- Reading the new blood pressure guidelines
- Behind the numbers
- More than blood pressure
- What should you do?
- 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults
- AHA: 130/80 mm Hg Is New National BP Target
- Blood pressure targets in the elderly
- Ideal Target Blood Pressure in Hypertension
- New blood pressure guideline could prevent 3 million cardiovascular events over 10 years
- Stricter Blood Pressure Guidelines Could Prevent Cardiovascular Events, but Debate Continues
Reading the new blood pressure guidelines
Harvard Men's Health Watch
If you didn't have high blood pressure before, there's a good chance you do now.
In 2017, new guidelines from the American Heart Association, the American College of Cardiology, and nine other health organizations lowered the numbers for the diagnosis of hypertension (high blood pressure) to 130/80 millimeters of mercury (mm Hg) and higher for all adults. The previous guidelines set the threshold at 140/90 mm Hg for people younger than age 65 and 150/80 mm Hg for those ages 65 and older.
This means 70% to 79% of men ages 55 and older are now classified as having hypertension. That includes many men whose blood pressure had previously been considered healthy. Why the change?
Behind the numbers
“Blood pressure guidelines are not updated at regular intervals. Instead, they are changed when sufficient new evidence suggests the old ones weren't accurate or relevant anymore,” says Dr.
Paul Conlin, an endocrinologist with Harvard-affiliated VA Boston Healthcare System and Brigham and Women's Hospital.
“The goal now with the new guidelines is to help people address high blood pressure — and the problems that may accompany it heart attack and stroke — much earlier.”
The new guidelines stem from the 2017 results of the Systolic Blood Pressure Intervention Trial (SPRINT), which studied more than 9,000 adults ages 50 and older who had systolic blood pressure (the top number in a reading) of 130 mm Hg or higher and at least one risk factor for cardiovascular disease.
The study's aim was to find out whether treating blood pressure to lower the systolic number to 120 mm Hg or less was superior to the standard target of 140 mm Hg or less.
The results found that targeting a systolic pressure of no more than 120 mm Hg reduced the chance of heart attacks, heart failure, or stroke over a three-year period.
More than blood pressure
The new guidelines have other changes, too. First, they don't offer different recommendations for people younger or older than age 65. “This is because the SPRINT study looked at all patients regardless of age and didn't break down groups above or below a certain age,” says Dr. Conlin.
The guidelines also redefined the various categories of hypertension.
It eliminated the category of prehypertension, which had been defined as systolic blood pressure of 120 to 139 mm Hg or diastolic pressure (the lower number in a reading) of 80 to 89 mm Hg.
Instead, people with those readings are now categorized as having either elevated pressure (120 to 129 systolic and less than 80 diastolic) or Stage 1 hypertension (130 to 139 systolic or 80 to 89 diastolic).
A reading of 140/90 mm Hg or higher is considered Stage 2 hypertension, and anything higher than 180/120 mm Hg is hypertensive crisis.
|The new guidelines note that blood pressure should be measured on a regular basis and encourage people to use home blood pressure monitors. Monitors can range from $40 to $100 on average, but your insurance may cover part or all of the cost. Measure your blood pressure a few times a week and see your doctor if you notice any significant changes. Here are some tips on how to choose and use a monitor.Choosing|
What should you do?
If you had previously been diagnosed with high blood pressure, the new guidelines don't affect you too much, says Dr. Conlin, as you still need to continue your efforts to lower it through medication, diet, exercise, and weight loss. “However, new information in the guidelines, your doctor may propose treating your blood pressure to a lower level,” he says.
The larger issue is that many men ages 65 and older suddenly find themselves diagnosed with elevated or high blood pressure, since the new normal is a whopping 20 points lower than before. Does this mean an automatic prescription for blood pressure drugs? Not necessarily.
“They should consult with their doctor about first adjusting lifestyle habits, such as getting more exercise, losing weight, and following a heart-healthy diet the DASH or Mediterranean diet,” says Dr. Conlin.
