Are you caring for an older person with hypertension, also known as high blood pressure? Or does your parent take medication to lower blood pressure?
If so, you are probably wondering just what is the right blood pressure (BP) for your older relative, especially given the 2015 publication of the Systolic Blood Pressure Intervention Trial (abbreviated as “SPRINT”) research results.
[Looking for information related to the November 2017 new high blood pressure guidelines? See here: New High Blood Pressure Guidelines Again: What the Cardiology Hypertension Guidelines Mean for Older Adults.]
The SPRINT study first made headlines in September 2015, in part because the findings seemed to contradict the expert hypertension guidelines released in December 2013, which for the first time had proposed a higher goal BP ( a systolic BP of less than 150mm mercury) for most adults aged 60 or older.
In particular, SPRINT randomly assigned participants — all of whom were aged 50 or older, and were at high risk for cardiovascular events — to have their systolic blood pressure (that’s the top number) treated to a goal of either 140, or 120. Because the study found that people randomized to a goal of 120 were experiencing better health outcomes, the study was ended early.
For those of us who specialize in optimizing the health of older adults, this is obviously an important research development that could change our medical recommendations for certain seniors.
But what about for you, or for your older relative? Do the SPRINT results mean you should talk to the doctor about changing your BP medications?
Maybe yes, but quite possibly no. In this article, I’ll help you better understand the SPRINT study and results, as well as the side-effects and special considerations for seniors at risk for falls. This way, you’ll better understand how SPRINT’s findings might inform the BP goals that you and your doctors choose to pursue.
Here’s what this post will cover regarding the SPRINT study:
- Who was included and excluded from SPRINT, and what the research intervention involved, including the type of BP medications that were used most often
- What the actual likelihood of benefits and harms was within SPRINT, and what you might expect if you are similar to the SPRINT participants
- Why you probably need to make a change in how your blood pressure is measured before considering a SPRINT-style systolic BP goal of 120.
- What this means for new blood pressure guidelines
[Note: This original version of this post explained why I supported the December 2013 blood pressure guidelines suggesting a higher BP treatment goal for most older adults. You can still find that content in the bottom part of the post, along with a link to a handy cheatsheet I developed to help family caregivers check an older person for worrisome BP, or risky drops in BP when standing. Also, in January 2017 the American College of Physicians and American Academy of Family Practice issued joint hypertension guidelines endorsing a higher BP treatment goal for most older adults.]
Who was — and wasn’t — studied in the SPRINT blood pressure trial
Do the study results apply to you or your older relative? This is one of the two most important questions to ask yourself, when you hear exciting news about clinical research. (The other question to ask is “What’s the “number needed-to-treat,” which corresponds to your odds of actually benefiting; more on that below.)
Why? Because a well-done medical study tells us what health outcomes happened when we applied a certain intervention to a certain group of people. If you aren’t like the people who were studied, then there’s a higher chance you won’t experience the benefits that study participants did.
So who was in SPRINT? Here are the criteria the researchers used to define the study group, and enroll participants.
What the SPRINT participants were like:
- Aged 50 or older, systolic blood pressure of 130-180mm mercury, and at “increased risk of cardiovascular events.”
- At increased risk for cardiovascular disease, which was defined by meeting one of the following conditions:
- Aged 75 or older. Yep, that in of itself puts people at risk.
- A 10-year risk of cardiovascular disease of 15% or greater on the basis of the Framingham risk score. You can check your own Framingham risk score here; you’ll need to know your total cholesterol, HDL cholesterol, and systolic blood pressure.
- Chronic kidney disease, defined by an estimated glomerular filtration rate (eGFR) of 20-60.
- Clinical or subclinical cardiovascular disease other than stroke. This means things like a history of heart attack, bypass surgery, peripheral artery disease, carotid artery stenting or surgery, or any testing considered “positive” for cardiovascular disease. For a full list of criteria, see the published study’s supplemental materials here.
It’s equally important to consider who was excluded from SPRINT. You may have already heard that SPRINT didn’t cover people with diabetes or stroke, but the exclusion list is much longer than that. (See the study appendix for the full detailed list.)
What the SPRINT participants were not like: Older persons with any of the following diagnoses, conditions, or circumstances were not eligible for the study:
- Diabetes
- Past stroke
- Clinical diagnosis of dementia, and/or being on dementia medication
- People residing in a nursing home. (Assisted-living was ok.)
- Substance abuse (active or within the past 12 months)
- Symptomatic heart failure within the past 6 months or left ventricular ejection fraction (by any method) < 35%
- Polycystic kidney disease or eGFR < 20
- “Significant history of poor compliance with medications or attendance at clinic visits.”
As you can see, quite a lot of common diagnoses and circumstances were grounds for exclusion from the SPRINT study.
Ultimately, 9361 people were enrolled between November 2010 and March 2013. The average age was 68, and 28% of participants were aged 75 or older.
Surprisingly to me, the average systolic blood pressure at baseline was 140, which struck me as better BP control than average older adults. And only 34% of participants had a systolic blood pressure higher than 145 at the start of the study. (For comparison, the CDC reports that only 52% of people with hypertension have it adequately controlled.)
On average, at the start of the study participants were taking two blood pressure medications.
What did the SPRINT intervention involve?
SPRINT participants were randomly assigned to be treated to a systolic BP goal of either 140, or 120.
Participants were seen once a month for the first three months, and then every 3 months after that.
To treat blood pressure, SPRINT provided all the major classes of BP medication for free, and also allowed clinicians to use other BP medications if they saw fit. Here are the main classes of medication used; I’ve organized them roughly by how commonly they were used (per table S2 of the appendix).
