Another month, another battle over changes to influential clinical guidelines for the treatment of major chronic diseases. In November it was the controversial new cholesterol guidelines. Then in December long-delayed revised guidelines about high blood pressure (hypertension) set off debates among physicians and undoubtedly confused many people.
The new blood pressure guidelines, based on well-designed clinical trials, came from a panel of experts selected by the National Heart, Lung, and Blood Institute. (Last June the Institute decided to stop producing clinical guidelines, however, so the panel published its blood pressure report independently.) The key change may seem small but could affect millions of older Americans. The guidelines raise the target for treatment of high blood pressure from below 140/90 to below 150/90 for people ages 60 and older, unless they have diabetes or chronic kidney disease. In other words, the cutoff for systolic blood pressure (the first number) goes from 140 to a more lenient, easier-to-achieve 150.
This means that if you are 60 or older and your systolic blood pressure is over 150 or your diastolic pressure (the second number) is over 90, you should be treated with medication, if lifestyle changes such as weight loss, exercise and improved diet don’t do the trick. And if you’re already taking hypertension medication, the systolic target should be below 150 (no longer 140).
For people under 60 and everyone with diabetes or chronic kidney disease, the cutoff remains at 140/90.
Critics, including several panel members, have rejected the more relaxed systolic target for older people, except perhaps for those over 80. They argue that the evidence for raising the number was insufficient, and that doing so would greatly reduce the number of older people being treated for hypertension or lessen the intensity of their treatment, potentially reversing the dramatic decline in heart attacks and strokes that has occurred since the 1980s. And in older people, elevated systolic blood pressure is an even stronger risk factor for cardiovascular disease than elevated diastolic pressure.
Meanwhile, the American Heart Association and American College of Cardiology are sticking with the old 140/90 cutoff; they are expected to come out with their own new guidelines next year.
Given the lack of consensus about raising the systolic threshold, we think that if you are between the ages of 60 and 80, your doctor should work with you to get your systolic pressure below 140 via lifestyle changes and, if that is not sufficient, medication. However, if you only get it down to, say, 145, and you are at relatively low risk for cardiovascular disease—or if there is an increased chance that intensifying drug therapy will cause adverse effects—systolic pressure between 140 and 150 may be acceptable. For those over age 80, the higher cutoff does make sense, since it usually takes more intensive treatment to get systolic pressure to less than 140 at that age, and they are more likely to experience side effects and interactions with other drugs.
But it’s hard to generalize. Treatment decisions should be individualized. That’s where the doctor/patient relationship comes in, along with clinical judgment and the “art of medicine.”