The American Heart Association (AHA) encourages everyone to
“know his or her numbers”. One of the numbers that the AHA wants us to know is
the blood pressure. The AHA recommends that the blood pressure be kept under
120/80. Is that the right number? Is that the right level for blood pressure
for everyone? If not, what is the “right” number for the blood pressure?
For those without established high blood pressure
(hypertension), yearly blood pressure checks are recommended. If the blood pressure is over 140/90 on three
separate occasions, weeks apart, in a person who is not currently ill, then
hypertension is diagnosed and treatment for high blood pressure is started. It is very important to measure the blood pressure
correctly. Often, the blood pressure is elevated in the doctor’s office (called
“white coat hypertension”) and checking the blood pressure at home is
advised. To do this properly, one must
sit quietly for 15 minutes, with the arm in a relaxed state, propped on a table
or armchair and at the level of the heart.
It is recommended that two to three blood pressure measurements be
obtained and averaged to determine a true number.
For those with established hypertension, two trials and some
recent expert opinions are important to know.
The SPRINT trial split 9000 hypertensive patients into two groups; one
group was treated to a blood pressure under 120, the other to under 140. The
under 120 group had less heart failure and deaths due to heart disease. The
trial concluded that hypertensive patients be treated to a blood pressure under
120. However this conclusion has not yet been universally accepted due to
several factors. The under 120 group was taking more medications (an average of
3 meds versus 2 for the 140 group) and had more side effects from medications
(falling, low blood pressure and kidney problems). In addition, the method used to measure blood
pressure was very vigorous and may not be representative of blood pressure measurements
in the real world. Lastly, SPRINT did not include diabetic patients.
The ACCORD trial was designed for the diabetic hypertensive
patient. This trial split 4000 patients into two groups as well: one group’s
blood pressure was treated to under 120, the other to under 140. The theory was that diabetic patients are at
high risk for heart disease and that treating aggressively (to under 120) would
be better. In fact, the trial found no difference between the groups. It
concluded that diabetic patients should be treated to under 140, as the more
aggressive target didn’t add any benefit.
What is the blood pressure target for the older hypertensive
patient? In 2014, the Joint National Commission changed the blood pressure goal
from under 140 to under 150 for those over 60 years old. In January 2017, the American College of
Physicians published an expert opinion document agreeing with treating patients
older than 60 to under 150. However, an
analysis of patients in the SPRINT trial who were over 60 years old showed that
they too had less cardiac problems when treated to under 120 compared those treated
to under 140. Lastly, in February 2017, a
trial following 10,000 older hypertensive patients showed that treating to a
blood pressure less than 140 decreased the risk for major cardiac events and
deaths.
So, what is the right blood pressure number for the
hypertensive patient? Clearly there is no single best number for all patients.
There is a lot of disagreement on the blood pressure target between trials and
between experts. For now, the best guidelines are the following. Diabetic
hypertensive patients should be treated to a blood pressure under 140.
Nondiabetic hypertensive patients under age 60 should be under 140 and those
who are younger (around 50 years old) or with other significant risk factors
for heart disease should be treated to a blood pressure under 120. Nondiabetic patients older than 60 years old,
definitely should be treated to under 150 and possibly under 140. As all blood pressure medications work and
all have their side effects, the best way to manage high blood pressure is for
the doctor and the patient to work together. The doctor should try to get the
patient’s blood pressure to a proper goal while simplifying the medication
regimen (taking meds once or twice per day) and minimizing the side effects.
The patient should faithfully take medications, check the blood pressure at
home, report side effects and follow agreed upon life style modifications. The best blood pressure treatment requires
constant collaboration and negotiation between the doctor and the patient.
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