And once again, high blood pressure is making headlines in the news: the American Heart Association and the American College of Cardiology (AHA/ACC) have just released new guidelines about hypertension.
Since this development is likely to cause confusion and concern for many, I’m writing this post to help you understand the debate and what this might mean for you and your family.
By the way, if you’ve read any of my other blood pressure articles on this site, let me reassure you: I am not changing my clinical practice or what I recommend to others, based on the new AHA/ACC guidelines.
The core principles of better blood pressure management for older adults remain the same:
- Take care in how you and your doctors measure blood pressure (more on that here),
- Start by aiming to get blood pressure less than 150/90 mm Hg, as recommended by these expert guidelines issued in 2017 and in 2014,
- And then learn more about what are the likely benefits versus risks of aiming for more intensive BP control.
Perhaps the most important thing to understand is this: treatment of high blood pressure in older adults offers “diminishing returns” as we treat BP to get lower and lower.
Scientific evidence indicates that the greatest health benefit, when it comes to reducing the risk of strokes and heart attacks, is in getting systolic blood pressure from high (i.e. 160-180) down to moderate (140-150).
From there, the famous SPRINT study, published in 2015, did show a further reduction in cardiovascular risk, when participants were treated to a lower systolic BP, such as a target of 120.
However, this was in a carefully selected group of participants, it required taking three blood pressure medications on average, and the reduction in risk was small. As I note in my article explaining SPRINT Senior, in participants aged 75 or older, pushing to that lower goal was associated with an estimated 1-in-27 chance of avoiding a cardiovascular event. (The benefit was even smaller in adults aged 50-75.)
SPRINT did not include people who have certain common conditions, including diabetes, heart failure, past stroke, or dementia. Hence it’s not clear that the (small) benefits of intensive blood pressure control would apply to those older adults who would not have qualified for the SPRINT trial.
I will come back to the SPRINT study later in the article, since it undoubtedly influenced the recent AHA/ACC guidelines. But first, a little on why the new guidelines are notable.
Why the new blood pressure guidelines are notable
The most notable thing about these guidelines is that the AHA/ACC has decided to redefine hypertension.
Whereas hypertension has historically been defined as a blood pressure higher than 140/90 mm Hg, this expert group is now declaring that a blood pressure (BP) above 130/80 constitutes high blood pressure.
For more key points from the new guidelines, see the ACC News story here: New ACC/AHA High Blood Pressure Guidelines Lower Definition of Hypertension.
The AHA/ACC is also taking a notable position regarding the treatment of high blood pressure in older adults: they are not recommending a higher BP treatment goal for most older patients.
Instead, their guidelines say “Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age) with an average SBP of 130 mm Hg or higher.”
(You can download a PDF of the full guidelines here: 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.)
This is in stark contrast to the clinical practice guidelines issued in early 2017 by the American College of Physicians (ACP) and American Academy of Family Physicians (AAFP).
Titled “Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets,” those guidelines suggest that “physicians initiate treatment in adults aged 60 years old and older with persistent systolic blood pressure at or above 150 millimeters of mercury (mm Hg) to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk of mortality, stroke, and cardiac events.”
The ACP/AAFP guidelines also recommend that treatment to a lower BP goal be considered for certain older adults, based on their cardiovascular risk and also after discussing the likely benefits and harms with patients.
Why different expert groups are issuing different guidance on blood pressure in older adults
Now, when an expert group issues guidelines, it’s never a quick or casual thing. Guidelines are always the result of a lengthy, careful process of reviewing the scientific evidence before issuing recommendations. And the healthcare professionals who review the science and create guidelines are invariably academics who are highly trained in conducting and assessing scientific evidence.
Still, the experts writing the guidelines do have their favored ways of thinking about healthcare. They also have to exercise some judgment in deciding how the science should be turned into practical recommendations.
In this case, the AHA/ACC group (the cardiologists) and the ACP/AAFP group (the generalists) reviewed the same scientific evidence. But they came to different conclusions about what to recommend to practicing clinicians.
Why did this happen? In practical terms, it looks like the cardiologists heavily relied on SPRINT to guide their recommendations. Whereas the generalists noted that it’s a good trial but only one trial, and they made more nuanced recommendations about when to consider more intensive blood pressure management.
It’s also possible that the generalist expert group was more aware of some practical realities when formulating their guidelines. Namely, they may have been more aware that in real life, working to lower blood pressure down to the minimum can take up time and energy that might be better spent addressing other important health needs a person has.
Think about it: an older person only has so much time with the doctor at each visit. And most people don’t want to — or can’t — go back to the doctor frequently. Furthermore, most older people don’t just have high blood pressure; they also have other chronic conditions, other symptoms, and other questions that need attention.
In that real-world environment, is trying to get blood pressure down to the cardiologist’s idea of “optimal” — assuming the older adult is similar to the SPRINT participants — a good way to expend the time and effort of both the patient and the doctor, as they work to help an older adult achieve better health and wellbeing?