Medications are recommended to lower blood pressure in Stage 1 hypertension if you've already had a heart attack or stroke or if your 10-year risk of a heart attack is higher than 10%. (You can find your 10-year estimation at www.cvriskcalculator.com.) For others with Stage 1 hypertension, lifestyle changes alone are recommended.
“Overall, the new guidelines may help people get more involved with monitoring their blood pressure, which can hopefully prevent complications from hypertension,” says Dr. Conlin.
As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review or update on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.
2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults
Joseph Scarpa and Coauthors
JAMA Network Open | Original Investigation, March 8, 2019
Michael Roerecke and Coauthors
JAMA Internal Medicine | Original Investigation, February 4, 2019
Peter J. Kaboli and Coauthors
JAMA Network Open | Original Investigation, December 14, 2018
Yuanyuan Zhang and Coauthors
JAMA Pediatrics | Research Letter, December 2018
Arman Qamar and Eugene Braunwald
JAMA | Viewpoint, November 6, 2018
Naomi D. L. Fisher and Gregory Curfman
JAMA | Editorial, November 6, 2018
Kevin O. Hwang and Coauthors
JAMA | Viewpoint, November 6, 2018
Thomas T. van Sloten and Coauthors
JAMA | Original Investigation, November 6, 2018
Sarah Melville and James Brian Byrd
JAMA | JAMA Insights, November 6, 2018
Tamar S. Polonsky and George L. Bakris
JAMA | JAMA Diagnostic Test Interpretation, November 6, 2018
James P. Sheppard and Coauthors
JAMA Internal Medicine | Original Investigation, October 29, 2018
George Howard and Coauthors
JAMA | Original Investigation, October 2, 2018
Kyle Morawski and Coauthors
JAMA Internal Medicine | Original Investigation, April 16, 2018
Robert B. Baron
JAMA Internal Medicine | Invited Commentary, April 16, 2018
Ian H. de Boer and Coauthors
JAMA | Viewpoint, April 3, 2018
Teemu J. Niiranen and Coauthors
JAMA Cardiology | Brief Report, March 21, 2018
Pascal Geldsetzer and Coauthors
JAMA Internal Medicine | Original Investigation, March 2018
Jeong Yun Yang and Coauthors
JAMA Internal Medicine | Teachable Moment, February 26, 2018
Jonathan Graff-Radford and Coauthors
JAMA Neurology | Original Investigation, February 2018
JAMA | Clinical Trials Update, January 23/30, 2018
João Delgado and Coauthors
JAMA Internal Medicine | Original Investigation, January 2018
Mattias Brunström and Bo Carlberg
JAMA Internal Medicine | Original Investigation, November 13, 2017
Rakesh Malhotra and Coauthors
JAMA Internal Medicine | Original Investigation, October 2017
Joshua D. Bundy and Coauthors
JAMA Cardiology | Original Investigation, July 2017
Shakia T. Hardy and Coauthors
JAMA Cardiology | Original Investigation, June 2017
Wan-Chuan Tsai and Coauthors
JAMA Internal Medicine | Original Investigation, June 2017
Dori Steinberg and Coauthors
JAMA | Viewpoint, April 18, 2017
Yuichiro Yano and Coauthors
JAMA Cardiology | Original Investigation, April 2017
Jerome H. Chin and Coauthors
JAMA Neurology | Viewpoint, February 6, 2017
Michelle C. Odden and Coauthors
JAMA Internal Medicine | Original Investigation, February 6, 2017
Aram V. Chobanian
JAMA | Viewpoint, January 30, 2017
JAMA | Global Health, January 17, 2017
Mohammad H. Forouzanfar and Coauthors
JAMA | Original Investigation, January 10, 2017
News From the Centers for Disease Control and Prevention
JAMA | January 2017
Rachel Puttnam and Coauthors
JAMA Internal Medicine | Original Investigation, January 2017
Ilana B. Richman and Coauthors
JAMA Cardiology | Original Investigation, November 2016
