New High Blood Pressure Guidelines Released – A Paradigm Change | Robert A. Erickson, M.D.
In an article entitled “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults, Paul A. James, et al.” published in the Journal of the American Medical Association in December 2013, the new guidelines released by the Eighth Joint National Committee for managing high blood pressure were presented. What most of the headlines in the newspapers and Internet emphasized was the panel declared adults older than age 60 should aim for a blood pressure level less than 150/90 mmHg., and not the previously recommended 140/90 threshold. For people aged 30-59 a blood pressure less than 140/90 mmHg was recommended. These conclusions were determined after looking at data from randomized controlled trials. However, if one reads the entire findings of the committee carefully, there are a number of important conclusions I will go into.
The committee members identified “threshold blood pressure” – that is levels at which treatment can begin, rather than defining at which blood pressure level hypertension begins. The committee members concluded their guidelines by adding “However, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.”
So what does this mean? For one thing, many people who had drug treatment started because of mild elevations in systolic blood pressure are now in an “over-treatment” category and patients who had high-normal values and were being treated for so-called “pre-hypertension,” a condition never officially sanctioned for treatment, are also being over-treated.
In patients with kidney disease and/or diabetes, the authors similarly stated we lack evidence for the right targets and so they settled on a goal of less than 140/90. This is a change for some people whose physicians may have been using a target of less than 130 systolic for these patients. The authors noted that the 130 systolic recommendation does not have evidence to base it on.
A second issue that came out of the panel report was there is insufficient medical evidence to support a systolic pressure threshold for placing people younger than 60 on anti-hypertensive drugs. This lack of medical evidence did not stop the authors from expressing an opinion to stay with the current threshold of 140 mmHg for systolic in this age group, even though it is based on opinion and not evidence. The panel did indicate the diastolic blood pressure (bottom number) should be less than 90 for people age 30 and older, and there is scientific evidence to support this recommendation.
Another important conclusion is that drug therapy, while lowering blood pressure, does not necessarily mean you have reduced someone’s risk for a heart attack or stroke, even though we know hypertension is a risk factor for these events. This conclusion was based on findings from several studies where patients with mildly elevated blood pressures that were lowered failed to reduce risk – this was a surprising finding. Please note there is no question that drug treatment of very high blood pressure levels is beneficial.
From my standpoint, the good news from this panel was the authors were led to be more conservative in their recommendations for drug treatment and they also emphasized the importance of a healthy diet, weight control and exercise. At the Center, we have found in some hypertensive patients the addition of magnesium supplements, potassium gluconate, and/or an herbal product called Natural Blood Pressure relief will lower blood pressure. We have also found stress reduction is very important, as is making sure a person’s home blood pressure machine is calibrated in an accurate manner.