Or might it be better for the clinician and older adult to address fall prevention, or find a way to help the older person build and maintain strength, or perhaps address depression, or any other of the many issues that are often important to better health while aging?
In short, the current divergence in guidelines reflects different groups of experts choosing to frame the scientific evidence in different ways, and also perhaps prioritizing health issues in different ways. Cardiologists are understandably quite focused on minimizing cardiovascular risk. Whereas generalists may have a broader view on an older person’s health, and everything that goes into that.
For a good commentary on this, see “Don’t Let New Blood Pressure Guidelines Raise Yours.”
It is a little unfortunate, in that it’s probably going to cause some confusion for the public, and even within the medical field. But that’s where we are for now.
What you can do: inform yourself
Given the debate and conflicting expert guidelines, what can you do?
Start by learning more about hypertension evaluation and management. Although the cardiology societies and generalist societies have made different recommendations in their guidelines, there are many important points about high blood pressure treatment that are not being contested. These include:
- Correctly measuring blood pressure is very important. The ACC/AHA guidelines recommend careful measurement with good technique, using at least two measurements obtained on at least two occasions in order to determine average BP.
- They also note that “Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.”
- Consider a person’s underlying risk of cardiovascular disease when choosing a treatment goal. People at higher risk of stroke or heart attack are more likely to benefit from hypertension treatment.
I also urge you to learn a little more about the SPRINT trial. It’s especially useful to understand who was — and wasn’t — studied in SPRINT, and just how much benefit and harm the participants experienced.
I explain SPRINT in these two articles:
New Blood Pressure Study: What to Know About SPRINT-Senior & Other Research
What the New Blood Pressure Guidelines — & Research — Mean For Older Adults
Be proactive about high blood pressure management
Regardless of which guidelines you find most persuasive, what is most important is for you to be proactive in making sure that your high blood pressure management is correctly tailored to you. This means:
- Making sure your blood pressure is correctly and reliably assessed. Ask questions if you are diagnosed or have your medication adjusted based on quick occasional office-based checks. Home blood pressure readings can be a huge help in getting BP reliably assessed.
- Talking to your doctors about what your BP treatment goal should be, and why. Goals are best determined through a conversation between health professionals and patients. Your doctor should be able to discuss with you the pros and cons of aiming for a moderate goal (i.e. less than 150/90) versus a more intensive goal. Obviously, you will be able to ask better questions if you’re informed about the key studies on high blood pressure in older adults; I describe them in my article about SPRINT-Senior.
- Getting help implementing lifestyle modifications that help lower blood pressure. Many non-drug approaches have been proven to help lower blood pressure, and they can often benefit your health in other ways.
I also recommend asking extra questions about blood pressure if you’ve had any concern about falls or near-falls. Although SPRINT did not find that intensive (compared to usual) blood pressure treatment resulted in increased falls, both groups did experience some falls and other research has linked blood pressure treatment to falls.
Per guidelines issued by the Center for Disease Control, an older adult who has been falling or seems to be at high risk should have blood pressure checked sitting and standing. You can learn more about medications that may affect falls through lower blood pressure here: 10 Types of Medications to Review if You’re Concerned About Falling.
You can also find more information on working with your doctor to address high blood pressure here: 6 Steps to Better High Blood Pressure Treatment for Older Adults.
And remember: you can learn everything you need to know about the SPRINT blood pressure trial in these articles:
New Blood Pressure Study: What to Know About SPRINT-Senior & Other Research
What the New Blood Pressure Guidelines — & Research — Mean For Older Adults
Do you have any questions or comments about managing high blood pressure in older adults? Post them below, I’d love to know what you think of this latest twist in the high blood pressure guidelines saga.
Thank you, Leslie
That was helpful.
I also read with interest yesterday’s editorial written by G. Gilbert Welch MD in Nov. 16th NY TIMES, “Rethinking Blood Pressure Advice.” He seems to agree with you.
My blood pressure used to be a happy 120/70 and now it’s crept up and is inconsistent so I am very interested in the various opinions about the SPRINT study.
Best,
Barbara Friedlich
Glad you found this helpful. I explain this in greater depth in my articles on SPRINT, but the main questions to ask yourself are:
– Are you like the participants in SPRINT?
– Are you and your doctors able to very carefully measure your BP, similar to what was done in SPRINT?
– What BP meds are you taking now? Any concerning side-effects or risks?
It is actually quite common for an older person’s blood pressure to become more and more variable as people get older, especially when they are in their late 80s or 90s. This can make it challenging to aim for intensive control.
Average age in SPRINT-Senior was 80.
