Blood Pressure

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New targets redefine high blood pressure
December 19, 2013, 10:22 AMPrint
By Elizabeth O'Brien

New guidelines could bring a sea change in the way that millions of people age 60 and over are treated for high blood pressure. If doctors put them into practice, it could mean that fewer older people will take medication to control the condition.


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Some patients may be able to do without drugs.
Currently, many people whose blood pressure registers above 140/90 take medication in order to lower their pressure below that target. The new guidelines, published on Wednesday on the website of The Journal of the American Medical Association, increase the target blood pressure in people 60 and over to a top number of less than 150 and in turn, raise the threshold for taking medication in this population. (The goal for the bottom number remains less than 90.)

A New York Times story on the new guidelines quoted an expert who estimated that millions of people age 60 and over have blood pressures between 140 and 150 and thus could stop taking medication under the new guidelines.

Hypertension, or high blood pressure, remains one of the most important preventable contributors to disease and death, wrote the 17-member committee of doctors and academics, which formulated the new guidelines after an extensive review of randomized controlled trials. Drug treatment can help alleviate the risk of heart attack, stroke, renal failure and death from this condition.

However, hypertension medications can have side effects that counteract some of the benefits, including weakness, leg cramps, fatigue, attacks of gout, and impotence, according to the American Heart Association.

The blood-pressure target for those younger than 60 remains less than 140/90. The committee noted, however, that that target isn’t well-supported by evidence, because studies have tended to focus on older people, who are more vulnerable to heart failure and stroke.

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5 Things to know about the new blood pressure guideline
By Deborah Kotz / Globe Staff
A panel of experts has published new treatment guidelines for the management of high blood pressure that could significantly change the way doctors think about hypertension and determine whether or not to prescribe medications. Here’s what you need to know about the new recommendations, published in the Journal of the American Medical Association.

1. The threshold for treating high blood pressure has been raised for older Americans. If you’re over age 60, you may not need treatment for hypertension unless your systolic blood pressure (the top number of the measurement) is 150 or above, according to the new guidelines. That’s instead of the previous recommendation to treat at levels of 140 or higher. The diastolic pressure (bottom number) is considered high enough to treat if it’s 90 or higher, which is the same as in the previous recommendations.

“We did not find evidence for additional health benefits in achieving a level of 140 instead of 150 in those over age 60,” said Dr. Paul James, co-chair of the guideline committee and chair of family medicine at the University of Iowa Carver College of Medicine. “We were particularly concerned about medication side effects in the elderly population like light-headedness and dizziness, which increases the risk of falling and broken bones.”

What’s more, older people tend to be on multiple medications for various conditions such as diabetes, arthritis, and high cholesterol; some of these, James pointed out, could interact with blood pressure drugs to increase side effects.

2. Drugs should no longer be used in older Americans to drive down their systolic pressure to below 150. That recommendation was made after the committee reviewed a number of recent large clinical trials and found that driving levels down closer to a healthy blood pressure reading—120/80—did not prevent additional strokes or heart attacks and led to more side effects from the medications. Older patients who are currently achieving those lower levels on their medications without side effects, however, can stay on the treatment regimen that’s working for them, the guidelines state.

3. Adults under age 60 should aim to have their blood pressure below 140/90.

This recommendation remains unchanged, with one exception. Those with diabetes or kidney disease, regardless of their age, should also now aim for systolic blood pressure levels of below 140 instead of the previous recommendation of below 130. “Again, we didn’t find evidence to support the need to get to this lower blood pressure for those with special health conditions,” James said.

4. Lifestyle changes to lower blood pressure should be emphasized along with medications. These include following a low-sodium diet, losing excess weight, daily exercise, and a diet focusing on fruits, vegetables, and whole grains. The guideline committee referred doctors to a new heart disease prevention guideline issued by the American Heart Association outlining specific advice doctors should provide to patients.

Dr. Randall Zusman, director of the division of hypertension at Massachusetts General Hospital Heart Center, who was not involved with writing the new guidelines, wondered why the authors did not include lifestyle recommendations specific to lowering high blood pressure such as relaxation techniques. His center offers a stress management program for hypertensive patients to teach them ways to elicit the “relaxation response,” which lowers blood pressure and heart rate.

5. Expanded array of drugs recommended as a first line of treatment. Doctors should now prescribe any of four classes of drugs: thiazide-type diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers to treat high blood pressure in those experiencing it for the first time. African Americans, however, should be prescribed calcium channel blockers or ACE inhibitors first because those medications are more effective at lowering their blood pressure. Beta blockers should no longer be prescribed as a first treatment of choice, the guidelines state, because a recent study found that patients who took them had a higher risk of having a stroke or heart attack, or of dying from heart disease than those who took other blood pressure drugs. more