New Blood Pressure Guidelines
Adults aged 60 or older should only take blood pressure medication if their blood pressure exceeds 150/90, which sets a higher bar for treatment than the current guideline of 140/90, according to the report, published online Dec. 18 in the Journal of the American Medical Association.
Guidelines were also developed by an expert panel. They recommend that diabetics and patients with kidney disease younger than 60 years old be treated in the same way as all other people, regardless of whether their blood pressure rises above 140/90. The only exception to this rule is when the blood pressure was above 130/80.
Blood pressure refers to the force applied on blood vessels by blood pumping. The systolic (or upper) reading measures the force exerted by the heart as it contracts and pumps blood out from its chambers. The lower reading (known as diastolic ) measures the force of contractions and relaxation. Normal adult blood pressure is 120/80.
Based on evidence from clinical studies, the recommendations do not offer any added benefit for patients. This is explained by Dr. Paul James who heads the University of Iowa Carver College of Medicine department of Family Medicine.
James stated that blood pressure levels below 150 for people older than 60 years of age are not likely to have any health benefits. It was clear that 150 was the optimal number.
Although the American Heart Association (AHA), and American College of Cardiology(ACC) didn't review the guidelines, the AHA expressed concerns about the conclusions of the panel.
"We're concerned about the possibility that we relax the guidelines and expose even more individuals to inadequately controlled bloodpressure," Dr. Elliott Antman is the AHA's president-elect. He's a Brigham and Women's Hospital cardiologist and Harvard Medical School professor.
The AHA and ACC jointly released their November treatment guidelines for high bloodpressure. They also published new guidelines to treat high cholesterol. This could increase the use of cholesterol-lowering statins.
According to the U.S. National Heart, Lung, and Blood Institute, about one third of Americans have high blood pressure.
The institute formed the Eighth Joint National Committee, or JNC 8, in 2008 to update the last set of high blood pressure treatment guidelines, which were issued in 2003.
The institute declared in June 2013 that it was no longer participating in any development of clinical guidelines. This includes the near-finalized blood pressure guidelines.
However, this announcement was made only after JNC 8's preliminary findings had been reviewed by the institute. JNC 8 decided not to abandon the project and continue working on the guidelines.
James stated that seniors should be started on medication when their blood pressure is higher. This recommendation was based on both evidence and concern about drug interactions.
The elderly have a higher chance of developing other conditions that need medication. He said that it is not unusual for him to encounter people on more than 10 medications for different illnesses. "If there's no proof of increased health benefits then why would we add these additional medicines?"
James explained that high blood pressure is defined as anything exceeding 140/90. He explained that lifestyle changes are recommended to help people with high blood pressure who fall below levels where medication is required.
The panel also recommended a "toolbox" of four different blood pressure medications that doctors could use treat patients -- diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs).
James explained that the diuretic classes offer options for doctors to start treatment. All classes also have generic versions. The slight distinction is from JNC7, where the patients preferred the diuretic as their first choice. There were no significant differences in the health outcomes of these four classes.
James clarified that this is a guideline for doctors. These guidelines should be read carefully by patients and not used to discontinue medication. "These recommendations are for highly-trained professionals, who can adapt them to each patient's individual needs.
JNC 8 came to its conclusion after reviewing 30 years of clinical trials. The AHA believes that these studies did not adequately assess the long-term effects of high blood pressure.
Antman explained that high blood pressure can have adverse consequences on health and may develop over many years, which is longer than the timeframe of some of the evidence-review trials.
Epidemiologic evidence has shown that a lower blood pressure is associated with lower rates of strokes, heart failure and death, he added.
Guidelines issued by AHA and ACC recommend lifestyle changes for people suffering from a systolic (or diastolic) pressure between 140 and 159. Treatment for blood pressure above those levels should include medication as well lifestyle modifications. The person with blood pressure above 140/90 would be treated.
Although the JNC 8 guidelines weren't reviewed by either the AHA nor the ACC, Dr. Harold Sox of Dartmouth Institute for Health Policy and Clinical Practice said that the panel provided sufficient transparency to warrant serious consideration.
"They presented all the evidence clearly and they were very careful in making recommendations so you can trace the evidence back without having to ask, 'How did that happen?' Sox stated.
Sox said that although they did not send guidelines to AHA/ACC, their documentation was so comprehensive that it was impossible for them to have learned more than the information they had in the initial review.
Curtis Rimmerman (staff cardiologist at Cleveland Clinic, Ohio) said that he will consider the recommendations when making future decisions about his treatment.
He stated, "I am going to have the responsibility to support responsible people who do responsible acts." It won't change the way I practice, but it will make me want to take in more information. Some patients may allow me to relax their blood pressure goals. This is especially true for older patients taking multiple medications.