Paul K. Whelton and Coauthors
JAMA Cardiology | Viewpoint, November 2016
Salim Yusuf and Coauthors
JAMA Cardiology | Viewpoint, November 2016
Thomas A. Dewland and Coauthors
JAMA Internal Medicine | Original Investigation, August 2016
David M. Flatt and Coauthors
JAMA Cardiology | Review, August 2016
JAMA Internal Medicine | Invited Commentary, July 2016
Jeff D. Williamson and Coauthors
JAMA | Original Investigation, June 28, 2016
Aram V. Chobanian/p>
JAMA | Editorial, June 28, 2016
Timothy B. Plante and Coauthors
JAMA Internal Medicine | Research Letter, May 2016
Sarah Lewington and Coauthors
JAMA Internal Medicine | Original Investigation, April 2016
Theodore A. Kotchen and Coauthors
JAMA | Viewpoint, January 14, 2016
Athanase Benetos and Coauthors
JAMA Internal Medicine | Original Investigation, June 2015
Connor A. Emdin and Coauthors
JAMA | Original Investigation, February 10, 2015
Hilary K. Wall and Coauthors
JAMA | Viewpoint, November 19, 2014
Gijs W. D. Landman and Coauthors
JAMA Internal Medicine | Original Investigation, November 2014
Richard J. McManus and Coauthors
JAMA | Original Investigation, August 27, 2014
Peter M. Nilsson and Fredrik H. Nystrom
JAMA | Editorial, August 27, 2014
Carlos J. Rodriguez and Coauthors
JAMA Internal Medicine | Original Investigation, August 2014
Paul Arthur James and Coauthors
JAMA Internal Medicine | Invited Commentary, August 2014
From The Medical Letter on Drugs and Therapeutics
JAMA | From The Medical Letter on Drugs and Therapeutics, June 4, 2014
Norrina B. Allen and Coauthors
JAMA | Original Investigation, February 5, 2014
Wanpen Vongpatanasin and Coauthors
JAMA | Grand Rounds, June 4, 2014
Laura A. Petersen and Coauthors
JAMA | Original Investigation, September 11, 2013
Marc G. Jaffe and Coauthors
JAMA | Original Investigation, August 21, 2013
Thomas R. Frieden and Coauthors
JAMA | Viewpoint, January 1, 2014
Brent M. Egan and Coauthors
JAMA | Original Contribution, May 26, 2010
AHA: 130/80 mm Hg Is New National BP Target
ANAHEIM — After years of contention among professional societies over raising blood pressure targets, national guidelines have reduced the goal from 140/90 mm Hg to 130/80 mm Hg for the general population, including community-dwelling seniors.
The American Heart Association and American College of Cardiology, which took over from the NHLBI's Joint National Commission in 2013, released the 2017 guideline with endorsement from nine other groups with key changes to the threshold, treatment algorithm, and blood pressure (BP) measurement.
Normal blood pressure remains below 120 mm Hg, but hypertension has been split into stage 1 (130/80 to 139/89 mm Hg) and stage 2 (140/90 mm Hg and higher) with different implications for treatment.
With the new target, the overall prevalence of hypertension among U.S. adults will jump to 45.6% compared with 31.9% the JNC7's 140/90 mm Hg threshold. That represents an additional 31.1 million people — National Health and Nutrition Examination Survey data through 2014 — for a total prevalence of 103.3 million, a simultaneously published study in Circulation indicated.
The targets were the same for older and younger adults, with the caveat that treatment decisions should be individualized for seniors with a high comorbidity burden and limited life expectancy.
The change was largely the SPRINT trial's finding that a target below 120 mm Hg reduced heart attack, stroke, or death in higher-risk older adults, with clear benefit and no evidence of increased risk of falls or orthostatic hypertension in elderly individuals in the trial.
