W

atching your blood pressure? You may have more breathing room than you thought.

In the latest pendulum swing on what blood pressure older adults should aim for, two of the nation’s leading medical groups issued guidelines on Monday recommending that people 60 and older get their systolic blood pressure (the first number) below 150.

That target is a departure from the 140 (or lower) that many physicians, particularly cardiologists, believe appropriate as a way to reduce the risk of stroke, heart attacks, and premature death due to hypertension. The difference reflects continuing debate within the medical community about the best balance of benefits and risks from treating hypertension.

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The new guidelines, from the American College of Physicians and the American Academy of Family Physicians and published in the Annals of Internal Medicine, are very similar to those that family physicians issued in 2014, calling for treatment of adults 60 and older when blood pressure is 150 or higher and aiming for less than 150, meaning a reading in the 140s is fine. (For people under 60, the goal was less than 140.) Those guidelines were controversial, and the new ones — coming in the wake of a high-profile 2015 study called SPRINT that argued for a lower target — are already, too.

“It seems like we’re back to 2014,” said Dr. Jackson Wright, director of the clinical hypertension program at University Hospitals in Cleveland and first author of the SPRINT study. “Even then, there was a lot of dissent and, since the SPRINT trial has come out since, I was surprised” by the new ACP/AAFP guidelines.

Even physicians who urged caution in adopting SPRINT’s aggressive, below-120 target in people at elevated risk of stroke and heart attack questioned the new, looser guidelines.

The “recommendations that clinicians initiate treatment in adults aged 60 or older with systolic blood pressure persistently at or above 150 are inappropriate,” said Dr. Franz Messerli, a cardiologist at the University of Bern in Switzerland. “Even less acceptable is a target … of less than 150 in this group. With such a elevated target there is substantial evidence of an increase in stroke risk.”

Last year, Messerli warned against embracing SPRINT’s aggressive blood pressure target, saying a goal of below 120 “clearly has to be considered absurd.” He believes that, for otherwise healthy patients, something in the 120s is OK.

The new ACP/AAFP guidelines are stricter for patients who have had a stroke or a transient ischemic event (known as a mini-stroke), or who have risk factors such as high cholesterol, obesity, diabetes, or atherosclerosis. In those cases, people should reduce their blood pressure below 140, the groups said. That, too, raised eyebrows. “Wouldn’t it perhaps be better [to get below 140] before such a devastating complication has taken place?” Messerli asked.

The medical groups defended their new guidelines, which are based on the SPRINT study and 20 other randomized controlled trials.

That research showed that “any additional benefit from aggressive blood pressure control” — meaning reducing blood pressure below 140 — “is small,” said ACP president Dr. Nitin Damle.

The more lenient targets also reflect the harms of aiming lower. As people take more kinds of anti-hypertension drugs (three is not unusual) and higher does of them in an effort to drive down their numbers, they are more likely to have side effects like coughing and low blood pressure, which causes lightheadedness or fainting.

Competing guidelines

As a whole, the analysis of the 21 studies found, most of the evidence for the benefits of treating high blood pressure came from studies of patients who started out above 160 and got into the 140s. Studies that aimed for less than 140 “showed no statistically significant reduction in all-cause mortality or cardiac events,” the authors wrote in the Annals paper, though they did find a reduced risk for stroke.

For instance, a 2012 Cochrane Review concluded that in otherwise healthy adults with blood pressure of 140 to 159, blood-pressure-lowering drugs “have not been shown to reduce mortality or morbidity [death or disease] in randomized clinical trials.”

The SPRINT trial offered the strongest counterargument to that, finding benefits in reducing blood pressure to 120 or less. But it studied only people at high risk for cardiovascular disease. And it has been criticized for measuring blood pressure differently from how doctors usually do it, with the result that a reading of, say, 120 in SPRINT would be 128 or so in ordinary practice.

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What’s indisputable is that the clashing, changing guidelines confuse both laypeople and doctors. The American Heart Association, for instance, says that in adults systolic blood pressure of 140 or more means “poor” cardiovascular health, 120 to 139 means intermediate cardiovascular health, and below 120 is “ideal.”

“For the public as well as practitioners, what the competing blood pressure guidelines illustrate is that there are different ways to interpret the same research,” said Dr. Vikas Saini, president of the Lown Institute, which warns against medical overtreatment. “The interpretation of the same data can be as different as half empty and half full.”