Good evening Dr Kernisan,
I really like your insight on this very troubling at times research findings where the medical world flips a coin then starts using the next new information as a guideline to increase medication. At 63 which I started Losartan at 25mg 1.3 years ago 6 months later he increased it to 50mg then the report came out he said its very very mild take 100mg. Oddly when i first met this cardio he looked into my eyes to see the small veins which he was amazed on how good they looked at my age. As I was reluctant for years he did take 1 year before he put me on any medication with a 3 month cycle of visits before the 25mg’s started. Oddly again, when I would see him it was 140/90 145/90 145/95 in the docs office. As I had bouts of 150/100 at home on stressful times I also had 117/77 in the morning although less than say 138/86 which is where I am now since I decided myself to stop taking this drug. Why? After the 50mg I started to have vertical imbalance in one eye which I though was my little CDB oil I took a few times a week so I stopped. I did dabble with Viagra and stopped that as well till about 6 months ago. After stopping all of this I went a person Chiro for a car accident whiplash who was 62 and had quad bypass Kindly and diabetese which was a wake up call. He suggested a Deflame diet similar to a Dash to remove carbs and start walking and excerise as I was not doing enough, 172lb 5 8″ in pretty good shape although drank 3 beers 4 nights a week on average I needed to change my life style. As The vertical imbalance was still effecting me i realized it was coming from the lorsartan! I began to wean myself off over a week which the 50mg or 1/2 from started about 3 weeks ago when the imbalance was increased with the 100mg. Now off its very seldom except when I’m tired. AS I do not trust the doctors interpretation actually I feel they are detached in the belief that these meds are safe. As its my body and yes I have at lying down between 112/84- 138/90 a few minutes after waking up I will go to the chair after 10 min which gives me anywhere from 150/98 after 3 mins seating to 124/85.
As I have had 117/77 and as low as 112/68 its possibly once a month. On the high on 100mg I had 154/102 and also this on 50mg and 25 mg and 0mg.
In conclusion to my first visit to the cardiologist I have not changed except for the side effects which I hope will go away. As I was told by him you can stop this drug at any time and that its very very mild I decided to not see him until I have a few months of this life style change of 5000 steps a day and 3 days a week on a bike with good resistance. I write you as a person who worked in fast food for years ate unknowingly high sodium finncrisp bread like 700mg for breakfast for sometime years back. I have been told no sodium no dairy where as this new person who lived a major event suggested Butter is good, olive oil, eggs, and stay away from carbs as carbs are sugar minus fiber equaling net sugar. As I have been very good except carbs, I eat wild fish and salads more I am not sure at all why the BP folks with aging arteries can lower these numbers while I am given based on studies more meds which in effect are causing me more trouble when I think my readings are higher at his office anyway which I showed him and calibrated my device to his and showed him 125/80 at home when it was 138/88 he said not that one. This quad heart person said to me, you know the doctors see the worse number and base their meds accordingly.
My main questions would be:
At 63 Male decent weight like a 26 index what is a morning lying down acceptable number? Sitting up 10 min after wake up? Evening in bed for 5 min lying down.
Is high blood pressure constantly high as mine is not even though at the doc and on some days with stress it does go 150/99 although only a few times a month. Should I be on medicine?? I say No! As It has been 125/84 this morning sitting yesterday it was 152/98 then the longer I sit the lower it goes say in the mid 130’s upper 80’s on these days.
I have an omron wrist which his mercury was close to the same.
In conclusion for me,
My walking and bike little work outs help, I also stopped all beer after he told me 3 beers is like eating a loaf of bread in carbs so I ended that. He says if you drink only straight with now mix is best or white or red wine which I have stopped which showed in a blood test last year a huge spike from beer as it became a favorite. Tri’s went from 140’s to 222 Cholesterol 225- 272. 30 days later after no drinking the tris were 115 and Cholesterol 215 which had me see this was also effecting my BP.
I assumes I have been in the 270’s since my 30’s as 25 years ago a doctor wanted me to be on lipador when I lived in Canada.
Had an echo cardiogram 5 years ago which that doc said you look ok to me.
I’m starting to see the business side of the drug dispensing with ease when I may not have very really needed it with my eye veins looking good as they did.
Thank you for reading!
Ray
Kudos to you for making all these lifestyle changes, and for being so proactive about your health and blood pressure. It sounds like you are on the right track. Re your question about lying down BP, I don’t know the answer, the large study SPRINT was done checking BP with people sitting. Of note, they sat quietly for 5 minutes and then in the study BP was checked 3 times in a row. A wrist monitor is much more sensitive to arm position than an arm cuff, I would recommend checking BP with an arm cuff if you can.
I understand not wanting to take medication, if after carefully measuring you find that your BP is often above 150, I think it would be reasonable to consider a small dose of BP medication. If losartan didn’t work well for you, there are other classes of medication to consider.
I am all for less medication, just hate to see people overly avoiding it too. Good luck!
Great article!
I’m glad to read this – that it doesn’t apply to elderly, since I mentioned the new higher blood pressure guidelines to my dad’s doctor and he said that he absolutely agreed that older people should not be taking so much bp medicine, because they might fall. He has lowered the dose that my dad takes and said that he could even stop it if he wanted. Now MY problem is that I have orthostatic tachycardia and the doctors tell me that my very low blood pressure is ‘great!’
