July 20, 2018
Perspective on the New Blood Pressure Guidelines
Be Well

Perspective on the New Blood Pressure Guidelines

by John Swartzberg, M.D.

If you have high blood pressure and are trying to lower it via lifestyle changes or medication, are you and your doctor aiming low enough? In other words, what should your goal be? That seems like a simple question, but the answer has been debated for years. And now that the American College of Cardiology and American Heart Association (ACC/AHA) have lowered the cutoffs defining hypertension—as we discuss in New Blood Pressure Guidelines: The Numbers Game—the debate has reached a boil.

When it comes to blood pressure, lower is better, unless it drops so low that it causes adverse effects. But achieving “normal” blood pressure (less than 120/80) is extremely difficult for many people with hypertension. The new ACC/AHA goal of less than 130/80 will also be very challenging. I know from my years as a practicing physician that even the longtime standard goal of 140/90 is difficult for many patients. That’s why some experts have been suggesting raising the target to 150/90, at least for people who are not otherwise at high cardiovascular risk.

The ACC/AHA guidelines are based largely on findings from a big government-sponsored study called SPRINT (Systolic Blood Pressure Intervention Trial), published in 2015, which found that aiming for systolic blood pressure (the first number) below 120—rather than the standard 140—reduced cardiovascular disease and prolonged lives.

SPRINT may have been a “landmark” study, but it had limitations. It in­­cluded only people over age 50 with hypertension and at least one other cardiovascular risk factor (but not diabetes or a history of stroke). That left out a lot of people. And while it found a 25 percent reduced risk of cardiovascular events in the group aiming for a systolic goal of less than 120 compared to those aiming for 140, in absolute numbers that meant that one additional cardiovascular event was prevented in every 61 people during a three-year period. That’s a relatively modest benefit, and would have been even more modest had the participants been at lower risk.

Keep in mind, too, that SPRINT participants received top-notch and frequent medical supervision—including highly accurate blood pressure readings, monitoring of adverse effects, and adjustment of medications when needed—which many people don’t get in the real world.

The ACC/AHA compromised by choosing a systolic target of less than 130, rather than the 120 used in SPRINT. That will still create many new candidates for blood pressure medication—probably far more than the 4 million estimated by ACC/AHA. Meanwhile, the American College of Physicians and the American Academy of Family Physicians are sticking with their systolic goal of less than 150 for people over 60 at average or low cardiovascular risk and 140 for those at high risk.

Clearly, there are no magic numbers for everyone, nor any one-size-fits-all treatment. What’s more, the debate about blood pressure goals is largely academic for the millions of Americans with hypertension who are making inadequate efforts to control it and are receiving little or no medical treatment, and whose numbers thus remain far above any of the goals.

If you have hypertension, talk to your doctor about the potential benefits and risks of lower treatment goals. Of course, the best option, as the ACC/AHA guidelines stress, is to lower your blood pressure via lifestyle changes, such as losing weight, quitting smoking, exercising, moderating your alcohol intake, and improving your diet, before turning to medication.