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.
Catharine says
Recently I came across a video from a British cardiologist Sanjay Gupta. He said it’s less important to focus on numbers than on overall health. A healthy person with SBD greater than 150 is different from an unhealthy person with the same bp.
Along those lines, I wonder if you’ve ever written a blog post about healthy people over 70. As an educated professional, I refuse all tests and meds unless the doctor can provide research papers supporting the recommendation and I look up my own. I simply don’t trust most advice written for lay people. As a result, I don’t take meds and avoid screenings but I do exercise and meditate and am in great shape.
On the rare occasions I need doctors, it is a nightmare. Some of them act like used car sales people pushing for tests and they don’t like patients who can read journal articles. There is ample evidence that older people can be healthy.
We really need some public discussion of the problems of older healthy people, especially as more of us will be single without caretaking children. I’ve found it helps to be polite at first and then the only thing that works is some pretty salty language.
Nicole Didyk, MD says
Hi Cathy. I edited your question, as we usually don’t include links to other websites in these posts.
It’s true that the number obtained when measuring blood pressure isn’t enough to decide on a management plan. For some, a lower BP still needs treatment, if they have other risk factors for cardiovascular or kidney disease. Most medical decisions should be made on an individualized, patient-centered basis.
I hope that you’re able to find some medical education trustworthy, though. For example, Dr. K and I turn to reputable sources to inform our articles and posts, and interpret medical data in light of our training and experience.
In terms of discussion about issues facing healthy elders, I agree with you. I hope that those visiting the site “Better Health While Aging” are older adults who are healthy, or who are wanting to become healthier. You’re correct that older age itself doesn’t automatically mean a person is unwell. As you mention, many older adults’ encounters with medical professionals can feel dismissive and unsatisfying.
Thanks for visiting the site and for advocating for yourself and other older adults.
Kathy says
Hi! I am just about to turn 65 and my blood pressure was high running in the 170-160 range with mostly 80’s below for a couple of weeks. My doctor recommended starting Chlorthidone. But after reading the side effects (increased risk of skin cancer, raising blood glucose and more frequent urination) I am concerned. I have been monitoring my blood pressure first thing in the morning and right before bed. While my morning rates are averaging in the 160-150 now with diastolic staying in the 80s. But at night before bed it drops to 115-130 with diastolic mainly in the 60s. If I take my BP in the day it is near 120/75. Otherwise I am in good health, exercise daily, good blood work although my glucose is a bit high. Do you recommend I start the medication or work to drop maybe 10 pounds to see where that leads. Thank you so much for your advice.
Nicole Didyk, MD says
Hi Kathy. It’s great that you’re interested in your health and blood pressure. I can’t give you specific medical advice, but according to the American Heart Association guidelines, those with Stage 1 hypertension and at low risk for cardiovascular events could try to make lifestyle changes (like weight loss) and be screened again in a few months. Good luck!
M.T. Burke says
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?
Leslie Kernisan, MD MPH says
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!
Jessica says
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?
Leslie Kernisan, MD MPH says
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!