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  • Hi,
    I am 54, my height is 6 feet 3 inches, my weight is 98 KGS, one year ago my I was suffering from kidney infection, now urine color flactuate from white to yellow or some time brownish, I check my bp daily twice at morning and at night yesterday my bp was 138/91 in the morning and today is 157/85, I don’t use medication. For both kidneys and blood pressure I think chemicals are harms for health. Please help me on the basis of humanitarian and obliged.I use yellow lemon and apple venigar only for both.
    Thanks a lot,
    Muhammad Tariq,
    Peshawar , Pakistan
    Cell # 03339741031
    eldoradopk87 @gmail.com

  • Thank you. As a patient, and no medical background, my doctor and I recently addressed symptoms of fatigue and lightheadedness. My bp averaged 110-120/65+/70s, respectively. My prescription was amolidipine benespril (sp?) 10/40 and dyrenium 50 mg a.m. My script is the same, except, dyrenium 100 mg, the a.m., and amlodipine, p.m. My side affects have subsided significantly. Thanks again, for the article.

  • SPRINT studied patients with hypertension and no comorbidities to have a benefit of that lower BP target. JNC8 has been out for almost 2.5 years showing that it’s okay to have higher target BPs (150/90) for those >60. That Swiss cardiologist doesn’t have the same population as the US so he may think it’s in appropriate, but it’s not in the US population. If a patient is hypertensive with comorbidities then the BP haven’t changed (still 140/90). Article is trying to confuse people…

    • Derk your comments, while potentially with some validity (but based on assumptions you cannot prove make a difference), contains one huge thing that is very disturbing and incorrect (and also creates an initial presumption that you have some kind of “bias” here and that makes the validity of your alleged factual assertions immediately suspect. By “bias” I mean you have some kind of hidden “agenda” or unstated goal that is driving all your comments). It’s your ultimate conclusion that this “article is trying to confuse people.” That’s simply false. Flat out false.

      The article is simply relating actual facts that are indeed occurring in the medical profession concerning opinions about blood pressure. Everything stated here is factual. These disputes are very real. I’m a doctor and know it’s true. There are disputes about many things in medicine. This article is simply informing readers that controversy exists. That is an absolute truth.

      The Federal government surprisingly adopted this very low blood pressure standard to govern physicals given to commercial vehicle drivers almost immediately after the SPRINT study came out. That study was a significant change from accepted norms before it.

      In 2013, the federal government agency who had made those recommendations that the department of transportation immediately adopted stopped making such recommendations based solely on studies. This was the national heart, lung, and blood Institute on Oct. 8, 2013 in the prominent and respected journal called “circulation.”

      It found out the practical truth-that there were different opinions about blood pressure issues coming from different organizations and different experts, both internally and extra early, as well as reviewing studies. And that based on the practicalities and especially knowledge advanced easily through the Internet, that simply basing guidelines on study results alone does not take into account the reality of different individuals.

      The obvious reason for supposedly wanting lower blood pressure was that it would lower cardiovascular negative events and extend peoples lives. however, the consequences of taking blood pressure medications and many other things made trying to reach these goals actually made many people have a very miserable life. Moreover, it was discovered that actually, people functioned much worse when their blood pressure was lowered to meet some of the standards than when it was raised.

      There is an old cliché that applies without question to almost all doctors. I see things differently because I did something else before I went to medical school. The cliché is that “If you are a hammer, then all of the world is a nail.”

      It means that you see the world only through what you know. And this shows up especially with cardiologists in medicine about blood pressure. They are always going to want your blood pressure lower and your cholesterol lower.

      But you must realize that almost all doctors were very healthy people and very bright people who were rarely sick and went into medicine after graduating from undergraduate school at age 22 and graduated from medical school at 26. Many of them never end up with major health problems until they reach age 50 or so. One of the strangest things I ever remember hearing in my training was being around an older ophthalmologist who was just starting to be required to put eyedrops in his eyes, and then complaining bitterly after he did it about how much the eyedrops burned.

      While it’s certainly true that the eyedrops burn, it was the shock of hearing this ophthalmologist to only be learning at around age 60 that something he had been telling people to do for 30 years actually was very uncomfortable. In fact, from my standpoint, he was saying they burned so much that it was like torture, and I really don’t think most people feel they burn that much. His reaction was very exaggerated.

      Medical education is virtually 100% memorization. And what you are taught today will be changed in 10 years. I’ve seen this happen countless times, over and over by people who were so confident about the supposed science behind what they were saying.

      The current fad of the day is the alleged “opioid epidemic.”
      Yet even the surgeon general of the United States admits that we were all required to take courses in pain management less than 10 years ago to just keep our licenses current that we were told to give pain medication all the time and that we were not using them enough.

      But what has really gone off the rails about the “opioid epidemic” is that this view of alleged increased misuse of painkillers is being applied to all controlled substances, the majority of them which are not opioids or pain medicines.