You probably have orthostatic tachycardia because your BP is TOO low, the body has to compensate when you stand up, BP lowers more, thus your tachycardia
I assume the low blood pressure is a chronic condition. (New low blood pressure can be the sign of a serious illness.) If it causes symptoms, it can be difficult, especially as one gets older.
The Mayo Clinic has a decent page explaining causes of low blood pressure here. Good luck!
High BP is not my problem. I’m concerned by the very slow ( four-five years) decline in my diastolic BP. It’s currently in the low 60’s. This change occurred in my mother and is occurring in my younger sister. I’m in my late 70’s.
It is extremely common for diastolic pressure to decrease as people get older. There are no clear data that provide guidance related to the minimum diastolic blood pressure that can be tolerated. Here are two articles; the first is available in free full version:
Hemodynamic Patterns of Age-Related Changes in Blood Pressure (1997)
Aging and pulse pressure widening: the inseparable duo?
Generally I don’t pay much attention to the diastolic BP of my patients, because it is low in most of them. Instead, I focus on assessing their systolic BP and also I check to see if their BP drops when they stand up.
Thank you so much for your inputs and concerns for the elderly. I am almost 80 and have trouble with most BP medications tried. Either does’t work or side effects. I would be interested in the non drug approach you mentioned. I appreciate your articles .
The non-drug approaches are basically to: avoid tobacco, lose weight (if overweight), increase exercise, consider stress-reduction and anxiety reduction techniques such as meditation or mindfulness, treat sleep apnea if present, and make changes to diet. A lower salt diet works for some but not all. The Dietary Approaches to Stop Hypertension diet has been shown to reduce BP.
More detailed nutritional approaches are described on sites such as NutritionFacts.org; search for “hypertension.”
I mainly recommend non-drug approaches because they tend to be very good for many other aspects of health while aging. However, in the vast majority of people, attempting them only results in a small decrease in blood pressure. (For instance, the DASH diet was found to reduce systolic BP by 7mm Hg.) This is in part because losing weight or significantly increasing one’s exercise habits is often hard to do, or sustain.
In terms of your own blood pressure and history with medications, I would say: how high is it? If your systolic is not usually above 150, the cardiologists might complain but the geriatricians will often decide it’s good enough.
If it is higher than what you and your doctor think should be your goal: have you been sure to check carefully, with good technique? Have you tried checking at home? Perhaps your true BP isn’t as high as you think. (See Choosing & Using a Home Blood Pressure Monitor, & What to Ask the Doctor)
Re the medications, some people are indeed very sensitive and prone to experience side-effects. I have treated a few individuals like this. We have sometimes been able to make medication work out, by starting with/using very low doses, and also by trying several different medications in a given class before giving up on that class of blood pressure medication.
Hope this helps.
Great article. I am a patient advocate in Mexico working largely with a geriatric expatriate population. One of the greatest causes of morbidity is a fall at night on the way to the bathroom
Many older men in particular take medication to reduce the frequency of urination at night due to prostate issues. The medications for this can cause sudden low blood pressure especially on standing up. It does not take much to thought to realize a baseline lower blood pressure combined with a sudden lowering of pressure when getting up in the night to urinate can and will lead to more falls and fractures in the older population.
I love your blog and post from it frequently. Deborah Bickel for BeWellSanMiguel.com
Yes, those medications for the prostate are in a class called “alpha-blockers.” They do often cause BP to drop with standing and have been associated with falls. I cover them and other medications that affect blood pressure in this article: 10 Types of Medications to Review if You’re Concerned About Falling.
Personally, in older people who have been falling, I tend to be concerned about BP meds if their sitting systolic BP is less than 120. I will also have them stand and check to see if the BP is dropping a lot, or falling to less than 110.
Thank you for sharing these articles, I appreciate it!
Thanks for a great article and the attached references.
You’re very welcome!
Not really for this post but could you please write something about the good and bad sides of statins? There seems to be growing evidence that they can cause much harm especially around muscle wasting (including the heart) and I have friends who are suffering as a result of – perhaps – being prescribed them.
Not sure when I will be able to write about statins in depth. Briefly, as best I can tell the public’s worries about statins are out of proportion to the harms documented in well-done research trials.
In fact, a study published earlier this year concluded that statins are associated with a “nocebo” effect, and that people are more likely to experience muscle pains when they know they are on a statin. (Whereas when participants are in a blinded randomized trial, the proportion of people getting muscle pains is the same whether they get the statin or not.) You can read more here: Statin side-effects only felt by those who believe in them – study
This is not to say that statins aren’t over-used or over-prescribed; they probably are. However, true cases of muscle damage from statins appear to be fairly rare.
High quality research does find that statin use is associated with a reduced risk of heart attacks and strokes, especially in people who are at higher risk (because they’ve already had a cardiovascular incident, for instance). Some experts have pointed out that the absolute chance of benefit is small, however, and that a person at “average” risk of a cardiovascular event only has a 2-in-100 chance of benefitting from taking a statin.
