Ask the Doctors February 2018 Issue

Ask The Doctors: February 2018

Michael Rocco, MD

Michael Rocco, MD, medical director of Cardiac Rehabilitation and Stress Testing at Cleveland Clinic

Q: I have borderline elevated blood pressure and was told there are new recommendations for blood pressure treatment. What are they?

A: A continuous association exists between hypertension (HTN) and increased cardiovascular disease (CVD). For every 20 mmHg increase in systolic blood pressure (BP) above 120 mmHg, risk doubles. There is strong evidence that a lower BP target is generally better than a higher one, particularly in patients with, or at high risk, for CVD.

The new recommendations you refer to were issued in November 2017. They were designed to encourage us to take steps to control BP earlier, and they emphasize how to accurately measure BP and diagnose HTN.

Major changes in these guidelines are found in the definition of HTN and its treatment goals. People with readings of 130 mmHg or more as the top number (systolic), or 80 mmHg as the bottom one (diastolic), are now considered to have HTN. Previously, HTN was defined as 140/90 mmHg or higher. A BP higher than 120/80 mmHg is still considered normal, but levels between 120 and 129 are now called “elevated.” With this change, 46 percent of U.S. adults now have HTN, compared with 32 percent under the previous definition.

This doesn’t mean there will be a massive increase in the number of people treated with antihypertension medications, however. It is estimated that only one in five of the additional adults now classified as having HTN will need medications. Medication use is directed toward individuals with the highest risk.

A BP target of less than 130/80 mmHg, antihypertension medications and lifestyle interventions are recommended for people with confirmed HTN and known CVD, diabetes, chronic kidney disease, an estimated CVD risk of more than 10 percent over 10 years or an initial BP reading of 140/90 mmHg or higher (known as stage 2 HTN). For others without additional markers of increased CVD risk, a target of less than 130/80 mmHg and lifestyle changes are reasonable.

Ask your physician to check your BP and discuss the best way to approach your goal, based on your BP and level of CVD risk.

Q: I am an active 76-year-old man. Last year, my doctor told me that it was okay for my systolic blood pressure to be in the 150s. Is this best for me?

A: Previous recommendations suggested patients aged 60 and older be held to a BP target of 150/90 mmHg. However, several studies since 2015 showed that treating older adults to a lower BP goal is beneficial. The SPRINT trial found that a BP target of less than 120 mmHg (vs 140 mmHg) reduced heart attacks, strokes and deaths by more than 30 percent in people aged 75 and older. Overall side effects and risk of falls were not worse with intensive therapy, but there was an increase in symptomatic low BP and changes in kidney function. Blood pressures in the study were also obtained with an automated process and may underestimate the typical BP obtained in an office. Based on these studies, a recent guideline recommends people 65 and older be treated to the same 130/80 mmHg goal as younger patients—with the caveat that treatment decisions be individualized for seniors with extensive comorbidities, limited life expectancy or residing in nursing homes.

When using medications to treat HTN, we need to weigh the risks of treatment against the benefits. This is even more important in the elderly. Older individuals may be more prone to sudden loss of BP, kidney problems, blood chemistry abnormalities and drug-drug interactions, which need to be watched when trying to achieve lower targets.

Since you are active and generally healthy, you should consider having your BP rechecked and discussing treatment options based on new recommendations with your physician. 

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