Shingles

For those who have had the disease, the term, "shingles" may evoke dread, pain and misery.  For those who have not, it may stir confusion and fear.  The name "shingles" comes from the Latin word "cingulum," which means belt or girdle.  Shingles is the reactivation of the chicken pox virus (herpes zoster) that lays dormant in our nerve roots.  We never completely get rid of it.  Later in life, the virus may escape the surveillance of our immune system, which keeps it in check, and will flare through one of the nerves.  These nerves commonly wrap around from the spine to the front of the body in a belt like fashion, thus the term "cingulum."  The rash irritates the corresponding nerve, resulting in pain which can be quite severe.  As opposed to muscle or joint pain, shingles pain does not respond well to the usual pain killers.


Sometimes the pain is the first symptom that presents itself.  At this stage it can be difficult to diagnose.  I have been fooled more than once by shingles, but if I am at all suspicious, I'll warn my patients that if a rash develops, to let me know. Recently I have been seeing a woman for back pain going down her leg.  It sounded very much like sciatic nerve pain.  We discussed using heat and she then told me that she had tried that but it gave her a rash.  I asked her to show me the rash and there it was: shingles.  It did not occur to her that it was related but her lack of response to the usual treatments for back pain made absolute sense when I realized the correct diagnosis.


Whereas chicken pox is a viral illness that goes throughout the body, shingles is confined to just the nerve root.  Chicken pox is highly contagious as it is spread through tiny droplets of moisture that is released in the atmosphere by simple breathing.  Shingles is only contagious to those who have never been exposed to the chicken pox virus or vaccine and only if there is direct contact to the rash.  If it is transmitted, the receiver will get chicken pox, not shingles.  You cannot give someone else shingles directly.


If shingles is diagnosed within three to four days of developing the rash, antiviral medications can be given which will shorten the duration of symptoms and decrease the chance of developing the painful nerve syndrome (post herpetic neuralgia).  If you think you have shingles, go see your doctor.  The rash may start as a few blisters on a red base (similar to chicken pox).  There is often a feeling of burning over the skin.  Many confuse this with a patch of insect bites.  


In addition to the antiviral medication, the pain can be treated with medicine that calms down nerve transmissions (such as gabapentin).  If the rash is in a defined area, topical lidocaine (lidoderm) can also be effective.  

It is now recommended that patients in their 60's receive the shingles vaccine (Zostavax).  It is quite safe, being the same vaccine used with children for the chicken pox virus, only it is given at a higher dose.  It decreases the chance of getting shingles by about 75%.  My patient with the back pain actually had been vaccinated, so it is not 100% foolproof.  The biggest issue with the vaccine is its cost.  Most facilities charge $250 for the shot and as of now, insurance coverage is spotty.  Check with your carrier first if you are considering getting the vaccine.

Managing Medications

I hold out hope that some day, I'll be able to send my patient to the lab for a "hypertensive DNA genotype array" which will check a person's genetic makeup and tell me why an individual has high blood pressure and which medicine will work the best for that particular patient.  We have learned much in the last 50 years in regards to why people have high blood pressure but we do not have a simple way as of yet to apply that on an individual basis.  As of right now when a patient needs medications to control their blood pressure, we as physicians use our knowledge, experience and our best guess as to what will work for a given person.  Trial and error is inevitable.  Some patients may require three, four or even five separate medications to control their pressure.  Others may be able to do it with life style changes alone.  Each medicine may have side effects that might limit its usefulness.  One may need to be stopped and another started.  As discussed previously, though, it is essential to get the blood pressure down and to keep it down.

I want to reemphasize that it is always better to be on less medication if possible.  I talk to all my patients with high blood pressure about their salt intake but very few of them really take me seriously.  I believe that it has a much greater influence than most people realize.  I came across a study some years back where researches studied a primitive island population in the Pacific.  They grew and or gathered almost all of their food.  Their diet was high in potassium given the high fruit content and it was extremely low in sodium in comparison to ours.  The astounding aspect to me was there was not a single person on the island that had high blood pressure.  Not even one.  Surely, I would suspect that someone would have a genetic defect giving them hypertension but it was overcome by a much healthier diet.  As stated in last week's post, it is essential to keep the sodium level under 2000 mg a day.

Some medications can be taken as needed.  Allergy medications, pain relievers or acid reducers can all be taken sporadically.  High blood pressure medications may not be used now and then.  They must be taken every single day.  The medicine will only work when it is taken and will have no lasting effects if doses are missed.  In fact, beta blockers if used inconsistently will trigger the blood pressure to spike to potentially dangerous levels.  I encourage all of my patients who are on daily medications to use a weekly pill box.  Many don't want to do so, saying they are not "old and senile."  We all will make mistakes if we are taking medicine from a bottle.  We can easily become distracted and then not remember if it was taken.  If we are using the pill box we will know for sure if it was taken or not.