Blood Pressure Medications Used in SPRINT:
- Angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), e.g. lisinopril, losartan
- Diuretics, e.g. chlorthalidone, hydrochlorothiazide, furosemide, spironolactone
- Calcium-channel blockers, e.g. diltiazem, amlodipine
- Beta-blockers (encouraged for those with coronary artery disease), e.g. metoprolol, atenolol
- Alpha-one blockers, e.g. doxazosin
- Direct vasodilators, e.g. hydralazine, minoxidil
- Alpha-two agonists, e.g. clonidine
Those last three classes of BP medication were used in 10% of people or less, which makes sense as none of them are recommended as first-line medication choices for hypertension, heart conditions, or kidney disease.
What about non-drug methods to manage high blood pressure?
In the scholarly publication, the SPRINT investigators say that “Lifestyle modification was encouraged as part of the management strategy,” but they don’t provide more specifics on what modifications were encouraged or how. So it’s hard to know how any non-drug methods — diet, exercise, salt reduction, stress reduction — might have factored into this study.
Benefits and Harms Observed in SPRINT
SPRINT randomly divided participants into an intensive-treatment group, which aimed for systolic BP less than 120, and a standard-treatment group, which aimed for systolic BP less than 140.
After one year, the average systolic BP among the intensive-treatment group was 121, compared to 136 among the standard-treatment group. The intensive group required an average of 2.8 medications to reach their lower BP goal; the standard group required an average of 1.8 medications.
The follow-up period averaged about three years.
Benefits of intensive BP treatment:
During follow-up, 1.65% per year of people in the intensive-treatment group and 2.19% per year of people in the standard-treatment experienced a significant cardiovascular “outcome event”: a heart attack, a stroke, acute decompensated heart failure, or death from cardiovascular causes.
The study authors calculated that “The numbers needed to treat to prevent a primary outcome event, death from any cause, and death from cardiovascular causes during the median 3.26 years of the trial were 61, 90, and 172, respectively.”
In other words, if you are like the study participants, and if you decide to switch from a systolic BP goal of 140 to a goal of 120, over a few years you’ll have:
- A 1 in 61 (1.6%) chance of avoiding a cardiovascular event
- A 1 in 90 chance (1.1%) chance of avoiding death from any cause
- A 1 in 172 chance (0.6%) chance of avoiding death from cardiovascular causes
(For more on the wonderfully useful statistic the Number Needed to Treat, see this informative NYT article and also the website www.thennt.com.)
Harms of Intensive BP Treatment
The SPRINT investigators were careful to track side-effects and complications. They found that serious adverse events occurred in 38.3% of the intensive-treatment group and in 37.1% of the standard-treatment group.
Adverse events included problems like hypotension (low blood pressure), syncope (passing out), electrolyte problems, declines in kidney function, and injurious falls. Most problems affected 1-7% of participants, with the exception of orthostatic hypotension — which means BP dropping with standing — which affected 16-18% of participants. (Standing BP was checked at baseline, 1, 6, and 12 months and yearly thereafter.)
Although many side-effects were a little more common in the intensively-treated group, injurious falls were equally common in both treatment groups, and affected 7.1% of participants.
This finding is actually consistent with what was reported in a 2014 study of serious falls (e.g. bone-breaking falls) in older people with high blood pressure. In that study, the researchers classified people as being on no BP medication, moderate-intensity BP treatment, or high-intensity BP treatment. Moderate- and high-intensity treatment was linked to a nearly equivalent risk of falling over three years (about 8.5%), whereas 7.1% of seniors on no BP medication had a bad fall.
How Blood Pressure Was Measured in SPRINT
Blood pressure was measured a very careful way that is quite different from the way patients usually have BP measured by their doctors. Here’s what they did in SPRINT:
- Had people sit down and rest for five minutes before checking BP
- Checked BP three times consecutively, using an automated BP monitor (Omron 907)
- Used the average of those three BP measurements to assess the person’s BP and determine whether medications should be adjusted up or down.
Obviously, this is not the experience that most people have in the doctor’s office, and likely led to lower BP measurements than those taken under usual circumstances.
If you are similar to a SPRINT participant and are thinking of aiming for a lower BP goal, be sure to request that your BP is checked in a similar way. In truth, it’s a much sounder basis for changing a patient’s medications, but it’s not usual care at this time.
Does SPRINT mean New Blood Pressure Guidelines?
[Note: In January 2017 the American College of Physicians and American Academy of Family Practice issued joint hypertension guidelines endorsing a higher BP treatment goal for most older adults. These guidelines account for the SPRINT trial results.]
Briefly, no. Or in any case, not yet. That’s in part because guidelines are the result of some expert group going through a very careful process of evidence review and synthesis. So it will take a while before any reputable group can synthesize SPRINT into the existing medical evidence, and finalize guidelines to be released to clinicians and the public.
Now, that doesn’t mean that some doctors won’t be attempting to get patients to a lower blood pressure goal right away. But it’s not clear that this should be done for most patients, and at a minimum, people should know that if they are like the SPRINT participants — which they probably aren’t — aiming for the lower BP goal likely gives them a 0.5%-1.5% chance of avoiding a bad health outcome. (Whereas they will have a very high percent chance of having to take more medication every day.)
In fact, I thought it was quite funny that the NYT headline reporting on SPRINT proclaimed “Data on Benefits of Lower Blood Pressure Brings Clarity for Doctors and Patients,” because many doctors have gone on the record with a more nuanced assessment. The NYT itself published a sensible commentary by a well-regarded cardiologist, Dr. Harlan Krumholz, which I would highly recommend: “3 Things to Know About the Sprint Blood Pressure Trial.”