But the SPRINT researchers have cautioned that the blood pressure measurements were taken with a careful automated process and in a clinical trial setting with a motivated population that differs from most clinical settings, such that their findings should not be directly applied to usual practice.
“It's much less evidenced-based than JNC8, but it's important to give advice. You can't study everything. There will never be another SPRINT,” commented Suzanne Oparil, MD, who was a reviewer for the new guideline but had co-chaired the JNC8 effort that resulted in unofficial recommendations after being disbanded by the NHLBI.
That controversial guideline had recommended looser thresholds for most hypertensive individuals 60 or older, starting pharmacologic treatment when the systolic pressure is 150 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.
“You can't get a direct conversion,” agreed ACC immediate-past president Richard Chazal, MD, “but it's about as 'science-y' as one can get.”
The guideline writing committee selected 130/80 mm Hg as an intermediate target balancing efficacy and safety for the general population, writing committee vice chair Robert Carey, MD, of the University of Virginia in Charlottesville, explained at a press conference. Even without SPRINT, though, the evidence across the more than 900 sources reviewed for the guidelines supported that lower is better for blood pressure, the group emphasized.
The blood pressure target for treatment also shifted to less than 130/80 mm Hg. However, there were key differences in recommended treatment by hypertension category.
- Stage 1 hypertension in the 130/80 to 139/89 mm Hg range was recommended for nonpharmacologic (predominantly lifestyle) therapy only unless the patient has clinical cardiovascular disease or at least a 10% 10-year risk of it the ACC/AHA atherosclerotic cardiovascular disease risk calculator already in use for cholesterol treatment decisions
- Stage 2 hypertension is recommended for blood pressure medication regardless of 10-year risk or cardiovascular disease status
- Elevated blood pressure (previously prehypertension) in the 120-129 mm Hg systolic range was recommended for non-pharmacologic attention to lifestyle therapy
Lifestyle measures are weight loss, the DASH diet, reducing sodium, increasing potassium through diet, physical activity, and moderate alcohol consumption (limit one drink per day for women, two for men).
Lifestyle change is challenging, acknowledged Paul Whelton, chair of the guidelines writing committee, also speaking at the press conference. However, “we have to come to grips with it, whether somebody can achieve the goals or not we have to provide them with the information and the mechanisms to achieve those goals.â€
The Circulation paper estimated a much smaller impact on prevalence of antihypertensive treatment than for overall prevalence because of the distinction by hypertension stage and risk level. It suggested an increase to 36.2%, up from 34.3% of adults with hypertension recommended for antihypertensive medication under the JNC7 guideline, representing an additional 4.2 million people.
â€œYes, this will be a new challenge for clinicians as many more patients will be classified as hypertension and need treatment â€” both lifestyle modifications and, in some, medications,â€ commented American Society of Hypertension President John Bisognano, MD. â€œBut this is a challenge that is worth taking for the right reasons and is the right approach to take.â€
Carey suggested “this guideline may be a can opener” to force change and a re-commitment to lifestyle improvements.
Donald Lloyd-Jones, MD, of Northwestern University in Chicago, predicted it will be a paradigm shift in how blood pressure is treated in the U.S.
The guidelines reiterated proper measurement techniques for BP measurement, including having the patient sit quietly for 5 minutes before a reading is taken.
Whelton also emphasized that the measurement should be averaged over two or three measurements taken on two or three separate office visits.
A new recommendation was for out-of-office BP measurement to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions.
The guideline itself was published in Hypertension, as a rambling, 192-page document that might be too much for many physicians to comb through, commented William Cushman, MD, a key SPRINT investigator.
â€œItâ€™s long because itâ€™s comprehensive,â€ Whelton said.
