Understanding the Guidelines for High Blood Pressure
High blood pressure (hypertension) is among the most under-diagnosed and under-treated health conditions in our country, affecting one in three adults. It’s a major independent risk factor for coronary artery disease, heart failure, stroke and kidney failure, with an estimated 67 million adult sufferers in the U.S. Accounting for 18 percent of cardiovascular deaths, hypertension is a major health care burden and costs us more than $47.5 billion each year.
First, a little background. Hypertension means a blood pressure reading above 140/90 mmHg (millimeters of mercury). In general, there are four main blood pressure categories: normal blood pressure (below 120/80 mmHg), prehypertension(120-139/80-89 mmHg), stage 1 hypertension (140-159/90-99 mmHg), and stage 2 hypertension (≥160/100 mmHg). The European Society of Hypertension (ESH) adds another category, stage 3 hypertension, for blood pressure ≥180/110. If your readings fall into two categories, your correct category is the higher one.
Several sets of hypertension management guidelines have been published in recent years. Virtually all the guidelines have struggled with one aspect of hypertension management: age. Age is a powerful risk factor related to systolic blood pressure (the first number in the reading) and cardiovascular death. Current guidelines have categorized age groups around 60 years, suggesting different diagnostic thresholds and drug choices.
The most recent Joint National Committee (JNC) 8 made changes in its guidelines in 2014, primarily defining the age of the elderly as 60 or older and establishing an arbitrary threshold for treatment at 150 mmHg for this population. This change remains controversial because the clinical evidence supporting this recommendation was sparse and was based on just a handful of less persuasive clinical trials.
Some recommendations from JNC 8 for those without other health complications (like kidney disease or diabetes) are as follows:
1) Start drug therapy to lower systolic blood pressure of ≥150 mmHg or diastolic blood pressure of ≥90 mmHg for the general population at age 60 or older.
2) Start drug therapy to lower systolic blood pressure of >140 mmHg or diastolic blood pressure of >90 mmHg for those younger than 60. (Based on available evidence, the recommendation for patients aged 30 to 59 years is strong.)
The most recent ESH/European Society of Cardiology guidance is extremely long and unduly complex. These guidelines recommend, for example, for individuals older than 80 years with an initial systolic blood pressure of ≥160 mmHg to reduce to between 150 and 140 mmHg, provided they’re in good physical and mental conditions.
Future guidelines will come from the American Heart Association/American College of Cardiology. I believe the new guidelines will be more widely accepted and more evidence-based, rather than based on expert opinion.
Their current guidelines recommend a blood pressure goal of <140/90 mmHg in patients younger than 80, particularly those with coronary artery disease, peripheral vascular disease, abdominal aortic aneurysm, stroke or mini-stroke (TIA). Patients older than 80 should have a blood pressure goal between 150 and 140 mmHg, which is also recommended by European guidelines.
What patients and physicians need to realize is that hypertension is an independent and significant risk factor of cardiovascular disease regardless of age or associated health conditions. Each 20 mmHg increment in systolic blood pressure doubles cardiovascular and stroke mortality over a 12-year period.
New evidence supporting lower targets comes from the Systolic Pressure Intervention Trial, an NIH-funded study known as Sprint, that ended more than a year early in 2015 because of conclusive positive evidence. Sprint demonstrated that those who were treated and reduced their blood pressure to <120/80 mmHg had significantly fewer serious health problems than those whose target was the more generally recommended level of 140/90 mmHg.
Following a low sodium, low fat diet (less than 2.4 g/day) rich in fruits and vegetables, maintaining normal body weight (Body Mass Index of less than 25 kg/m2), aerobic exercise for 30 minutes at least four days a week, and limiting alcohol intake (no more than two alcoholic drinks/day for men and one drink for women) can help reduce hypertension.
Lifestyle changes can significantly lower blood pressure and in turn the need for medications and antihypertensive therapy, which can have serious side effects.
Your doctor will begin medical therapy to keep you at your goal blood pressure, if necessary. Following this therapy, along with lifestyle changes, is critical to lowering your blood pressure and maintaining a healthy level.
The type of medical therapy prescribed depends upon severity, race and associated medical conditions. The major classes of antihypertensive medications, which have proved very successful, include thiazide diuretics (water pill), beta blockers, calcium channel blockers, angiotensin receptor blockers, angiotensin converting enzyme inhibitors and renin inhibitors. Talk with your doctor to find out more.
Patients who also monitor their blood pressure at home have better control of their hypertension. Home monitoring provides more accurate information of your overall blood pressure control and helps your healthcare provider better modify treatment, as needed. The American Heart Association recommends home blood pressure monitoring for all patients diagnosed with hypertension.
You should calibrate your blood pressure monitor at the doctor’s office to confirm accuracy and consistency of readings. Also important is measuring resting blood pressure and maintaining a log of readings that can be shared with your doctor during your visit. These simple steps can help improve your health.
Hypertension continues to be poorly controlled in the U.S. despite the fact that this condition is treatable. Patient education and lifestyle changes play important roles in managing hypertension. Following medical therapy and home blood pressure monitoring are also critical to ensuring optimal control.
The good news is that when well controlled, those with hypertension will have a significantly better quality of life along with reduced long-term morbidity and mortality.
(Reference sources for this article are posted below.)
Anay Pradhan, M.D., a board-certified physician in internal medicine, cardiology and interventional cardiology, completed his residency and cardiology fellowship at Penn State University and interventional cardiology fellowship at Brown University. He sees patients at Brandywine Valley Cardiology in Thorndale and is a member of the Interventional Cardiology team at Brandywine Hospital.
Understanding the Guidelines for High Blood Pressure – References
Anay Pradhan, M.D., Ph.D.
References for this article:
- ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, et al. J Am Coll Cardiol 2011;57:2037–114.
- 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, et al. Eur Heart J 2013;34:2159–219.
James PA, Oparil S, Carter BL, Cushman WC, Dennison- Himmelfarb C, Handler J, et al. 2014 evidence based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507–20.
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