As Dr. Krumholz points out, most people who currently have high blood pressure would not have qualified for SPRINT. It’s especially notable that people with diabetes were excluded; that was in part because a similar well-done study called ACCORD found that intensively treating the blood pressure of people with diabetes did not reduce mortality.
(An added little twist to consider: Yet another research group has studied clinical trials that end early, and found that studies that end early usually report bigger effects than studies that don’t end early. See this JAMA article.)
Personally, I agree with Dr. Krumholz’s conclusions:
- These results should not be considered a mandate for people to run out and get treated so their blood pressures are below 120.
- The potential benefits of lowering blood pressure must be weighed against the harms.
- We need more information about the balance of risks and benefits for each person so that the choice can be personalized.
In terms of my personal practice: I see a lot of older people who are worried about falls, and a well-done study published in 2014 found that blood pressure treatment was associated with serious — as in, bone breaking — falls. (Read my coverage of this study here.)
I also find that many of my patients are struggling to manage multiple medications, and are at risk for interactions from their medications. For instance, all the medications used in SPRINT have side-effects to watch out for, and many can interact with other medications or chronic diseases.
There is indeed good scientific evidence that for those older adults who have a systolic BP in the 160s or higher, getting them down to a systolic in the 140s does reduce the chance of strokes and other serious cardiovascular diseases. (See here and here.) So it’s certainly important to identify serious hypertension in seniors, and treat it if possible.
But given the relatively small absolute benefit of aiming for a systolic blood pressure of 120, I expect that for most of my patients, aiming for a systolic BP in the 140s will remain reasonable.
Now, you are likely still wondering what’s the right blood pressure goal for your older relative. I can’t tell you for sure for your particular situation. But here’s more information on why to be careful about over-treating high blood pressure, and why I agreed with the December 2013 guidelines recommending a systolic BP goal of 150 for most seniors.
Why Seniors Should Watch Out for Over-Treatment of High Blood Pressure
In my experience, many older adults are taking more BP medication than they need, meaning they’ve reached a point at which the risks and burdens outweigh the benefits (compared with less aggressive treatment of high blood pressure).
This can cause falls or dizziness due to orthostatic hypotension, and one of the most common medication changes I implement as a geriatrician is the cutting back of blood pressure medications. (For more on orthostatic hypotension, see this article at HealthinAging.org, and also this FAQ I wrote about why elderly people get dizzy when standing up.)
If you want to read a longer article that I wrote on this topic, shortly after the December 2013 high blood pressure guidelines were released, see my post at AgingCare.com:
“What the New Blood Pressure Guidelines Mean for Caregivers“
AgingCare.com only publishes articles that won’t be published elsewhere on the web, so I can’t post the whole thing here. But here are the highlights related to the December 2013 BP guidelines:
- A higher target BP for adults aged 60 or older. The recommended goal BP is now less than 150/90, instead of less than 140/90 (which was the target recommended in prior guidelines, published in 2003).
- A higher target BP for people with diabetes and/or kidney disease. The recommended goal BP is now less than 140/90, instead of less than 130/80.
What does this mean for you, if you’re caring for aging parents or other older persons? It means you should check on how their BP has been doing.
If it’s been much lower than the numbers above, you should consider discussing the BP medications with your parent’s doctor. This is especially important if you’ve had any concerns about falls or balance. For specific recommendations on how to make sure your older loved one isn’t getting too much blood pressure medication, read my full article at AgingCare.com. I also offer tips on checking BP in this post: Why I Love Home Blood Pressure Monitors.
Last but not least, I provide more guidance on figuring out hypertension treatment here: 6 Steps to Better High Blood Pressure Treatment for Older Adults.
Related Articles:
New High Blood Pressure Guidelines Again: What the 2017 Cardiology Hypertension Guidelines Mean for Older Adults
New Blood Pressure Study: What to Know About SPRINT-Senior & Other Research
[Note: In January 2017 the American College of Physicians and American Academy of Family Practice issued joint hypertension guidelines endorsing a higher BP treatment goal for most older adults. In November 2017 the American Heart Association and American College of Cardiology issued new hypertension guidelines that do not suggest a high BP treatment goal for older adults. These guidelines account for the SPRINT trial results. I explain how to understand the two sets of guidlines in this article: New High Blood Pressure Guidelines Again: What the 2017 Cardiology Hypertension Guidelines Mean for Older Adults.]
I definitely endorse using less medications to control BP, but I seriously doubt whether 150/90 is low enough to prevent cardiovascular events or strokes. Many doctors are not happy with this new guidelines.
It’s true that there’s been controversy over the guidelines and some doctors disagree.
I’ve reviewed some of the studies in depth, and it’s very hard to prove much benefit in lowering SBP below 150. By far the greatest benefit is in bring SBP down from 170s-180s to about 150.
We can’t rule out a benefit in getting an older adult’s SBP from 150 to 130, but it’s probably a very small reduction in risk, such that you’d have to treat hundreds of people to prevent one stroke or CV event. Whereas the risk of harm from aiming for a low BP target is fairly substantial in people who are frail or at risk for falls.
J point mortality
The J-curve is a bit of technical concept for this blog. But since you mention it, I have found a decent resource explaining this phenomenon: The renaissance of the “J-shaped curve” for on-treatment low blood pressure values
Well, now we have some evidence that treating to below a systolic of 140 can benefit some older patients. As noted in this updated post, as of November 2015, the SPRINT study found that in older adults who met the inclusion and exclusion criteria (noted above in the post), treating to a target systolic BP of 120 rather than 140 led to a 1.6% absolute reduction in risk of a cardiovascular event over about 3 years.