Still, “I generally think it is a very good guideline. I agree with most of recommendations,” he told MedPage Today. “I do think more emphasis could be made that the
Blood pressure targets in the elderly
1. Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) J Hypertens. 2013;31:1281–1357. [PubMed] [Google Scholar]
2. Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351:1755–1762. [PubMed] [Google Scholar]
3. SPRINT Research Group. Wright JT, Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–2116. [PMC free article] [PubMed] [Google Scholar]
4. Kjeldsen SE, Narkiewicz K, Hedner T, Mancia G. The SPRINT study: outcome may be driven by difference in diuretic treatment demasking heart failure and study design may support systolic blood pressure target below 140 mmHg rather than below 120 mmHg. Blood Press. 2016;25:63–66. [PubMed] [Google Scholar]
5. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014;311:507–520. Erratum in: JAMA 2014; 311:1809. [PubMed] [Google Scholar]
6. Wright JT, Jr, Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med. 2014;160:499–503. [PubMed] [Google Scholar]
7. Butt DA, Mamdani M, Austin PC, Tu K, Gomes T, Glazier RH. The risk of hip fracture after initiating antihypertensive drugs in the elderly. Arch Intern Med. 2012;172:1739–1744. [PubMed] [Google Scholar]
8. Smulyan H, Mookherjee S, Safar ME. The two faces of hypertension: role of aortic stiffness. J Am Soc Hypertens. 2016;10:175–183. [PubMed] [Google Scholar]
9. Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887–1898. [PubMed] [Google Scholar]
10. Nayor M, Stevenson MD, Musani SK, Xanthakis V, LaValley MP, Larson MG, et al. Incidence of cardiovascular disease in individuals affected by recent changes to US blood pressure treatment guidelines. J Hypertens. 2017 [PMC free article] [PubMed] [Google Scholar]
11. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903–1913. Erratum in: Lancet. 2003; 361:1060. [PubMed] [Google Scholar]
12. Bavishi C, Bangalore S, Messerli FH. Outcomes of intensive blood pressure lowering in older hypertensive patients. J Am Coll Cardiol. 2017;69:486–493. [PubMed] [Google Scholar]
13. Julius S, Kjeldsen SE, Weber M, Brunner HR, Ekman S, Hansson L, et al. Outcomes in hypertensive patients at high cardiovascular risk treated with regimens valsartan or amlodipine: the VALUE randomised trial. Lancet. 2004;363:2022–2031. [PubMed] [Google Scholar]
14. Dominiczak A, Delles C, Padmanabhan S. Genomics and precision medicine for clinicians and scientists in hypertension. Hypertension. 2017;69:e10–e13. [PubMed] [Google Scholar]
15. Currie G, Delles C. The future of “omics” in hypertension. Can J Cardiol. 2017;33:601–610. [PMC free article] [PubMed] [Google Scholar]
Ideal Target Blood Pressure in Hypertension
1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127–e248. [PubMed] [Google Scholar]
2. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39:3021–3104. [PubMed] [Google Scholar]
3. Kim KI, Ihm SH, Kim GH, et al. 2018 Korean society of hypertension guidelines for the management of hypertension: part III-hypertension in special situations. Clin Hypertens. 2019;25:19. [PMC free article] [PubMed] [Google Scholar]
4. Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. JAMA. 1967;202:1028–1034. [PubMed] [Google Scholar]
5. Effects of treatment on morbidity in hypertension. II. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA. 1970;213:1143–1152. [PubMed] [Google Scholar]
6. Hypertension-Stroke Cooperative Study Group. Effect of antihypertensive treatment on stroke recurrence. JAMA. 1974;229:409–418. [PubMed] [Google Scholar]
7. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the hypertension detection and follow-up program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA. 1979;242:2562–2571. [PubMed] [Google Scholar]
8. The Australian therapeutic trial in mild hypertension. Report by the Management Committee. Lancet. 1980;315:1261–1267. [PubMed] [Google Scholar]
9. Medical Research Council Working Party. MRC trial of treatment of mild hypertension: principal results. Br Med J (Clin Res Ed) 1985;291:97–104. [PMC free article] [PubMed] [Google Scholar]
10. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet. 1998;351:1755–1762. [PubMed] [Google Scholar]
