University College of Physicians and Surgeons.

Should people take a daily low-dose aspirin to prevent heart disease?

From Beth A. Barron, M.D.

Beth A. Barron, M.D.
Beth A. Barron, M.D.

Like any medication, there are risks and benefits to taking aspirin therapy. The advantages of aspirin are that it is an extremely inexpensive and effective medication. Aspirin has been shown over and over again to reduce the risk of having a heart attack or stroke in the right patient population--men over 50 years of age, women over 60 years of age, or any patient who is at high risk of having a heart attack (e.g., patients with diabetes, high blood pressure, a family history of heart disease, or who smoke).

However, it is important to talk with your doctor about aspirin therapy as there are side effects. People who are prone to bleeding for any reason are at increased risk for side effects from aspirin. Aspirin thins your blood and prevents clots. While that is a good thing in preventing a heart attack or a stroke, it can be a bad thing if you are at risk for bleeding from something like an ulcer or are taking medications that thin the blood such as warfarin (Coumadin) and clopidogrel (Plavix). Also, aspirin therapy is contraindicated (not advised) in patients with a recent hemorrhagic stroke.

For most people, taking one baby aspirin each day is enough protection. People who experience a stroke or heart attack on this low dose may need a higher dose or a different blood thinning medication. It is important not to stop aspirin therapy abruptly. The body gets used to aspirin's blood thinning effect and rapidly stopping therapy can cause the body to clot even more than it normally would, which increases the risk for heart attack or stroke. Thus, talk to your doctor before making changes to your therapy.

Beth A. Barron, M.D. is a Co-director of the Hospitalist Program at NewYork-Presbyterian/The Allen Hospital and an Assistant Clinical Professor of Medicine at Columbia University College of Physicians and Surgeons.

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