This means 61 people have to adopt the more intensive treatment to prevent one cardiovascular event.
Some people will conclude that this risk reduction is worth the extra effort controlling blood pressure, and also worth a small extra risk of side-effects. Others, who might prefer to be on fewer medications, will decide that aiming for this extra benefit isn’t for them.
What is most important is that people make their decisions after being well-informed as to likely benefit, likely risks, and alternative treatment options (especially non-drug alternatives).
Thank you for you information. I am 73 and knew that I was overmedicated and reduced the meds on my own. I notice I still get dizzy sometimes. I will see what my doctor thinks. I know, they all got the same training and swear by it. I am in the market for a more open-ended doctor who has research more wholistic methods. Thanks anyway.
It’s great that you’re being proactive about your health. I would encourage you to look into things if you are sometimes feeling dizzy.
Have you checked your blood pressure sitting and standing, to see if it drops when you stand?
In terms of doctors, I think what’s most important is that the doctor be willing to work closely with you to find the right health management plan that works for you.
after an overnite fast bp was 129/67, 10 mgs per day bp med age 65 is this good?
Generally you want to check BP at the same time on a few different days, before drawing any conclusions about whether the current regimen is right for a person or not. If the top number is usually around 130, that’s good for many people, but you will want to ask the doctor what the right goal should be and why.
If you have any concerns about falls or overtreatment, then I’d recommend checking BP sitting and standing. If systolic BP is more than 20 points lower with standing, it’s good to let the doctor know.
Great info, Leslie. Thank you! My mom recently fell, I’ll ask about her BP and meds. Things changed recently.
Yikes, sorry to hear your mom recently fell. Being over-treated for high blood pressure is sometimes a factor, but often there are other things going on as well.
See the post “8 Things to Have the Doctor Check After an Aging Person Falls” for a list of common issues that can cause falls.
There’s a list of other posts related to falls and fall prevention here. Good luck!
72 years old on lisonpril 10/12.5 bp on waking 150 goes down within hour of rising balances out to 130 should l worry
Blood pressure does go up and down during the day, so going from 150 to 130 is not very surprising.
A drop from 150 to 130 systolic with standing is a fair sized drop. 130 itself is not very low, but if a person feels any dizziness or unsteadiness with that drop, it might be worth discussing with a doctor.
In general, you should always talk to the doctor to determine what is the right target blood pressure for a given older person — because it depends not only on age, but on chronic health conditions, fall risk, personal health history, what kind of health risks you prefer to take, etc — and the doctor should be able to explain why he or she is recommending a given target.
I generally am most concerned about BP in seniors who are having falls or near falls.
I noticed that most recent articles don’t make it into podcasts. I prefer podcasts to the written word, when available. Will you be recording more podcasts ?
I really enjoy & learn s lot from your articles / podcasts,
Thank you for your services ,
Thanks for your interest in the articles and podcast episodes!
Yes, I am planning to continue publishing a new podcast episode every two weeks. I do turn most newer articles into podcast episodes, but sometimes it takes a while before I’m able to do so.
I’m on maxide and also atenolol of 25 mg. If I take a whole atenolol, it drops my pulse way down to 55-58 many times. Is that a problem? MY bp goes anywhere from 120-140 depending upon when I take the medication and sometimes higher as it wears off.
Atenolol is a beta-blocker type of blood pressure drug, which acts in part by slowing the heart rate. Whether a pulse of 55-58 is ok for you depends on how you feel (do you ever feel dizzy or faint?) and your other health conditions; you should discuss with your doctor if you are concerned.
Beta-blockers used to be prescribed widely for treatment of high blood pressure but recent guidelines suggest that other types of blood pressure medication should be prescribed first, unless there is a specific indication for a beta-blocker (such as having coronary artery disease, heart failure, or atrial fibrillation). Some studies actually suggest that atenolol is more likely to cause problems than other beta-blockers; this review concluded that atenolol in older adults is associated with higher stroke risk.
I would encourage you to bring up your concerns with your doctor. If you don’t have a particular indication for atenolol or for a beta-blocker, you may want to ask your doctor about switching to a blood pressure medication that’s currently considered first-line, such as an ace-inhibitor or calcium-channel blocker.
(Your doctor can see the latest recommendations by viewing the UpToDate article on choice of therapy in hypertension or treatment of hypertension in the elderly. Most doctors have a subscription to this resource, and you can buy access yourself for $20/wk or $45/month; or see if your doctor is willing to print a given topic for you.)
Hi, I am 73 years old woman, I take 12.5 mg hctz, but I always worry about loosing magnesium, salt, water , potassium, may cause electrolyte unbalance. Blood work says sodium and potassium ok but how often I need blood work. Do I need to eat high potassium food like two banana, potatoes daily and magnesium rich food, how much I loose these mineral on 12.5 mg hctz, and does it cause kidney damage. Does it cause blurred vision. In winter it is hard to keep blood pressure under 140, so what to do in winter , you seems to consider all aspects not just follow strictly guide line, thanks.
Your dose of HCTZ (hydrochlorothiazide) is small. That said, it’s true that it can affect your electrolytes, so it’s good for you to be thinking of this. It is much less common for your dose of HCTZ to cause kidney dysfunction, although it might contribute to it if you become dehydrated for other reasons. I’m not aware of this drug causing blurred vision very often.
If you have been taking HCTZ for a while, your blood tests should reflect how it is affecting your electrolytes and kidneys. I would recommend asking your doctor to review the results with you and explain them. I explain common blood tests here:
Understanding Laboratory Tests: 10 Commonly Used Blood Tests for Older Adults
Be sure to ask your doctor to help you understand if your results are on the high or low side of normal. I would also recommend asking the doctor if it’s advisable for you to try to eat more potassium-rich foods.