11. Klahr S, Levey AS, Beck GJ, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. N Engl J Med. 1994;330:877–884. [PubMed] [Google Scholar]
12. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560–2572. [PubMed] [Google Scholar]
13. ACCORD Study Group. Cushman WC, Evans GW, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575–1585. [PMC free article] [PubMed] [Google Scholar]
14. Wright JT, Jr, Bakris G, Greene T, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: results from the AASK trial. JAMA. 2002;288:2421–2431. [PubMed] [Google Scholar]
15. Ruggenenti P, Perna A, Loriga G, et al. Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial. Lancet. 2005;365:939–946. [PubMed] [Google Scholar]
16. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) J Hypertens. 2013;31:1281–1357. [PubMed] [Google Scholar]
17. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) JAMA. 2014;311:507–520. [PubMed] [Google Scholar]
18. SPRINT Research Group. Wright JT, Jr, Williamson JD, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–2116. [PMC free article] [PubMed] [Google Scholar]
19. Pappaccogli M, Di Monaco S, Perlo E, et al. Comparison of automated office blood pressure with office and out-off-office measurement techniques. Hypertension. 2019;73:481–490. [PubMed] [Google Scholar]
20. Roerecke M, Kaczorowski J, Myers MG, et al. Comparing automated office blood pressure readings with other methods of blood pressure measurement for identifying patients with possible hypertension: a systematic review and meta-analysis. JAMA Intern Med. 2019;179:351–362. [PMC free article] [PubMed] [Google Scholar]
21. Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957–967. [PubMed] [Google Scholar]
22. Xie X, Atkins E, Lv J, et al. Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. Lancet. 2016;387:435–443. [PubMed] [Google Scholar]
23. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels – updated overview and meta-analyses of randomized trials. J Hypertens. 2016;34:613–622. [PubMed] [Google Scholar]
24. Lee CJ, Ryu J, Kim HC, et al. Clinical benefit of treatment of stage-1, low-risk hypertension. Hypertension. 2018;72:1285–1293. [PubMed] [Google Scholar]
25. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP) JAMA. 1991;265:3255–3264. [PubMed] [Google Scholar]
26. Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet. 1997;350:757–764. [PubMed] [Google Scholar]
27. Wang JG, Staessen JA, Gong L, Liu L Systolic Hypertension in China (Syst-China) Collaborative Group. Chinese trial on isolated systolic hypertension in the elderly. Arch Intern Med. 2000;160:211–220. [PubMed] [Google Scholar]
28. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887–1898. [PubMed] [Google Scholar]
29. JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS) Hypertens Res. 2008;31:2115–2127. [PubMed] [Google Scholar]
30. Ogihara T, Saruta T, Rakugi H, et al. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension. 2010;56:196–202. [PubMed] [Google Scholar]
31. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA. 2016;315:2673–2682. [PMC free article] [PubMed] [Google Scholar]
32. Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med. 2006;144:884–893. [PubMed] [Google Scholar]
33. Böhm M, Schumacher H, Teo KK, et al. Achieved blood pressure and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials. Lancet. 2017;389:2226–2237. [PubMed] [Google Scholar]
34. Kimm H, Mok Y, Lee SJ, Lee S, Back JH, Jee SH. The J-curve between diastolic blood pressure and risk of all-cause and cardiovascular death. Korean Circ J. 2018;48:36–47. [PMC free article] [PubMed] [Google Scholar]
35. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering treatment in hypertension: 8. Outcome reductions vs. discontinuations because of adverse drug events – meta-analyses of randomized trials. J Hypertens. 2016;34:1451–1463. [PubMed] [Google Scholar]
36. Bansilal S, Castellano JM, Garrido E, et al. Assessing the impact of medication adherence on long-term cardiovascular outcomes. J Am Coll Cardiol. 2016;68:789–801. [PubMed] [Google Scholar]
New blood pressure guideline could prevent 3 million cardiovascular events over 10 years
In 2017, the American College of Cardiology and the American Heart Association released new blood pressure guidelines, lowering hypertension threshold to 130/80 mm Hg from the previous 140/90 mm Hg.
