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.
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!