      Controlled substances are put into different categories based on the severity of their potential for addiction or misuse and danger. The lower the number, the more dangerous the medication is considered.

      Yet schedule five controlled substances that are not opioids or pain killers are treated as part of the “opioid epidemic” the same way that schedule 2 controlled substances are, such as vicodin and the ones that have been focused on so much. The public is barely even aware of that fact.

      But this crack down on what is really all controlled substances has made it where orthopedic surgeons can hardly give someone they just did major ankle ligament repair surgery on Vicodin or oxycodone for 3 to 5 days if necessary as outpatients. Some pharmacies will not even stock both of those medications, so if the surgeon prescribed me oxycodone for super severe pain, the patient has to go to a different pharmacy to get it than the original vicodin for lower-level pain.

      This kind of thinking is short sighted and too extreme. It probably comes from our country’s incredible focus on filling our prisons with people on drug-related charges.

      There can be no worse sin in America than to use drugs. It carries a terrible stigma with it that virtually identifies someone as a criminal or stigmatizes them as a “drug addict.”

      I can tell you that I virtually never prescribe controlled substances. They’re just not necessary for most people. But if you have undergone General anesthesia and have had a bunch of pins and metal rods and things like that put into your legs and ankles, when you make up, you’re going to hurt and you need pain medication. That’s what these medications are for. And for people to generalize that either the doctors or the patients out there all misuse these kind of medications is just an extreme overstatement that is not true at all.

      As for your comments about the doctor in Switzerland and his comments being irrelevant simply because his patients are not the same as the ones in the United States is an assumption that cannot be proven and what part of the United States are you even talking about? The eating habits in different parts of the United States, as well as in different socioeconomic classes within the United States differ significantly.

      You may be a physician yourself. But if so, you have missed the whole point of the article and actually a lot of competing information out there. You act as if you are the one and only authority and state one very specific guideline as if it is God’s truth in America.

      You also refer to “JNC8” and say it’s been out greater than 2.5 years. I would actually have to look this specific study up to even know what you’re talking about. It’s not mentioned in the article. I don’t know what makes “JNC8” the “Bible from God” about hypertension issues, but you have missed the whole point of this article.

      This article was not trying to confuse anyone, although apparently you were confused. it was trying to say that there is no one “God’s truth” out there that is agreed-upon by everyone in America or in the world or in any specialty about blood pressure. That’s what the article was saying and that is the truth. It was just letting readers know that there is conflict about such standards within the medical profession. If you are saying that is false, then you are absolutely wrong.

      And anyone who thinks that blood pressure is the only thing that physicians disagree upon is naïve. Being a doctor involves some science, but it is not hard science like physics. That is why it is called the “art” of practicing medicine.

      And as a final comment, the idea of relying on studies only or some kind of one limited guideline as to how to treat patients is so restricted in knowing how studies are really done and all the underlying data is often altered or not relevant to what someone is interested in is dangerous in its naïveté. I can tell you that there is a very prominent study from the Netherlands many doctors rely on that supposedly stands for as its title and how the media refers to it, which is all the physicians who are trying to remember things through memorization processes are going to get because they’re overwhelmed with way too much information, or the public is going to see, supposedly means that stents do not help atherosclerotic blocks in arteries any more than medical therapy using drugs alone is incredibly bizarre.

      Certainly, if you read the study, it does not support the fact that using stents works better than using medical therapy alone.

      But it is bizarre to think that this study has anything at all to do with that issue anyway.

      The first thing about the study is that it never involved a single patient who was supposed to ever get a stent or whoever got a stent. Yes, that is the hard cold truth. How did it get this reputation? Someone had an agenda.

      I could make the reasonable assumption that it is the insurance companies not wanting to pay for interventions because it’s cheaper to pay for medications, but I don’t know whose agenda it was. All I know is that there were about 46 patients who got medical therapy and 46 patients who started out that were supposed to get angioplasties, but no stents though. That’s because the study took place before stents were hardly even being used, especially the current drug eluting stents that are used almost all the time. And that most of the 46 patients in the medical therapy completed the study but only 14 patients in the angioplasty arm completed the study. Yet the statistics act as if all 46 of the patients in the angioplasty study completed it and compares the mythical 46 in the angioplasty part to the real 46 in the medical study part.

      I do not recall the acronym for this particular study off the top of my head, but I can tell you that it is a leading study that many cardiologists were following at the time and many still believe it.

      So don’t put your reliance in studies alone. And to believe that the underlying data is not altered or that the study does not stand for what you’re being told it does is very naïve and dangerous in trying to use only one method or source of information to come to major conclusions that affect people’s lives.

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