A new study predicts that achieving and maintaining the 2017 guideline blood pressure goals could prevent more than 3 million cardiovascular disease events over ten years.
The results of the study will appear online in the November 19 issue of Circulation.
“Treating high blood pressure is a major public health opportunity to protect health and quality of life for tens of millions of Americans,” said the study's lead author Adam Bress, Pharm.D., M.S., assistant professor in Population Health Sciences at University of Utah Health. “Achieving these lower goals will be challenging.”
Bress and his team wanted to explore the impact of achieving and maintaining the lower guideline-recommendations on the public compared to earlier blood pressure and treatment levels, as well as patients' ability to achieve and maintain earlier guideline recommendations.
The team predicted the number of cardiovascular events averted in middle-age adults the blood pressure goals of the 2017 blood pressure guidelines (< 130/80 mm Hg), the seventh Joint National Committee (JNC7) guidelines (< 140/90 mm Hg) and the eighth Joint National Committee (JNC8) guidelines (140/90 mg Hg for patients younger than 60 and 150/90 mm Hg for patients older than 60).
Their analysis projects 3.3 million fewer cardiovascular disease events after achieving and maintaining the 2017 blood pressure goals compared to current blood pressure levels. They also found that achieving and maintaining the JNC7 and JNC8 recommended blood pressure goals would prevent 2.6 and 1.6 million cardiovascular disease events, respectively.
This study made these predictions using several contemporary, population-based databases. The NHANES dataset is a national representative survey of the U.S. adult population and provides population sizes of hypertension treatment groups by blood pressure levels and chronic conditions.
The REGARDS database provides a source for the risk of fatal and nonfatal cardiovascular events.
A recent meta-analysis of 42 randomized blood pressure-lowering clinical trials, consisting of more than 140,000 participants, provides the risk reduction predictions for cardiovascular events achieving and maintaining different blood pressure treatment targets.
The majority of cardiovascular disease events prevented came from those with current blood pressure levels above 140/90 mm Hg. Models assumed that patients achieved and maintained blood pressure goals over the course of the simulation.
Previous studies suggest the initial upfront investment for treating more adults for hypertension leads to health gains and cost savings over the lifetime of treatment. But change does not always come easily.
“A change in longstanding clinical guidelines is disruptive to patients and providers who are accustomed to clinical practice patterns that integrate the earlier guidelines,” said Andrew Moran, M.D., M.P.H.
, associate professor of Medicine at the Columbia University Irving Medical Center and senior author on the paper.
“It is important to project and quantify the range of potential benefits and risks expected if we make these fundamental changes to the way health care providers practice.”
Treating more patients to achieve lower blood pressure goals does have risks. Bress notes that medications often come with side effects, which need to be monitored and managed.
“The number of medication-related adverse events was roughly equivalent to the number of cardiovascular disease events prevented,” Moran said. “But the adverse events tend to be minor and transient, while the avoided cardiovascular events can lead to serious life time health problems and are sometimes even fatal.”
The results are a database that is not representative of the diversity in the country, including information for only white and black patients that are at least 45 years old. It also does not directly account for future changes in blood pressure or changes in antihypertensive medications through time.
“A conversation and shared decision making between provider and patient about benefits and risks of increasing the dose of a medication or adding a new medication to achieve a lower target are important,” Bress said. “Benefits to reduce the risk of heart attacks, stroke and heart failure are clear and may often outweigh risk of minor, transient side-effects.”
Materials provided by University of Utah Health. Note: Content may be edited for style and length.