Regarding BP control in the winter, I would first recommend you make sure that you and your doctor are using a good reliable way of monitoring BP, such as a high-quality home monitor. I’m not sure why BP would be higher in the winter, but if you are getting a good quality measurement and your BP is above goal, you will need to work with your doctor, in order to select a suitable way to try to bring it down. I explain my recommended process for managing blood pressure here:
6 Steps to Better High Blood Pressure Treatment for Older Adults
Good luck!
Hi . I am 45 years old and was taking tozaar 50 for my blood pressure . On a routine examination after a long gap my Bp readings came very high 188/100 . Doctor has advised me to change the medication and I am now taking Telma 40 AD in the morning and same medicine half dosage in the night . Now my BP readings have come to 140/90 . We did a lot of tests to determine any specific cause like heart 2d echo , kidney renal Doppler , blood tests , lipid profile etc . Only triglycerides have come high and all other tests are normal . Currently waiting for adrenaline and nor adrenaline tests results . Please advise if I need any further tests and also the best line of treatment .
Sorry but I can’t say whether you need any further tests or best line of treatment; you will need to ask doctors who can review your results in detail and otherwise work w you one-on-one. I can’t even tell you how we’d usually manage this in geriatrics because you are quite young (for us) and BP issues are different in older adults.
If you think your high blood pressure might be unusual in some way (hard to control, or worrisome features that suggest another underlying problem w kidneys or some other part of the body), and you want to make sure you’ve had a good evaluation, you can try doing some research to learn more about such high blood pressure should be evaluated. I have some information towards the end of this post on how you can do your own research, to double-check on your care and identify good questions to ask the doctor.
Some platforms such as HealthTap are designed to enable people to ask more detailed questions of doctors.
Last but not least, I highly recommend you research non-drug ways to lower high blood pressure. Dr. Michael Gregor of NutritionFacts.org recently published a book about nutrition and health, and he has a whole chapter on nutritional approaches proven to improve high blood pressure. Plus there are a variety of other lifestyle changes that can help control blood pressure. Good luck!
I am 65 years, and the only problem I have been having is hyper-acidity. Every time I had visited a doctor or some other problems like stomach upset etc., the doctors had checked my bp and it had always been normal. But a few months ago, I visited my family doctor and my bp was 150/90, this after some hectic running around on personal business during the earlier three days and no sleep at all for more than 36 hours, of which 4 hours were in a flight. An ECG and X-ray were taken and both found normal. I visited the doctor again after two days, which were also very busy days with a lot of moving around, and my bp was about the same. The doctor diagnosed this to be confirmed hypertension and put me on 20mg per day Telemisartan. After returning home, I have been checking my bp regularly at different times of the day, most of the times its between 125 to 135/78 to 82, for the past three months, without starting the medication. I am now not sure if I need to start taking the medication or not. Thank you
I would recommend you bring your home BP readings to your doctor. Studies have found that relying on just a few office-based measurements often incorrectly classifies people as hypertensive, compared to several home BP measurements. In any case, it sounds like BP medication would be unlikely to provide much benefit.
Ideally every patient would decide for themselves (with the assistance of doctors) whether a certain likely benefit is worth the hassle and risks of a given treatment. Your BP sounds like it’s usually not very high, which means the likely benefit of treating with medication would be quite small.
I would also recommend talking to the doctor about non-medication ways to optimize your cardiovascular health. Certain diet and exercise changes can lower BP a little, plus they have many other benefits for health.
Thank you Doctor, for your very valuable advise.
After taking losartan for BP, I developed an occlusion in my left eye. What can you tell me about losartan and blindness. Thanks.
I am not aware of a relationship between losartan and blindness, and when I searched on Google scholar (which you can try as well), I didn’t see anything turn up.
Anything is possible but it sounds like a highly unusual connection. If you’ve had an occlusion in your eye, I would recommend talking to an eye specialist about what might have provoked it, and how such events can be treated and/or prevented.
Thank you Doctor, for this awesome and valuable advise. Nice blog
Interesting, especially the manner in which BP is measured by doctors. I had my BP measured with arm hanging down my side, while the Omron is pumping being interviewed to save time (the most common practice), when I was sick, on my arm where I had rotator cuff surgery and biceps tenodesis, in a ten-minute consultation because the doctor was running behind schedule. Always once only due to time constraints. I booked longer appointments but this seems to bore the doctors just to measure blood pressure and the same happened even during longer appointments. My Omron device at home has been consistently higher than measurements taken by doctors with a sphygmomanometer. Doctor standing looking down at the scale while taking measurement with sphygmomanometer. When BP was higher than 140/90 the device pumped up to 200/something which is very painful making me gasp. Every doctor so far has ignored this. I am 67, my blood chemistry is perfect, including weight and fitness. There ought to be a placard in every doctor’s clinic to remind doctors (and patients) on how to measure BP correctly. Once I was prescribed BP meds and when I checked the patient information on the net (our medications do not come with patient information anymore) there was the following advice: “To be prescribed with caution in patients over 65.” Do I trust doctors? No.
Thank you for sharing your story. Yes, it can be tough to get a carefully and correctly checked BP reading at the doctor’s office.
Hard to say why your own Omron device consistently reads higher than the doctor’s office. Checking BP manually with a sphygmomanometer requires good positioning of the patient PLUS good technique in sufficiently inflating the cuff, slowing deflating the cuff, and carefully listening to the sounds. I think it’s not easy to be very accurate, especially when one is in a rush.
