Changing Blood Pressure Targets Frustrate Patients – and Doctors.
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A Sphygmomanometer measuring for blood pressure.

Most people know that having high blood pressure is unhealthy. But how high is too high? The answer depends on which health organization you ask.

However, the conversation got even muddier in January 2017 when two physicians’ groups released recommendations that set safe blood pressure targets higher than ever for adults 60 and older – a group at high risk for complications from high blood pressure.

If you’re confused about why the target for this high-risk group changed, join the party. We’re just as frustrated. But before you think you need to adhere to one number, know that these are broad recommendations. They don’t apply to every single person. Instead, we need to focus on what’s healthy for each person.

Differing blood pressure guidelines

One in three adults in the U.S. has high blood pressure, or hypertension. That number climbs to two in three when you talk about adults 60 and older. We measure blood pressure using two numbers, expressed as millimeters of mercury (mm Hg):

  • Systolic blood pressure: The first number in your blood pressure reading that measures pressure in your blood vessels when your heart beats.
  • Diastolic blood pressure: The second number that measures pressure in your blood vessels between heart beats.

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We’ve long considered hypertension to be at or above 140/90 mm Hg. This is the level at which many organizations, including the American Heart Association, recommend beginning treatment to lower blood pressure.

However, on Jan. 17, 2017, the American College of Physicians and the American Academy of Family Physicians published revised recommendations in the Annals of Internal Medicine. These new guidelines state that patients older than 60 should begin treatment if their systolic blood pressure reaches 150 mm Hg. If the patient has high cardiovascular risk or a history of stroke, treatment should begin at 140 mm Hg.

This revision is controversial because it comes after a series of studies that show that a lower systolic blood pressure increases heart-health benefits for adults 60 and older, including reduced risk of heart attack and stroke. In fact, the distinguished Systolic Blood Pressure Intervention Trial (SPRINT) in 2015 found that targeting a blood pressure of 120 mm Hg or lower was more effective to reduce the rates of major cardiovascular events than targeting 140 mm Hg.

However, it’s difficult to draw absolute conclusions from these studies for a variety of reasons.

Challenges of blood pressure research and measurements

Examining blood pressure studies can be challenging due to the many variables, including what each study is looking for, who the participants are, what drug the study uses and whether lifestyle changes are being made.

And it’s important to remember that blood pressure doesn’t just measure pressure. It’s also a marker for other things going on in your body, such as stress, heredity factors, diet and exercise. That’s why often, when talking about blood pressures in the 140 to 150 mm Hg range, we don’t automatically prescribe drugs. Instead, we think about lifestyle interventions, which play a big role in blood pressure.

I think we sometimes ask too much of blood pressure drug treatments. Let’s say I treat a patient with high blood pressure who also smokes and is overweight. I give him a pill and his blood pressure goes down. But he doesn’t make any lifestyle changes. How much do those other factors continue to affect his heart risk? Probably a lot.

That’s not to say we should stop treating high blood pressure with medication. Clearly, lowering your blood pressure does improve your health. We just can’t discount all the other factors that contribute to heart health.

4 steps to manage your blood pressure

While there may not be a consensus for when blood pressure is too high, there are steps you can take to achieve and maintain a healthy blood pressure:

  1. Know your numbers. Blood pressure changes from minute to minute, so it’s important to monitor yours regularly to get an accurate measurement.
  1. Practice healthy lifestyle habits. This includes avoiding tobacco, eating a low-salt diet, exercising regularly, reducing stress and limiting alcohol intake.
  1. Have a careful discussion with your doctor. If your blood pressure creeps up to 140 mm Hg, we’ll talk about what you can do to lower it. Lifestyle modifications are always the first answer, but if we exhaust those options, we’ll discuss medication.
  1. If you begin drug therapy, stick to the regimen. Don’t skip pills. Once your blood pressure drops to a healthy range, we may discuss carefully weaning you off the medication. This likely would depend on you making lasting lifestyle changes.

The conflicting guidelines are confusing. But I want you to know that there’s no magic blood pressure number that applies to everyone. Your health history and lifestyle greatly influence your heart health and what’s safe for you. Work with your doctor to monitor and effectively manage your blood pressure, and don’t hesitate to ask questions if you get frustrated or confused.

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