Make sure you set up a routine.  Many patients will say that they remember their morning medications but often forget in the evening.  Put the medicine next to your tooth brush (which you should be using every night !), set an alarm if you need to.  Leave a note next to your bed stand to remind you.  Make sure you are consistent.

I want to finish with a word about side effects.  The printout given by the pharmacy is rather daunting.  It lists so many possible problems that most feel rather timid about taking any medication.  In general, medicines have 2-3 potential side effects that are more common.  If you think you are having a side effect to a medication, ask your physician.  Don't just stop the medicine and tell him three months later.  It is not always easy to tell if a symptom is related to a medication or not.  Remember that uncontrolled high blood pressure has side effects also.  The risks of both need to be weighed prior to making changes.  Your doctor is your health partner.  Don't leave him or her out of your important medical decisions.

Harnessing Hypertension

Does having hypertension automatically consign one to taking medications for the rest of one's life?  What about all of the side effects of taking medications?  Aren't they bad for you?  Knowing the risks posed by high blood pressure (see my previous post), what can be done to keep the pressure down?  answers to these questions are not always straightforward and can only be answered correctly on an individual basis.  Let me discuss some generalities first.

It is always better to control blood pressure without medications.  Always.  It may not always be possible to lower blood pressure enough with healthy living alone, but doing so will certainly decrease the number and or the dose of medications needed to keep it under control.  There are four basic precepts to keep in mind in harnessing hypertension.

First, if you smoke you must quit.  Nothing else you do will matter much if you keep smoking.  You may have a perfectly normal blood pressure, controlled with medications but your risk of heart disease and stroke will not go down significantly if you keep smoking.  Nicotine is a vasoconstrictor.  This means that it narrows the blood vessels.  Think of your garden hose.  If you want to increase the pressure in the hose to wash off your deck you apply a device at the end of the hose that narrows it.  Every time a cigarette is smoked the blood vessels narrow for about twenty minutes.  I see this all the time in my office.  A patient will come in with a higher than normal blood pressure.  One quick sniff tells me that they likely had one last cigarette before walking in the door.  At the end of the visit, I'll recheck the blood pressure and it will have come down.  In the beginning these changes are reversible.  With time, the stress on the walls of the blood vessel cause it to become thickened.  This is like taking that garden hose and turning it into a pipe.  As there is no elasticity or give in the blood vessel wall, pressure shoots up even more.  This whole cascade is caused from cigarette smoking.  I know that it is hard.  You must quit smoking.

Second, regular cardiovascular exercise is as good as taking a medication.  The side effects are much better.  It will not give you a cough, make your ankles swell or take away your sex drive.  It will give you more energy, relieve stress and help you sleep better.  The biggest side effect from exercise is injury, of course.  Start slow and gradually build up.  Consistency is the key.  To effectively lower blood pressure some sort of exercise needs to be done at least four days of the week.  During exercise, the blood pressure will actually go up.  This is normal.  The muscles need more blood flow during exercise to provide fuel and oxygen to the muscles.  The heart responds by contracting more quickly and with a greater force.  As the heart itself gets in better shape, it pumps more efficiently.  A well conditioned athlete will have a very low heart rate and excellent blood pressure readings. This is a sign that the blood vessels are relaxed and the heart is not burdened.

If you want to avoid taking medications or limit the number that you need, make sure that the fuel you give your body is of the highest quality.  In particular, limiting the salt content in your food will help your blood pressure.  The sodium in salt causes your body to retain more water in the kidneys.  This is equivalent to turning up the knob on the garden hose.  The higher the volume in the tubes, the higher the pressure.  You must first break the habit of salting your food.  This includes tomatoes and cantaloupe.  In addition, much of the food that we eat has a lot of salt in it to begin with.  Make the effort to look at everything that you eat in a day.  Look at the labels, find out how much sodium is in all that you eat.  Your total sodium intake in a day should be less than 2000 mg.  It is easy to find a website to tell you how much salt is in common foods (here's one).  If it is in a package, a wrapper or a can, it likely has salt in it.  If it says "low fat" it likely has salt in it.  Guess what has not salt in it at all?  Fruits and vegetables.  In fact, fresh fruits and vegetables are naturally high in potassium.  When potassium is delivered to the kidney it exchanges with sodium, excreting it in the urine.   By eating fruits and vegetables you are actually getting rid of salt.  The best diet to lower your blood pressure is the DASH diet (dietary advice to stop hypertension).