The Mayo Clinic has a useful decision aid here: https://shareddecisions.mayoclinic.org/files/2011/08/Statin_DA_avg21.pdf
In short, it’s not clear that statins are all that helpful to most who take them, but it also seems that in most cases they are unlikely to cause serious harm. I usually don’t spend a lot of time trying to get patients off of them, as people are often taking many other medications that I consider riskier to their health.
I’m not aware of any research to support concern about “muscle wasting including the heart.” Hope this helps.
Thank you for your posts. I have been following you for almost year. I especially appreciate your deep research with level headed interpretation. You’re a gem of a find for this 80 year old.
Thank you for this comment! I’m always glad to know the site is helpful, but especially enjoy hearing from older readers, because when I started this site, I was told that the public would not be interested in geriatrics and that older adults don’t read blogs 🙂
Thank you for all that you are doing. So much information out there really makes it hard to know the right path…. I’m 67 year old male and have been taking blood pressure meds now for over 20 years. My doctor started me when BP reached 140 over 80….. Side effects have been life altering…. if had it to do over would not have started….. I take no other drugs…..I strongly recommend anybody just considering high blood pressure meds take time and get a second professional opinion and self educate yourself….. Thanks again
Thanks for sharing your story. I would say that it’s not all that common for people to experience “life altering” side-effects from their blood pressure medications. But it does happen to some people. So sorry that’s been the case for you. I hope you’ve been able to find ways to manage your BP without suffering unduly from medications.
Dear Dr.
My mother is 97 and is in very good health. However her geriatric doctor has her on a blood pressure medicine that has reduced it to about 115/60’s. Without it, at Home, her blood pressure has been generally less than 140/ 80. My sister and i are against her being meficated especially with the updated standards. My mom gets a little nervous when going to the doctor and we suspect that the thought of seeing the doctor pumps up her blood pressure
She has a healthy diet and takes a fabulous liquid whole food based multi vitamin. Other supplements are 200 mg coq10, 200mg magnesium citrate a 2000iu vitamin D.
The doctor is not open minded and believes he is a God. We would appreciate your thoughts.
Thank you for a very informative blog.
Regards
Sam
Hm. Regardless of what is reasonable or optimal in terms of your mother’s BP management, it is definitely a problem that the doctor is not receptive to your concerns and preferences. (Hate it when they have the “God” syndrome.)
It is possible that he has legitimate medical reasons for wanting to continue your mother on her current BP meds. For instance, there are some heart or kidney conditions for which taking certain types of BP meds has been associated with better outcomes. Doctors also often have a preference, when a patient appears stable, to not “rock the boat.”
Still, he should be able and willing to engage in a dialogue to explain his recommendations better, and also, in the end they should be recommendations, not orders that you have to follow and not question.
Last but not least: we don’t have scientific studies to tell us what should be the right BP or BP management approach for people your mother’s age; people her age haven’t been studied in trials. So everything is conjecture or an educated guess on the doctor’s part and hopefully he would admit this if pressed.
Some possible approaches you could try:
– Be sure to show him her home BP readings; express concern that the BP is often low at home and say you’ve heard this can lead to falls in older adults. This can be an especially effective concern to raise if she has had any falls or near falls.
– Ask him to explain what is the downside of treating her BP a little less aggressively. Then say you (or your mother, depending on who is the medical decision-maker) are willing to accept those risks and downsides, as you have a strong preference to minimize medication at this stage in her life.
– Suggest a trial of less medication, to see how she does.
– Let the doctor know that you feel he’s not very receptive to hearing what your family’s preferences and values are, regarding medical care, and that you were hoping he’d be able to provide patient-centered care that takes your opinions into account. Tell him that this has been disappointing and that you would love to find a way to work together better.
– Look into a second opinion. Or consider switching to a different doctor.
There are also some people who just reduce or stop their BP medication on their own, but you want to be very careful with this approach, because sometimes people don’t understand all the medical reasons that their doctor had recommended a certain medication at a certain dose. (This is why it would be much better to first try to engage him in a conversation, to understand just why he feels it’s important to keep your mom on her current medications. Also why it’s good to consider a second opinion rather than attempting to manage things on one’s own.)
Good luck, I hope that your next conversations with the doctors will be more supportive.
Dr. Kernisan,
My husband forwarded me this article (I’m now following your well-written blog) because of your last paragraph. I’ve tried several different BP meds after stents last year, and have not been able to tolerate any of them. The pain has been excruciating, my brain becomes completely useless, etc. I am on ONE prescription med, Celebrex, which is the only one which has ever helped with my CFS pain. How do you go about making sure a recommendation plays nice with what patients are already on – and need? The fine print in the patient insert for the last one, Valsartan, said that 1) use with Celebrex could cause renal problems including renal failure, and 2) that the antihypertensive effects of Valsartan may be attenuated by the Celebrex. I’m wondering if that is the possible source of the horrible side effects. Ie, they fight each other. I tolerate few medications, don’t want to change the pain medication that works, and have told them so from the beginning.