I think you are right to be proactive about double-checking your healthcare. Unfortunately, many doctors are rushed or distracted, in part because of the pressures that our dysfunctional healthcare system puts on them. And, it’s still very common for them to prescribe medications that should be used with caution in people aged 60 or older.
I have more information on getting better care here: 4 Steps to Getting Better Medical Advice from Doctors
So keep being involved, as you are doing. Sometimes switching to a clinic designed to care for older adults can help. You may also want to bring your home BP monitor to the doctor and see if it can be compared to one of the Omron machines in the clinic. Good luck!
Thank you so much for your reply, Dr Kernisan, as well as the link!
Dear Dr. Kernisan
I loved the perspective from a practicing doctor. Quick question, what is your take on using CoQ10 therapy for hypertension?
A 2007 meta-analysis by Professor FL Rosenfeldt and colleagues showed that CoQ10 treatment lowers both systolic (avg. decrease of 16.6 mm Hg) and diastolic (avg. decrease of 8.2 mm Hg) blood pressure. (Source: https://www.ncbi.nlm.nih.gov/pubmed/17287847).
Seems like a very affordable supplementation with pharmaceutical-grade CoQ10 (without known side effects) rather than expensive medication might be worth a try? Also, it has shown to be good for atherosclerosis and overall cardiovascular mortality in clinical trials.
Curious about your take on this information, Dr. Kernisan.
Sincerely,
Marianne
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.”
The Mayo Clinic is another good place to learn about the evidence for supplements, and they say it’s mixed for hypertension but there is some evidence coenzyme q10 helps with congestive heart failure. Coenzyme Q10
If you are interested in trying this 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. (Seems it’s generally safe and well tolerated.) Then give it a try and be sure to carefully monitor your blood pressure while doing so, 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!
It’s hard for me to change my dad’s thought on lowering his hypertension. He always refuses to do exercise and always take medication any time his BP gets high. Luckily he is reducing salt intake.
That must be frustrating for you, as I imagine you want him to have the best health possible.
If you haven’t already done so, you might want to try exploring what’s behind his refusal to exercise, and you might also ask more questions about how he sees his blood pressure problems. Sometimes doing a lot of listening helps us better understand how to help an older person with their health goals.
Hello Dr leslie ! I really appreciate your posts. I m hereby names Cedrick I. a student nurse in university of Rwanda. I wish to know more about high blood pressure in psychiatric women patient aged 70 years on Amitriptyline to treat major depressive disorder and propanolol treatment. Home BP Monitoring reveals systole between 130-140.
1. Can the signs of headache and dizziness she experiences be treated as hypertensive disorder or pscychoatric?
2. The palpitation sign she experiences, is it the positive sign for hypertension to be treated with such propanolol or other treatment drug group can be successful?
Thanks alot!!
So, in the United States it has become very rare to treat major depression with an older drug such as amitriptyline, because it has a lot of anticholinergic side-effects (not good for the brains of older adults) and there are many newer drugs that are better tolerated.
Propanolol would also be a very unusual choice here, to treat high blood pressure. Beta-blockers are now mainly recommended for people who have a history of myocardial infarction or heart failure; for primary hypertension, our guidelines now recommend using thiazide diuretics, calcium channel blockers, or ACE inhibitors.
Many things can cause headache and/or dizziness. A systolic BP of 130-140 is not very high, so I wouldn’t expect it to cause headache and I would look for other causes.
It is hard to say why she is experiencing palpitations, she really needs more evaluation to determine whether her feeling of palpitations corresponds to tachycardia or some other kind of arrhythmia, before you can determine what a suitable management plan would be. In the US propanolol is mainly used for essential tremor and sometimes as-needed to manage tachycardia related to public speaking, or similar circumscribed stressful events. Good luck !
Hi,
My mom is 70 yrs old. Her BP is usually below 108- 110/ 63-67 in the afternoon and in the morning 110-70 before taking the BP meds. Is it normal this range of BP for elder women?
She is being treated with Lorista (Losartan 50 mg) for now 3 years.
Thank you in advance!
M
Your mother’s BP is not uncommon in women her age, esp if they are on BP medication. The more important questions you may want to ask her doctors are:
– What should her goal BP be?
– Is there a good reason to treat her with BP medication to the point that her systolic BP (the top number) is so far below 120?
– Would there be a major downside to cutting back on her BP medications a bit?
As I explain in the article, in the SPRINT study the more intensive BP control arm aimed for SBP<120, the other group aimed for SBP<140. There was a benefit to aiming for the lower BP goal, but it was small in absolute terms.
I would recommend discussing further with your mother's health providers. If she has a preference to be on less medication when possible (which is often safer from a side-effect perspective, and can be cheaper as well), it may well be possible to cut back on her BP medications without putting her at substantial risk. Good luck!
Hi!
Is there a significant difference in the blood pressure values between a man and a women aged over 65 years old? Also, is it normal for me to have a blood pressure ranging between 150 to 140 for my systolic pressure and between 90 to 80 for my diastolic pressure (I am a woman 65 years old)
Thank you !
Murielle
There is research ongoing into the differences when it comes to men and women for hypertension and BP control. For now, guidelines apply to both genders and we don’t generally change management based on the gender.
A systolic BP between 140-150 is not uncommon in women your age. It is also common for BP to vary somewhat, as it’s very dynamic and is often changing within the body, depending on one’s position, activity, and emotional state.
According to the 2017 American College of Cardiology guidelines, SBP>140 would be considered Stage 2 hypertension. If you are 65 and not frail or seriously ill, it would be reasonable to consider trying to treat your BP to bring it down somewhat.