Lastly, limit the toxins in your system.  Admittedly this includes nicotine and salt but those two are so important they get their own category.  In addition, alcohol can be an issue.  Up to four glasses of red wine has been shown to have a beneficial effect on cholesterol levels but not more, and not any other kind of alcohol.  No amount of beer, vodka or other forms have been shown to have any beneficial effect.  The alcohol molecule itself can have adverse effects on the heart.  Alcohol also contains sodium and "empty calories" (they don't do your body any good).  Caffeine is not as bad as nicotine but it is a stimulant.  It will artificially raise the heart rate.  The only safe way of doing this is through exercise.  Just this week I saw a patient in follow up who has dramatically reduced his blood pressure by eliminating soda, coffee and adding exercise.  Many medications can make blood pressure worse.  Anti-inflammatory medications such as Aleve (naproxen) or Advil (ibuprofen) can have a deleterious effect, especially in older individuals. ADD drugs such as Aderall and Ritalin can also raise blood pressure.  The anti-depressant Effexor also must be used with care in addition to the migraine medications like Imitrex.  Decongestants are especially bad for hypertension and should not be used.  This is just a sample.  Look on the labels of anything that you take and make sure it does not give warning in regards to high blood pressure.

In summary, I have not given any advice in this post that I have not given previously.  I have tailored it specifically to high blood pressure.  The advice remains simple, putting it into practice is difficult.  Choose on thing that you can do better and work on that.  Make a positive step in your health today.

The Silent Assassin

Like an unaware target of a vigilant sniper, most people with high blood pressure live their lives with no suspicion that danger lurks at all times.  Hypertension rarely causes immediate effects on health but its constant influence causes stress on blood vessels and the walls of the heart.  This leads to thickening of the artery walls causing them to become hard and more brittle.  The most dreaded complication due to this process is in the brain in the form of a stoke.  There are usually no warning signs of a stroke.  When blood supply to the brain is cut off it happens quickly and suddenly.  Depending on which portion of the brain is affected, the effects can be devastating.

The muscular walls of the heart respond to the stress of high blood pressure the same way a weight lifters muscles respond to working out, by getting bigger and thicker.  At first thought you may ask, "What is wrong with having a "buff" heart.  Strong, thick muscles are good for quick bursts of action but it is the lean, thin muscles of the marathoner that we would rather pattern our heart muscle after, not the hulk of a weight lifter.  Ideally we want that heart muscle to pump slow, steady and efficiently, beat after beat after beat.   When the heart muscle gets too big, it gets stiff and has a hard time relaxing.  The stiff walls of the heart inhibit the flow of blood into the chamber.  If less blood enters the pumping chamber, less blood is ejected.  To compensate for this, the heart speeds up, making it even harder to fill the chamber.  As it gets harder and harder to fill the pump, the blood flow to the heart backs up like a partially clogged sink and fluid starts to fill the lungs leading to a form of congestive heart failure.  This form of heart failure is completely preventable by controlling blood pressure. 

In addition to causing heart failure and strokes, high blood pressure can trigger a heart attack.  If the lining over a cholesterol deposit breaks open, the body will respond by creating a clot on top of that plaque (see below).  This can take a non important 50% blockage and turn it into a deadly 100% blockage resulting in damage to the heart muscle.  High blood pressure makes the likelihood of that lining being broken open much higher.  The higher the sheer forces on the blockage, the greater the chance of rupture.  

Other areas of the body can also be damaged severely by high blood pressure, including the delicate tissues of the eye and the specialized filters of the kidney.  When combined with diabetes, blood vessel damage is exceedingly more likely.  The vast majority of patients on hemodialysis (artificial kidney machine) have one or both of these conditions.

Waiting to lower blood pressure until something bad happens is a recipe for disaster.  First, make sure you know what your blood pressure is.  If you haven't been in to see your doctor, do so.  Put your arm in the machine at the grocery store or pharmacy.  If you have a family member with a home machine, try it out. There are two numbers associated with your blood pressure.  The top number (systolic pressure) is the pressure in your blood vessels as the heart contracts.  The bottom number (diastolic pressure) is the pressure after it relaxes.  Both numbers are important.  If either one of them are elevated, your blood pressure is elevated.  Normal blood pressure is to have your systolic less than 130 mm Hg and the diastolic less than 80 mm Hg.  Real damage start to occur when your levels are consistently greater than 140/90.  Next week I'll discuss what to do if your levels are too high.