The same interaction problems are mentioned online for ARBs, ACE inhibitors, and beta blockers. I don’t want a diuretic because maintaining blood volume is crucial for CFS patients (I take extra potassium daily so I don’t need IV infusions of electrolytes). How do doctors pick what to give someone? Any advice? Thank you.
Thanks for joining our community and the site.
Well, doctors often pick what to give someone based on their usual practice habits.
Probably a better approach is this: best practices and evidence-based guidelines are meant to be a sensible starting point to guide clinical care. From there, many patients do require modifications, based on their other conditions, their preferences and values, and also based on how they personally seem to respond to certain medications or therapies. A certain amount of trial and error might be necessary.
For people who seem to be very sensitive to medications or prone to have side-effects, we sometimes try smaller doses. Really there is no magic formula; clinicians need to make a choice based on the information they have available and then see how it works, adjust as necessary, and so forth.
Although I can see how Celebrex and an ARB such as valsartan could interact and affect the kidneys, it’s not clear to me that taking both would be likely to cause the symptoms you describe. But of course, anything can happen, especially in people who are very sensitive to medications.
I would recommend you keep raising these concerns with your usual health care providers. Basically, you need attentive and tailored therapy, and that takes time and a good partnership between the patient and the clinician. If your current provider doesn’t feel like a good partner, you may need to look for someone else. Good luck!
Thank you for your reply – and I agree with your last paragraph. I will see the new cardiologist this Thursday (unless the nor’easter buries us too long). I’m scared, and it’s hard to plan for a visit that way. The old doctor prescribed amlodipine today (finally called me back after almost two weeks); it is one of the ones I had such problems with last year. And prescribed a bigger dose this time! Definitely not listening.
Dear Dr. Kernisan,
I am very concerned over starting BP medicine. I am 67 years old and my readings in my opinion are well within the limits for my age and overall health. I too have reactions to all medications including vitamins. I was diagnosed two years ago with CLL and am “wait and watch”. I have a WBC of 30 with no other symptoms and my other blood counts are still good. I do not want to take any medication in case I have to start treatment some day. My readings this week have been 132/85, 125/87, 132/89, 143/85 and so on. I do not think I need to take a BP med. yet. I am 90 LBS. do not drink or smoke and I am very active not necessary in “exercise” but am going from morning till night. I take Thyroid Med. and Ativan to sleep. I just feel very strong about not taking anything yet. What is your opinion?
Well, my opinion is that the health provider’s role is to help patients make an informed decision, rather than mandating what a patient must do.
Your BP readings, for the most part, are not alarmingly high, most are close to a systolic of 130. So if you have a strong preference to not take blood pressure medication, it seems to me that it’s a reasonable approach to focus on lifestyle management to manage BP and cardiovascular risk.
On a different note: the sedative lorazepam (brand name Ativan) is a medication that can affect balance and thinking, and in geriatrics we generally encourage older adults to consider reducing it or tapering off if possible. This is a process that can take months or even years to do, but it’s much better to attempt it earlier rather than later. You can learn more about the risks of Ativan here:
How You Can Help Someone Stop Ativan
Good luck!
I was on BP med of adalat (nifedipine cc) for 20 years. I am now 69. I maintained my BP at 120-130/70-80. I moved and have new doc. She says no one prescribes adalat any longer and moved me to Irbesartan. Now I am at 179/100 and thereabouts. What is your advice about moving back to the other? I have no history of heart problems or other issues. I am admittedly 20 lbs. overweight. Thank you for any morsel you can pass along.
Hm. Well, long-acting nifedipine is perhaps less “in” than newer medications, but as far as I know, it’s never been proven to be harmful or problematic in its long-acting form. It’s a dihydropyridine calcium channel blocker, which is one of the classes of medication that’s considered a reasonable first choice for treating hypertension.
Especially if you were doing well on this medication before, I think it would be reasonable to talk to your doctor about whether you might be able to switch back. You may also want to ask if there is a particular reason she thinks you should be on irbesartan or a similar medication. (That class of medication is sometimes recommended for diabetics or certain types of kidney disorders.) Good luck!
Hello Dr kernisan,
Thankyou thankyou so much for your blog , I live in Australia and my mother of 82 has been suffering ptsd from a traumatic life ,you have been a life saver with fantastic advice and information . You and your blogs are so valuable to all of us seeking hope,advice and comfort.
Thankyou
Zita
Thank you so much for leaving this lovely comment. I’m delighted to be helpful and am so glad you’re finding the site’s information useful.
I too think your site is very helpful. I am male, live in the UK and am 68 next week. For approaching 20 years now I have been taking a combination of Candersartan (currently 32mg) and Lercanidipine (currently 20mg) and during a week in August, I measured my Blood Pressure (generally) 3 times each day with 2 readings being taken each time . All 34 readings were from a seated position in my left arm and they averaged 138/86. Individual systolic readings could be as high as 152 or as low as 117.
