By Paul Goldfinger, MD, FACC
As you may know, blood pressure measurement consists of a top number (systolic) and a bottom number (diastolic.) Both numbers are important, but recent research trials and guidelines have been focusing on the systolic end points. The exact way to express a BP reading is 120/80 mm Hg. But for this article we will just use the number–e.g. 120/80.
Blood pressures are usually taken in the sitting position. Some doctors ask their patients to sit for 5 minutes before taking a measurement. This will result in a number that is often about 10 points lower than an immediate office reading and may be different than readings obtained at home.
I recommend that all patients with hypertension (“high blood pressure”) buy a device and keep track of readings at home. I suggest an initial reading and then another after 5 minutes. Keep a written record for your doctor with the measurements, date, time and circumstances (eg “just had an argument with my spouse”) Remember that blood pressure readings do vary, so show your physician all your readings when you go for an office visit.
Experts have been disagreeing lately regarding the “target” systolic numbers that physicians should aim for when treating older patients (over age 60) for hypertension (high blood pressure.)
No one disagrees that treatment should begin for readings over 170, but most physicians will begin therapy for readings averaging over 150/90. Studies show benefits of treatment even for those over age 80. Doctors will legitimately differ in deciding when to start therapy, depending on the circumstances. The current treatment guideline controversies surround the question of how low to go.
The basic concept is that BP control will prevent stroke and cardiac events as well as reduce cardiac mortality rates. In older individuals, there is a special concern regarding lowering the systolic number too much.
If the BP is caused to be too low, quality of life issues may take center stage including important problems such as fainting, dizziness, cognitive impairment, depression, hip fractures, impotence, and fatigue. Sometimes patients will stop their meds due to such reactions. Tell your physician if you suspect side effects.
There are a variety of drugs that doctors use to treat hypertension and they are often utilized in combination. If you doctor wants to use beta blockers, keep in mind that this class of drugs may not be as effective for prevention as others and may be associated with significant side effects.*
One recent discovery is that statin drugs, added to anti-hypertensive drug therapy, will improve the prognosis regardless of LDL cholesterol levels.
The JNC 8 (Joint National Committee) guidelines came in 2013, after not revising the recommendations for over 10 years. They decided to lighten up on their target systolic reading concluding that up to 150 was OK for “seniors” instead of the prior goal of 140.
But some experts would prefer to see the pressure lowered to below 140, and even to 130 if tolerated by the patient, especially if the patient is at higher risk, such as diabetics and those with prior stroke, TIA, known heart disease or significant risk factors.
Another recent trial called Sprint advocated a target below 120 for patients 75 and older. The study found that patients with a target of 120 did better than those with 140, but that study was criticized on procedural grounds, and that goal could be risky in older patients who run a significant risk of side effects with such low readings. Even 130 may be associated with problems. The doctor has to be very careful when aiming for those aggressive targets.
So what is the physician to do given all these disagreements? The answer is to be knowledgeable regarding research trials and official guidelines, but to decide each case individually.
Dr Franz Messerli , a BP specialist and Clinical Professor of Medicine at Columbia U. School of Medicine is quoted on Medscape Cardiology 2/28/17.: “After JNC 7, it took 11 years to get one more set of guidelines. Now we have six or seven, and they all tell a different story. It has become very confusing to the practicing clinician.
“The patient in front of you never quite conforms to the patient in the trial or to the patients from whom the evidence was derived for the latest guidelines. Despite all the guidelines, you still have to be a doctor, and you have to individualize therapy and continue to learn.”
Dr. Messerli concluded by saying, “Most physicians know that guidelines are more for lawyers than for doctors.”
*Prof. Messerli: “Despite lowering blood pressure, there is no— and I repeat, no—evidence that beta-blockers reduce heart attack, stroke, or death in hypertensive patients ≥ 60 years. Ironclad evidence has been put forward that beta-blockers are not acceptable antihypertensive drugs in this age group.”
Here is an important link from our series on treating hypertension. It is from 2013. You can read our other posts in that series by typing “hypertension” into our search bar (above).