I would recommend discussing what your goal BP should be with your doctor. You may want to discuss non-drug methods of addressing BP; these don’t always enable people to entirely avoid medication, but they are good for one’s health in many ways and can allow someone to manage BP with lower doses of medication.
I also offer suggestions in this article: 6 Steps to Better High Blood Pressure Treatment for Older Adults. Good luck!
My name Adriaan Albertsz . I’m 67 from the Island Aruba and have 1 stent on my heart. I’ m worry over my blood pressure diastolic that still below 70 and some times 60. What can I’m do Doctor to normalize my blood pressure that is was today 126/61 pulse 63. My question is . Is my blood pressure ok Doctor ?
Generally, a diastolic BP less than 80 is considered normal. A systolic BP of 126 is not particularly high or worrisome.
I would recommend you talk to your usual health providers about what your BP should be, and whether you need to be concerned about your recent readings. Good luck!
My blood pressure reading is186 over 91 my pulse rate is 76 l have been having pain in my hands And my wrists and head ache but not all the time l am age 70 female I am taking bendruvluside the lowest dose and small dose of patasiem tablet but lm always tired do you think this as any thing todo with my blood pressure .
At age 70 — and really at any age — there are many things that can cause feeling tired. These include anemia, endocrine disorders, metabolic disturbances, sleep problems, issues with the heart and lungs, I could go on and on. So I would recommend talking to your health provider and asking for an evaluation.
High blood pressure, in of itself, does not usually cause fatigue or noticeable symptoms. BP medications can cause side-effects such as fatigue, but that is less common at low doses.
The BP you report is quite high; if it’s usually that high, I would recommend talking to your health provider about how you might control it better. We usually start by suggesting that older adults get their systolic BP (the first number) in the 140s, and then we decide whether it makes sense to aim for an even lower BP. Good luck!
Thankyou this was every helpful I will make an appointment with my doctor .
I see a PA yearly and VA every six months. In recent years my BP started to go up, I was first put on Hydroclorthizide later Lisinopril 10mg. But my BP still not controlled as readings all over the place. Is their a particular practitioner that deals/has expertise in BP issues. I’ve yet to have explained to me just what is normal for me and what I can do to better control it, with exception to info I’ve found on line.
I’m five months shy of 73, six foot tall @ 200 lbs, more active than most half my age. Don’t use tobacco, moderate drinker (beer), have never used drugs other than legal OTCs. I might add since retiring, I’ve developed, “White Coat Syndrome” as my BP goes out the roof in the MD office. Thank you.
So, generally high BP can be managed by generalist clinicians. I am not sure just how “all over the place” your readings are, but BP is dynamic and it’s quite common for a single person to show fairly varied reasons, especially if they are not checking at the same time every day. For this reason, it’s helpful to record BP over several days at home.
Specialists are usually considered either if the generalist cannot control BP after using a combination of 2-3 medications at high doses, or if there’s reason to suspect something more complicated going on. Either a kidney specialist or a heart specialist could be consulted, depending on the circumstances.
I’m not sure it’s productive to ask a clinician what is normal for you. High BP is very common in older adults, and it’s generally considered a condition that should be treated, especially if the SBP is over 150. Your own BP readings will reveal what is common for you, and then your health provider can advise you as to what would be a suitable BP goal, what would be the pros/cons of intensifying your BP treatment, and how you might proceed.
Good luck!
Thanks Dr. Leslie,
Re: my b.p. ZIGZAG as high as 199/ 98 as low as 110/ 66. Despite I’ve (41) diseases, I feel healthy.
Couple days ago i was discharged from ER having my 41st illness. I have been in the ER 20 times in 19 months, and two times hospital observation.
I took 17 different RX, 12 of them had severe reaction. My specialist said: appears your body is rejecting RX, And week ago I was taking off 2 RX one for blood pressure after I sent b.p. one week readings chart. Well, my b.p. is back to athletic reading 113/71 pulse 71 and as of today still have excellent b.p.
ALL DOCTORS, SPECIALISTS SAID: MY ILLNESSES IS A “GENE”. well, i looked back to my family and ancestors none had more than one to two illnesses… appears i collected all the illnesses in my tribe….
I have went thru 100s of lab tests including catherization, ultrasound and xrays, c.f. with dye and you name it.
I KNOW MY BODY AND HOW I FEEL 24/7
and my doctor visits are extended visit meaning 40 to 30 minutes. But, no doctor can diagnose any illness unless you document daily facts
So, do your homework it will help you to live much longer and possibly happier despite some doctors see it as anxiety and prescribe RX and you don’t needed.
Thank you for sharing your story. Sounds like you are a bit of a medical mystery, as you have had a lot of testing and the doctors are still unsure of what you have. This does happen to some people, it can be very frustrating to live through this. I hope the issues resolve soon, and that you find whatever answers are needed to stabilize your health.
I am a 59 year old male. I check my bp twice per day. In the morning after waking it averages 135/85, sometimes 140/90 or a little higher. In the evening, after exercising (which I do 6 days per week) it is usually 125/ 82, but many times it has been as low as 114/78. It is always lower after exercising. I am on 10-40mg. Amlodipine / Benazepril since October when my bp was 217/110. I have no side effects. I have been working out for many years, eat a low carb healthy diet, and have never been on any meds until now. I did drink alcohol on the weekends, probably more than I should have, and have since cut way back. All blood work is normal as well as EKG and Echo. I do have a heart murmur that causes no symptoms as of yet. I am 5’9”, 144 lbs. There is a history of high bp in my family (Mom & Dad both) and my Mom died of a heart attack at age 72. Does my treatment sound correct to you? Is it normal for my bp to drop so much after exercising? I do all the right things but I am still on meds. Is is truly possible this is hereditary? Thanks!