For a long time (20 years at least) I have also had a slight hand tremor and in the Spring, in particular, I was suffering from intermittent dizziness. Accordingly, I was referred to a specialist to see if I might possibly have Parkinson’s. Both my doctor and the specialist found a hint of cogwheeling affecting my left upper arm. However, the specialist thought that I have a benign dystonic tremor. I have been referred though for a DAT scan and I am waiting for this to take place. The specialist did wonder if my intermittent dizziness was due to fluctuating blood pressure rather than any neurological issue.
As I get older, I am naturally concerned about falls. I should be very grateful for your thoughts as to whether I should be thinking about asking my doctor to make any changes to my medication. I should say that I also take Amitryptyline (10mg), one or two tablets each night to deal with a painful back. I have been taking this for about 3 or 4 years and it helps. Until I started taking it, I was routinely waking up at about 4.00 am in pain. Taking this medication, I am able to sleep through until a reasonable time although when I do wake up it is with a back pain which is relieved when I get up and start moving about. X rays on my back have shown spondylotic changes which I understand are part of normal ageing.
Looking forward to hearing from you.
Alan
Sorry for delayed reply.
If you are wondering whether blood pressure is contributing to dizziness, I would recommend asking your health providers to check your BP sitting and standing. Usually we presume that it’s a drop when standing (or generally low BP when standing) that might cause dizziness.
Amitriptyline is a medication which is anticholinergic. This means it slows down brain function somewhat, and is sedating. Whether this class of medication really increases fall risk is less clear, but because of the effects on brain function, we generally recommend that older adults avoid or minimize this medication. Of course, if it’s the only way for you to get a decent night of sleep, you may conclude that the benefits (which you are enjoying now) outweigh the risks.
For more on medication and falls, see here: Preventing Falls: 10 Types of Medications to Review if You’re Concerned About Falling.
I also offer a mini-course on fall prevention. Good luck!
I am 66 and new to chasing the rainbow of lower BP. Personally I was relieved to read that “150 sys is a good target” for BP. While I realize that many doctors have good intentions, they seem to ignore the impact of the debilitating side effects that most if not all BP meds have on our lives. We get dizzy, can’t work, weakness, tire easily, nausea, etc. etc. Not to mention the stress imposed to measure and achieve the BP numbers of a 20 year old athlete. If that is the best we can do, we really do have a long way to go to achieve a balance of quality of life vs “healthy” life.
Thanks for sharing these thoughts. Yes, I agree that it’s important to balance quality of life with the work (and worry) of trying to get BP lower.
I do think there is generally more chance of meaningful benefit when people control their BP earlier in life (e.g. your age) than later (e.g. late 80s and later).
Your health provider should be able to help you determine what is a suitable BP goal for you. Generally it depends on a person’s medical history, particular circumstances, response to attempts to control BP so far, and of course, their preferences and values when it comes to medical care.
For people in their 60s, unless they are frail or have a lot of illness burden, it’s often reasonable to aim to get systolic BP down to the 140s or even 130s. But it does depend on how much work that requires.
Good luck!
Last October I posted on your website about my medication for hypertension (Candersartan, currently 32mg, and Lercanidipine, currently 20mg) and mentioned the slight hand tremor and intermittent dizziness I had been experiencing. You kindly let me have some thoughts for which I was very grateful.
I have just had the result of a DAT scan which confirms my specialist’s diagnosis of benign dystonic tremor. I am, of course, very relieved that I do not have Parkinson’s. The specialist has suggested that in view of my fluctuating blood pressure I might take Primidone at 25 mg up to 50mg rather than a beta blocker to help with the tremor. However, the tremor doesn’t bother me enough at present to justify taking Primidone especially because it can have side effects, mainly of sedation.
Now that the Parkinson’s issue has gone away, I intend to look into the issue as to whether my blood pressure is contributing to dizziness, I have just bought an Omron blood pressure monitor (very similar to the one you recommend) and will check my blood pressure regularly over the next week or so standing as well as sitting as you mentioned in your reply to my last post.
Thank you also about your comment concerning Amitryptyline which I take for a painful back and I intend to see if I can get by on one 10mg tablet at night rather than the two I have generally been taking.
Thank you for the update. If you have been concerned about dizziness or falls, I think you are right to be careful about starting any medication associated with sedation or dizziness. Good luck!
Dr. K,
Thank you so much for your commonsense portrayal of the divergent medical guidelines for high blood pressure. I am a very active fully employed 70 year old retired Marine aviator. 6′ 1″ tall/180 pounds. My lifestyle includes exercise: free weights and cardio. For this, my blood pressure is a bit high but below the 150/90. I have been advised to track my blood pressure and to consider going on blood pressure meds. There are no indicative high blood pressure issues. The meds are something I don’t want because my health, energy and physical fitness are excellent. My view, we don’t own our bodies. We lease them from the almighty. Thus, I am into care and feeding when medicine is not directed. Your article is convincing and most helpful. I will track, pay attention, continue exercising and respect the gift of life.
