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Hypertension is a leading cause of disease in the United States. As a killer, it's second only to tobacco. Lifestyle changes and medication will bring high blood pressure down. But as NPR's Brenda Wilson reports, they aren't used enough.

BRENDA WILSON: Sixty-five-year-old Lee Musick is checking his blood pressure using a portable home unit. Keep in mind that most doctors are happy if that top number is under 120. Consistently over 140, the patient has hypertension.

Mr. LEE MUSICK: Well, we got a very high rating.

WILSON: Oh, no.

(Soundbite of laughter)

Mr. MUSICK: Let's do it again.

WILSON: What was it?

Mr. MUSICK: One-sixty-three, which is most unusual for me, so let's try it again.

WILSON: Usually, he says, his blood pressure is around 138 over 60 to 140 over 70, and even lower at times.

Mr. MUSICK: I'm looking back in February at some 128 numbers, another 128, 127 for a couple of days, 125.

WILSON: It's not unusual that his pressure shot up during an interview. Musick's doctor, cardiologist Thomas Lee of Harvard University, says it's the average blood pressure that counts.

Dr. THOMAS LEE (Cardiologist and Professor, Harvard University School of Medicine): It's the average amount of wear and tear you're subjecting your body's arteries to. It's not like you have any one blood pressure. Your blood pressure jumps all around from minute to minute - five, 10, 15 points.

WILSON: As we get older, blood vessels stiffen, he says. There's a resistance to blood flow, so the heart has to pump harder. As blood surges, those rigid blood vessels are weakened and may burst. That can lead to a stroke and heart failure.

Most people seem to have diastolic blood pressure under control - that's the bottom number, a measure of the heart at rest. It's the top number from the heart pumping, systolic blood pressure, that's the biggest problem.

An Institute of Medicine report recently found that systolic blood pressure is undiagnosed and uncontrolled in 85 percent of people who see doctors regularly. Maybe because as recently as 2003, many doctors believed blood pressure had to reach 160 before the patient was thought to have hypertension.

Research has shown that it takes years for doctors to follow new treatment guidelines. But the patient also has a part to play in putting off treatment. For 30 years, Dr. Thomas Lee has been Lee Musick's doctor. About 15 years into that relationship, hypertension crept in, then diabetes and high cholesterol.

Dr. LEE: There's an interesting little dance that goes on where both the doctor and the patient are in a little bit of denial as blood pressure goes up to 140, 150, 160.

WILSON: In Musick's case, they made a deal. Dr. Lee wouldn't put him on medication right away, and Musick would change his lifestyle by exercising, watching how much he ate, cutting out the salt and boosting potassium levels by eating a lot of fruits and vegetables.

Mr. MUSICK: The weight has been a creeping problem for me over time. I've got it stabilized over the last few years. But I wish it would have stabilized about 20 to 30 pounds less. And the diet, I definitely avoid salt, but processed meat and snacks are very favored by me.

WILSON: Musick doesn't like the idea of being on medication he'll probably have to take every day for the rest of his life. He's like many patients Thomas Lee sees.

Dr. LEE: They want to give lifestyle a chance at lowering their blood pressure. And, of course, they should, because often, if they really give it a go, they can drop their blood pressure.

WILSON: The medication sometimes makes patients feel depressed, causes dry mouth, erectile dysfunction and insomnia. Dr. Lee says sometimes the dance with patients over medication can drag on too long.

Dr. LEE: Physicians want to be the heroes. They want to be nice guys. And they say, okay, we'll give you another three months. But then some of them don't come back because they have strokes or heart attacks. We can't tell which ones are going to be the ones who are unlucky, but some of those strokes and heart attacks could have been prevented if we jumped right in and got their blood pressure under control.

WILSON: Music and Lee really work together, office visits, email. Lee will say to cut a dose of medication or add a pill. Musick will walk an extra mile to balance out a Starbuck's frappe. So far, so good.

Brenda Wilson, NPR News.

(Soundbite of music)

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