If there is a history of high BP in your family, then probably there is a genetic predisposition to high BP or other health factors that could trigger high BP. I would recommend you not spend too much time trying to sort out the genetics and instead focus on optimizing your BP control.
You are relatively young and so you are more likely to reap the benefits of getting your BP control optimized. Amlodipine and benazepril are recommended medications for treating high BP, and the combination of these two classes of BP drugs (calcium channel blockers and ace inhibitors) has performed well in studies.
Exercise does tend to lower BP because of its physiologic effects on the body.
The main thing that I notice in your story is that your morning BP is borderline high. This might be because of what time of day you take your medication, but some people also tend to have higher BP at night and this has been associated with worse health outcomes. To see if you really have higher BP at night (BP is supposed to go down at night by the way), you would probably need to wear a 24 hour BP device for a few days, this is called 24 hour ambulatory BP monitoring.
I would recommend you talk to your doctor. First of all, ask for him or her to clarify what your BP goal should be. You may want to aim for the lower BP goal used in SPRINT. Next, you could ask for help evaluating this relatively high morning BP. You could also ask about changing your BP medication dosing so that you take the same amount of medication but in two divided doses; this has been shown to be more effective in one study.
Here are some relevant clinical studies:
Treatment of Hypertension: Favourable Effect of the Twice-Daily Compared to the Once-Daily (Evening) Administration of Perindopril and Losartan
Association of Morning Hypertension Subtype With Vascular Target Organ Damage and Central Hemodynamics
Comparative Effects of an Angiotensin II Receptor Blocker (ARB)/Diuretic vs. ARB/Calcium-Channel Blocker Combination on Uncontrolled Nocturnal Hypertension Evaluated by Information and Communication Technology-Based Nocturnal Home Blood Pressure Monitoring ― The NOCTURNE Study
Good luck!
I feel like I’m between a rock and a hard place. I’ve had health anxiety all my life. When I was a boy, I was convinced I had certain deadly diseases—-long story. Growing up, at times I’ve been as normal as anybody, at other times the old demon of anxiety raises its ugly head. I am now a month shy of 62 years old. Have always been very athletic and was a fairly serious runner in the 1990s (60 mile weeks sometimes). Lots of upper body strength training for many decades also. Even though anxiety nut, had gone 30 years without seeing a doctor when I made an appt with a cardiologist in early 2015. I went because I started getting nutty about my bp (kept measuring it over and over and over till it finally had a systolic peak of about 218 briefly). I was desperate to find some peace and relief. The EKG did find a left bundle branch block–we believe it is from the countless bp surges I’ve had in my life. Sometimes –well most times– my bp is normal. I’ve even measured a systolic in the 80s on a few occasions when very relaxed. Lately, I’ve been obsessive about the bp again. I’m not a fan of drugs and don’t take any, even OTC pain relievers because I don’t get headaches or have other pains most people have. I never drink alcohol and have never smoked. I have avoided going to see a doc because I know they will simply prescribe drugs or may suggest meditation or yoga, so why bother? I’ve read that the usual anti-hypertensive drugs don’t work with anxiety-driven high bp anyway. Is that true? I forgot to mention the cardiologist did a resting echocardiogram and found normal heart function. I just bought a new Omron automatic cuff and my bp usually runs 130-150/59-82 or so. My manual cuff I bought from CVS runs about 15 or more points lower with the systolic. I believe I react less with the manual cuff. Sorry so long winded, but do you have any suggestions for my case? THANKS!
Well…have you tried meditation or cognitive-behavioral therapy for your anxiety? The main reason I ask is because you are very likely to face a variety of health concerns as you get older. Anxiety will leave you feeling worse and will also impact your health (all those stress hormones in the blood stream are not great for your cells and organs), so if you can make headway in controlling it, you will benefit.
Re your BP, it sounds like there are a few different approaches you could take, any of which would be reasonable. The only way to really know whether your BP would be better on medication would be to try taking medication. Otherwise, you can work on non-pharmacological approaches, including diet, stress-reduction, mindfulness, etc. (Sounds like you have the exercise part covered.)
The truth is that it’s impossible to have perfect certainty over what to do, or perfect control over one’s health, especially as one gets older. Trying to optimize your BP beyond what is in now may reduce your risk of cardiovascular events, in absolute terms mostly likely by a little bit. I think you’d be better off trying to work on your anxiety, even though it is a lifelong condition and hence will require a lot of time and effort to change. Good luck!
I have diabetes type 2,and with that I take blood pressure medication to lower my blood pressure I am 75 years old female,what should my blood pressure be? I am trying to get my possatiam level down for I do not consume a lot of food with salt
People with diabetes were excluded from the SPRINT trial. A large well-known randomized study called ACCORD (Action to Control Cardiovascular Risk in Diabetes) did not find that targeting a lower BP (systolic <120 mmHg) did not improve outcomes, compared to targeting a systolic BP <140 mmHg. However, some experts still feel that people with diabetes should aim for a systolic BP of 130 or lower.
Deciding on a suitable BP goal requires understanding a person's specific health history and then discussing the pros and cons of aiming for a given goal. So you will need to discuss this with your own doctors.
In general, for an older person with diabetes, it's probably reasonable to start by aiming for a systolic BP of 130-140. If the person is able to reach such a BP, then the person and the doctors can discuss whether or not to try getting the BP down further.
Your usual health provider should also be able to advise you regarding your potassium. Good luck!