Tom Brannon
Thank you for your comment, I’m so glad you found the article helpful. Good luck and take care!
Thank you so much both for this post and your willingness to respond so personally and at length to those who comment.
Found the post when wondering about bp guidelines and how to consider them
I am a very healthy 63 yo not on any meds or supps with an average bp 130s/80s. Been watching and wondering.
What do you think of coq10 and magnesium? I have paternal history (and sibling) with heart disease.
I am a healthcare provider (certified nurse midwife) and found your approach super refreshing and evidence based. Love it.
Glad if the info here is helpful. Your BP is not very high but it’s certainly possible that implementing some lifestyle changes might bring it down a little.
I haven’t personally used coenzyme Q10 with patients. (I rarely recommend supplements, in large part because the production and quality is poorly regulated in the U.S.)
However, the evidence for coenzyme Q10 has been evaluated by the Cochrane group (they do well-respected reviews of the literature), see here:
Blood pressure lowering efficacy of coenzyme Q10 for primary hypertension.
Their conclusion is that there is “moderate-quality evidence that coenzyme Q10 does not have a clinically significant effect on blood pressure.”
Magnesium has also been studied, here is a recent review:
Effects of Magnesium Supplementation on Blood Pressure: A Meta-Analysis of Randomized Double-Blind Placebo-Controlled Trials.
The effect of supplementation seemed to be small. That said, in other studies high dietary magnesium intake has been linked to lower BP, so it’s possible that this is yet another instance of where it’s better to get your nutrients in real food than in supplements.
If you are interested in trying either supplement to help lower blood pressure, I would recommend talking to your doctor to make sure there are no particular reasons it might be risky. Magnesium in particular is cleared by the kidneys and older adults with diminished kidney function can build up high levels.
Be sure to carefully monitor your blood pressure if you make changes, that way you’ll get a sense of whether it seems to be working or not. Most blood pressure medications create an effect within a few days at the most. Good luck!
My mom recently noticed her current hypertension medication is not working as well as before. I had advised her to talk to our GP on changing the medication since she has been taking the same one for almost 10-15 years. However, she gets frustrated and impatient with the trial n error method when trying new medication. Our current family doctor seems to be too passive and he often gives in to mom’s request. Like to seek your opinion on changing medication. Is there a more efficient and less damaging method than trial n error?
I’m not sure what you mean by “trial and error method.” Usually, based on usual practice and on experience, if BP is not longer adequately controlled, a health provider will recommend either increasing the dosage of current meds or adding a new medication or switching…which one depends on the specifics of the person’s health situation. (Of course, some initial evaluation to make sure the change in BP is not due to a new medical problem — or not taking current meds — is also in order before changing BP med dosages.)
Once the medication change is made, there’s no substitute for seeing how the person responds, as everyone is individual.
We are not yet able to scan people’s genome or biometrics and know just which medication and which dose will work, if that’s what you’re wondering.
If your mother is getting frustrated or impatient, it might help to gently explore that with her. What’s behind that? What does she want for her healthcare? Just some empathetic listening sometimes helps people get over some frustration and put up with unpleasant realities (e.g. that if her BP meds are changed, what’s safest is to check and make sure the new medication is at the right dose.)
Good luck!
Thank you for your articles. Question as I am a little confused. My husband is 79 and has been on Avapro 150 mg. for some time. About 20 years ago he had a AAA repair and the following year a heart attack. He was never dx with high blood pressure but after the stint for the heart attack he was prescribed the anti-hypertensive. He did have a second blockage LAD 8 years ago. I have questioned the dose many times but now he has had symptoms of dizziness when standing and sometimes walking (he is 6 feet 5 inches tall ). Just visited PCP and he took husband off Avapro for 2 weeks and revisit. He was running a BP of 114/60 to 120 and now is 120 to 125, he says he feels better, much better. Can he be off the anti-hypertensive for now on?
Irbesartan (brand name Avapro) is an angiotension receptor blocker (ARB) type of antihypertensive. My guess is that your husband was first put on it because he basically had significant cardiovascular events, and using either an ACE-inhibitor or an ARB (they are closely related types of BP medication) is often recommended for “secondary prevention.” Secondary prevention means trying to prevent another cardiovascular event in someone who has already had one; those are the people at highest risk.
I just looked it up in my clinical reference. Research suggests that using an ACE-I or ARB helps reduce cardiovascular risk, however I’m not sure we know just what the risk reduction is in someone who currently has fairly low BP. He does feel better now, which is important.
I would recommend asking his health provider to review with you what seem to be the likely benefits of resuming a low dose of ARB, versus the risk of not taking it. If your husband and his providers have taken other steps to reduce his cardiovascular risk, then perhaps the low dose of ARB would be of minimal extra benefit, and not worth the burden of his feeling dizzy.
I would also recommend asking the PCP to review all your husband’s medication, with an eye towards identifying others that might contribute to dizziness. Good luck!