A smaller number of older Americans with hypertension could be put on blood pressure-lowering medications if doctors follow new advice from a panel of experts. The guidelines, published online Wednesday in the Journal of the American Medical Association, raise the threshold for treating those over age 60, recommending that doctors don’t prescribe medications until levels reach 150/90 mmHg instead of the previous recommendation of 140/90 mmHg that was issued 10 years ago.
Older patients with hypertension also shouldn’t be treated with additional medications or higher doses to drive down their blood pressure levels to below 150/90 mmHg—a change from previous advice.
“We did not find evidence for additional health benefits in achieving a level of 140 instead of 150 in those over age 60,” said Dr. Paul James, co-chair of the guideline committeee and chair of family medicine at the University of Iowa Carver College of Medicine. “We were particularly concerned about medication side effects in the elderly population like light-headedness and dizziness, which increases the risk of falling and broken bones.”
Anyone with diabetes or kidney disease, regardless of their age, should now aim for blood pressure levels of below 140 mmHg instead of the previous recommendation of below 130 mmHg. The recommendations didn’t change for younger folks with high blood pressure: treat when their levels go above 140/90 mmHg and use drugs to lower elevated levels down to that point.
Hypertension remains one of the biggest factors involved in stroke and heart disease deaths, and the guideline emphasizes the importance of controlling high blood pressure through lifestyle changes like weight loss, reduced salt intake, and exercise in addition to using medications. About one-third of Americans currently have high blood pressure, and 90 percent develop it at some point after age 55.
James said the guideline was intended to simplify the old recommendations, which had differing advice for specific groups of patients like those who had a previous heart attack or stroke. “We wanted to get advice out to the primary care community of doctors, not just cardiologists, since family doctors are often the ones treating hypertension.”
In terms of treatment, the panel recommended any of the four classes of drugs: diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers. African Americans, however, should be prescribed calcium channel blockers or ACE inhibitors first because those medications are more effective at lowering their blood pressure.
Hypertension experts who weren’t involved in the guideline development applauded the panel for basing their recommendations on clinical trials, disclosing any financial relationships with drug manufacturers, and not allowing panel members with financial conflicts to vote on the recommendations. But some also pointed out that the guideline was likely to generate controversy and could lead to unintended consequences.
“It has taken a decade to teach clinicians and patients that high BP is defined as levels higher than 140/90 mmHg, so how long will it take to teach them that these targets need to be altered to 150/90 mmHg for patients who reach 60 years of age?” wrote the authors of an editorial that accompanied the study. They pointed out that only half of those with hypertension have reached the 140 mmHg treatment goal, and it’s likely the new recommendation will mean fewer than half will now reach the new 150 mmHg goal.
Dr. Randall Zusman, director of the division of hypertension at Massachusetts General Hospital Heart Center, said he would have preferred a more detailed set of recommendations that pertained more to patients with a mix of medical conditions beyond simple hypertension.
“What about people with congestive heart failure, coronary artery disease, heart arrhythmias? There are lot of individual characteristics that these guidelines don’t address,” said Zusman, who was not involved with the guideline. He also would have like to have seen more emphasis placed on lifestyle modifications specific to lowering high blood pressure like a relaxation techniques. (The authors referred doctors to a new guideline issued by the American Heart Association recommending lifestyle measures to prevent heart disease.)
A number of cardiologists also complained that the new guideline was not issued by any major medical group or government entity. The National Heart, Lung, and Blood Institute previously endorsed guidelines outlining treatment for hypertension, high cholesterol, and heart disease prevention, but they decided, for unexplainable reasons, to remove themselves from this process earlier this year.