Stricter Blood Pressure Guidelines Could Prevent Cardiovascular Events, but Debate Continues
A 2015 study sponsored by the National Institutes of Health made a change in blood pressure guidelines seem inevitable. But there is disagreement between the standards promoted by societies for family physicians and those for cardiologists, leading to confusion for those in daily practice.
A year ago, the American College of Cardiology (ACC) and the American Heart Association (AHA) updated new blood pressure guidelines that lowered the threshold at which some patients should be treated for hypertension, from 140/90 mmHg to 130/80 mmHg.
A new study, published today in the AHA journal, Circulation, finds that change could translate into 3 million fewer cardiovascular disease events over 10 years, compared with earlier guidelines.
1 “Treating high blood pressure is a major public health opportunity to protect health and quality of life for tens of millions of Americans,” said lead author Adam Bress, PharmD, MS, assistant professor of Population Health Sciences at University of Utah Health, in a statement. “Achieving these lower goals will be challenging.”
But Bress’ study is just one among several that have come recently, along with commentary that show despite a landmark National Institutes of Health (NIH) study in 2015 that seemed a mandate for lower blood pressure targets, not everyone is on board. The new study additionally says that for the highest-risk cardiovascular patients, the new guidelines could result in an increase of treatment-related serious adverse events, which suggest the need for personalized care.One challenge is the Western diet, which is cited as the cause of rising levels of obesity and diabetes around the world. The assumption that blood pressure must rise with age may not be true, and it may be more closely connected to what we eat.
A study published last week in JAMA Cardiology compared blood pressure of 2 remote South American tribes, one which had no exposure to Western dietary patterns and the other which had some exposure to processed foods with higher levels of salt. Despite similar genetic backgrounds, the tribe that consumed saltier foods had higher blood pressure. Many believe the real key to treating heart disease and diabetes is getting serious about dietary and nutrition policy.
Bress and his team calculated fewer events in middle-aged adults the 2017 blood pressure goals when compared with guidelines in the seventh Joint National Committee, known as JNC7, as with the eighth Joint National Committee (JNC8), which put the cutoff for hypertension at 140/90 mmHg for patients younger than 60 years of age and 150/90 mmHg for those age 60 years and older.
Last month, Franz H. Messerli, MD, and Sripal Bangalore, MD, MHA, writing in the Journal of the American College of Cardiology explained how physicians are justifiably confused.
They offer a case study of a 63-year-old female patient with blood pressure readings that average 148/86 mmHg.
Guidelines between ACC/AHA, which cover 25,000 cardiologists, and those of the European Society of Hypertension and European Society of Cardiology, which cover 75,000 physicians, are not in alignment.2
ACC/AHA guidelines say her blood pressure should be 130/80 mmHg. The European guidelines say her blood pressure should be 140/90 mmHg. But guidelines for the American College of Physicians and the American Association of Family Physicians say she’s just fine at 150/90 mmHg. The guidelines don’t align on how many medications to use when starting treatment, either.
Ironically, all 3 guidelines are the same study; called SPRINT (Systolic Blood Pressure Intervention Trial), this was a large trial by the NIH that stopped early because it became clear that treating patients to a lower blood pressure target was resulting in fewer fatal cardiovascular events.
Despite this, the ACP guidelines insist that treating blood pressure to a target of 130/80 mmHg across a population of older adults will result in “low value care.”Messerli and Bangalore see more frustration ahead. “The above hypertension guideline fiasco eloquently illustrates the potential shortcomings of dogmatic clinical directives and, if anything, is prone to increase the rift between those who preach, those who teach, and those who treat,” they wrote. “Unless we make a concerted effort to do so, as the number of guidelines is increasing more rapidly than does iron-clad evidence, we are prone to see more and more schism among recommendations, confusion among physicians, and anxiety among patients,” the authors concluded.
- Bress AP, Colantonio LD, Cooper RS, et al. Potential cardiovascular disease events prevented with adoption of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline [published online November 19, 2018]. Circulation. doi: 10.1161/CIRCULATIONAHA.118.035640.