How high is too high for blood pressure?
The Centers for Disease Control estimates that about 75 million Americans have high blood pressure. That is one-third of the general population, and the percentage climbs to more than two-thirds in people over the age of 60.
Most people know that lower numbers are better when it comes to blood pressure, so it came as a surprise to many when the American College of Physicians and the American Academy of Family Physicians raised the recommended numbers for those over the age of 60.
On January 17, the ACP and AAFP published the results of their evidence-based joint study in the Annals of Internal Medicine, recommending that for those over 60 with no history of heart attack and stroke, a systolic reading of under 150 is safe for otherwise healthy adults. For those who have a history of stroke or heart attack or are at increased cardiovascular risk from other factors, the recommendation is to keep the number under 140.
The higher numbers are quite a bit different from the American Heart Association’s recent recommendation that blood pressure remain lower than 120/80 to fall in the normal range. In reaction to the news in January, the AMA republished a news brief firmly backing their own more stringent recommendations.
“When the organizations themselves don’t agree on the recommendations, it gets tricky,” said cardiologist Lawrence McAuliffe, MD, of Cape Cod Healthcare Cardiovascular Center in Hyannis. “I don’t think anybody would dispute that ideally we would like to have the systolic, or the upper number of blood pressure, be less than 140. The AHA guidelines are 120 or less but it’s very hard to achieve that number without a substantial amount of pharmaceutical intervention.”
The problem with prescribing a lot of medication is that blood pressure drugs can have side effects such as a dry cough, fatigue, increased frequency of urination or a dry mouth. When people feel poorly while taking the meds, they are less likely to be compliant about taking them, Dr. McAuliffe said.
Plus, there is a danger with older patients of causing blood pressure to fall too low, which leads to symptoms like nausea, dizziness and lightheadedness, which can cause dangerous falls. This is one of the reasons the ACP and the AAFP recommended raising the number, he said.
The physicians’ organizations also cautioned against “white coat hypertension” where a patient’s blood pressure is falsely elevated in clinical settings. That could lead a physician to prescribe a medication that isn’t actually needed. With that in mind, they recommended that before a prescription is written, doctors do multiple blood pressure measurements over time and that patients do home monitoring as well.
“Sometimes you make them sicker if you manage to the number,” Dr. McAuliffe said. “The key is knowing your patients and being practical – not being dogmatic about the guidelines, but incorporating the guidelines in such a way that makes sense for the individual patient to achieve reasonable success.”
Even so, lower is still considered better, he said. The trick is to find the optimal blood pressure each patient can thrive on, because statistically you can draw straight parallels between uncontrolled or poorly controlled blood pressure and end organ conditions like heart attacks, strokes, peripheral vascular disease and kidney failure.
With that in mind, Dr. McAuliffe wouldn’t feel comfortable letting one of his patients stay consistently at or near 150 systolic pressure. If a patient who generally had numbers lower than 140 one day had a number of 144, he wouldn’t be overly concerned.
He would make sure that they were still taking their medication, warn them to limit salt, and encourage them to exercise regularly and eat a healthy diet. He would also recommend increasing the number of times they check their blood pressure to make sure there isn’t an upward trend.
“Most doctors on the front line understand that managing a patient is a dynamic exercise of advice, guidance and compromise,” he said. “You can’t be so rigid and uncompromising that patients don’t listen to you.”