New guidelines for the treatment of hypertension have raised systolic target numbers from 140 to 150 mm Hg for adults age 60 and older, and from 130 to 140 for adults with diabetes or kidney disease, according to a study published in the Annals of Internal Medicine.
The guidelines are based on a review of 21 clinical trials, including the landmark SPRINT study that seems to contradict the new recommendations by suggesting significant health improvements when systolic pressure is lowered from 140 to 120.
The new guidelines take into account the strength of the evidence in previous studies, as well as the possible side effects of hypertension medications, particularly in elderly patients.
For years, patients have been led to believe that if their blood pressure is 140 or higher, then it’s too high. The new guidelines took a fresh look at the evidence and concluded that while lowering blood pressure below 140/90 does lower the chance of stroke and cardiac events, it doesn’t reduce mortality. The clinical trials the researchers examined provided strong evidence that getting blood pressure below 150/90 is a good idea, but further benefits were supported only by low- to moderate-strength evidence.
At the heart of the issue is how aggressively hypertension should be treated. Blood pressure is typically measured along with the vital signs of temperature, pulse and respiration. As a risk factor for heart attacks and strokes, it is the topic of countless public health campaigns. But the medications used to treat hypertension come with their own risks and problems.
Like every conversation about healthcare, cost is a factor. If a patient doesn’t reliably take prescribed blood pressure medications due to cost, there is little point in increasing the dosage or adding another drug. In addition, many drugs are filtered through the kidneys, a burden that may not be worth the risk for people with kidney disease. Furthermore, as people age, the effect of medications on their bodies changes, so dosing is more challenging and side effects may be magnified.
The guidelines do include a recommendation that some patients might be better off with a target systolic blood pressure less than 140 mm Hg, which is consistent with the previous guidelines for senior patients. But the most important (and seemingly least discussed) recommendation is for clinicians to select treatment goals based on individualized assessments and discussions of risks versus benefits. This highlights how precision medicine and personalized care could be inching more and more into a physician's workflow.