Be calm. Lower your BP.  Visit the Ocean. Paul Goldfinger photograph © California.

By Paul Goldfinger, MD, FACC

Part II:   What are the numbers?

Earlier this month we posted Part I where we introduced the subject of hypertension.  In that discussion we spoke about the use of guidelines for doctors to follow in diagnosing and treating this important condition. We also mentioned  that there are some disagreements among the experts world-wide regarding how to diagnose and  manage hypertension. Here is a link to Part I.

https://blogfinger.net/2019/02/18/confessions-of-a-high-blood-pressure-doctor-2019/

Fifty years ago, there wasn’t much interest in the management of hypertension because there were no good studies, and doctors tended to downplay the subject.  Many thought that a  blood pressure of 150-160 or even up to 180 wasn’t so bad, and a major cardiology text said that mild hypertension didn’t require therapy.  FDR  had a blood pressure  far exceeding 200 at Yalta, and very little could be done for him. There were few drugs available that could help. He died of a complication—a stroke.

In recent years, and for a long time, the diagnosis of hypertension was made when BP exceeded 140/90.  We learned from research trials that effective treatment of high blood pressure could prevent death, strokes, cardiac events, vision loss, and chronic kidney disease.

But there have been different appraisals of this research, resulting in a variety of guidelines, largely by the Joint National Commission (JNC 8, 2014), the AHA/ACC*  (2018), the American Academy of Family Practice (2017,) and the European Society of Hypertension (2018).  The disagreements mostly revolve around how to diagnose the condition, how to treat it, when to treat it, and whether to pay attention to age or not. The Americans strive for the same treatment goal  (130/80) regardless of age, but the Europeans and the AAFP believe in seeking 140/90 as the cutoff for those over 65.

But others disagreed in a more fundamental way: 

In an  analysis in the European Heart Journal, 2018, we have some quotes:

1. “130/80 mm Hg is the new magic number as recommended by the AHA/ACC guidelines for diagnosis of hypertension.  By defining hypertension down from 140/90, the number of people in the USA said to be hypertensive increased overnight by 31 million.” 

2.  Guidelines for diagnosing systolic hypertension vary by 20 points among the various recommendations. This needs to be settled.  The measurement of blood pressure is often done inaccurately, even in doctors’ offices.

This is a quote from a research paper, “The measurement of blood pressure is likely the clinical procedure of greatest importance that is performed in the sloppiest manner.”

3. “Among those with hypertension under both old and new guidelines, only 24% were receiving anti-hypertensive treatment.  The vast majority of participants between 25 and 35 years (87%) were untreated, as were 56% of participants over age 65. And, for those begun on drug therapy, half have stopped it by 12 months.

4. “Blood pressure management needs to be individualized to minimize the likelihood of harm (side effects of treatment)  while maximizing the likelihood of benefit. 

5. Some have even doubted the wisdom of treating hypertension at all.   In 1931, in the British Medical Journal, JH Hay said, “The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it.”

You can now begin to appreciate the complexity of all this, and we will continue talking about these matters until we run out of topics:

For now, here are the American guidelines, 2017, by the *American Heart Association and the American College of Cardiology  (AHA/ACC).  The official papers are long and very involved, but here are the basics:

a. “Normal BP” is defined as less than 120/80.  If 120-129 /80, that is considered “elevated BP.”

b. Any patients with sustained readings of over 130/80 are considered to have hypertension, regardless of age.

c. Stage I hypertension is 130-139/80-89

d. Stage II hypertension is over 140/90

e. The goal of treatment is to get BP under 130/80 regardless of age.

The Europeans use 140/90 as their cutoff, and they recommend going easy with drug therapy for those over age 65.  In that case, the goal is 140, not 130. They tend to be skeptical of the aggressive American approach and they especially worry about getting too pushy with the elderly because of dangerous side effects in that age group.

I sympathize with the Europeans.  Their approach seems more practical, more possible, and less wedded to sheer numbers.

The goals and decisions about treatment depend also on whether the patient has other issues such as heart disease, coronary risk factors, congestive heart failure and other risk factors.

Here is the quote of the day from Feb 19, 2019 in the McGill University Office of Science and Society  (“Separating sense from nonsense”):

“The current hypertension guidelines controversy is in many way much ado about nothing. Given the history of controversies which we have endured with respect to blood pressure it is remarkably minor. First we had to figure out how to measure , then whether we should measure it at all, whether we should bother trying to lower it, and then now how low we should go. And given that we used to tolerate blood pressures of up to 200 mm Hg, the current argument of 130 vs 140 is a very minor disagreement indeed.  The average reader would best be served by ignoring the curent disagreement. Worry about it too much and it will inevitably raise your blood pressure.”

We will get into a variety of other  topics such as how to measure blood pressure properly, what are the risks of drug therapy, which drugs should be used, what about the elderly and their particular risks, when should treatment be started, and what about non -pharmacologic therapy?

Tune in for Part III.

KARRIN ALLISON:   Spring time will contribute to lower blood pressures:  a non pharmacologic fact of nature, with no side effects. Other such BP lowering factors include music, art, love, good sleep, happiness, faith, comfort, optimism, weight control, exercise, nutrition, and others.  Depression, anger and anxiety need to be overcome.