Recheck Your Numbers

Think your blood pressure levels are fine for now? You might want to think again, as new guidelines have lowered the level at which heart associations recommend taking action to treat hypertension.

In November, the American College of Cardiology/American Heart Association issued new guidance for when to treat high blood pressure, lowering the cutpoint from 140/80 to 130/80 — effectively shifting 31 million American adults from pre-hypertensive to a full-blown diagnosis of hypertension, many of them younger adults. The task force did not change the cutpoint for what is considered normal blood pressure (less than 120/80).

Nearly half of all American adults (46 percent) would be considered hypertensive under the new guidelines — 14 percent more than previously believe to fit this category. The authors of the new guidelines expect that the number of men under age 45 who have high blood pressure will triple under this definition and the number of women in this age category will double.

However, most of those who meet the new criteria won’t need medication, says Paul K. Whelton, MB, MD, MSc, FACC, professor at Tulane University School of Public Health and Tropical Medicine/School of Medicine in New Orleans, and lead author of the new guidelines.

“It does not change dramatically the number of people needing drug therapy,” Dr. Whelton says. “Mostly what they need is a lifestyle change. That’s the underlying cause of most hypertension — it’s due to poor diet or lack of physical activity.”

He says that the writing committee reexamined the guidelines in light of a wealth of new research published since the last comprehensive analysis was conducted in 2003.

The classifications for hypertension had not been changed since 1993. The cutpoint was lowered to encourage people to take steps to lower their blood pressure if high, and, for those at risk, to prevent any elevation.

“We now have a lot more precise information on risk and a lot of new treatment trials,” Dr. Whelton says.

On the risk side, he says, “It’s now very clear that people with average systolic levels or 130 or more are already at pretty high risk. They generally have double the risk of having a heart attack or stroke compared to those with levels in the normal range. We know from clinical trials that getting pressures down below that level is really beneficial.”

There are three major factors that contribute to the risk of having a heart attack or stroke, says Dr. Whelton: diet, physical activity and smoking. Each of these risks can be reduced.

If you smoke, talk to your healthcare team about starting a cessation plan. Smoking not only increases blood pressure levels, it decreases your tolerance for exercise, according to the American Heart Association.

And exercise is key to lowering blood pressure levels, says Dr. Whelton — especially aerobic exercises, such as walking, running or swimming. Other activities, such as weight lifting, have also been shown to help. “But any increase in physical activity is beneficial,” he says.

Losing weight, if you are overweight, is also important, he says. This can be done through both exercise and diet. “Getting to an ideal weight is the goal, but any weight loss is beneficial,” he says. As with exercise, says Dr. Whelton, there’s no perfect method for reaching your goals, though some are better than others.

“Any healthy diet is good,” he says, but the DASH diet — which is rich in fruits and vegetables, whole grains, potassium, calcium and magnesium, while low in sodium and fat (https://www.nhlbi.nih.gov/health-topics/dash-eating-plan) — is “particularly constructed to lower blood pressure.”

Avoiding excess intake of sodium and increasing potassium, which helps the body excrete sodium, are key elements to any diet designed to lower blood pressure, he says.

Reducing alcohol consumption can also help lower blood pressure, says Dr. Whelton. “If you drink, your blood pressure will go up,” he says. However, because moderate alcohol consumption has been shown to beneficially impact lipid profiles and raise HDL cholesterol, the guidelines allow for two drinks per day for men and one for women.

“Those are the nonpharmacological approaches that everyone should take,” says Dr. Whelton. “But as your pressure climbs up and gets closer to the cutpoints for hypertension, you have to take it more seriously. Prevention is always better than treatment.”

The new guidelines place blood pressure levels into five categories, eliminating prehypertension.

Normal: systolic less than 120 mmHg and diastolic less than 80 mmHg.

Elevated: systolic 120-129 and diastolic less than 80.

Hypertension, Stage 1: systolic 130-139 or diastolic 80-89.

Hypertension, Stage 2: systolic at least 140 or diastolic at least 90.

Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

Medication is not recommended for people in the “elevated” category, say Dr. Whelton. Nor is it recommended for everyone in Stage 1.

“In terms of making a decision about whether to treat with medication, we suggest an approach that’s different than before,” he says. “We say all patients with hypertension should have an assessment of their underlying atherosclerotic cardiovascular risk to see if it’s high. We look at whether they’ve had a previous stroke or a heart attack. If they have, they are at high risk for a second event and should be treated with medication. If they have not, we put their risk factors into a risk calculator and it will predict their chances of having an event in the future. If that risk exceeds ten percent over the next ten years, we consider that high and that person should be on medication.”

Dr. Whelton says people can calculate their own risk using an online tool. One to try: https://www.acc.org/tools-and-practice-support/mobile-resources/features/2013-prevention-guidelines-ascvd-risk-estimator.

Adults over the age of 65 and those with diabetes or chronic kidney disease are automatically considered high risk and should be treated with medication if their blood pressure exceeds the normal range, he says. Medication is also beneficial for those with stage 2 hypertension.

Dr. Whelton noted that some people with high blood pressure do not test high in their provider’s office but do show elevated levels at home. Therefore, he recommends that people test regularly at home and provide this data to their healthcare team.

“This is called masked hypertension, and it’s relatively common,” he says. “It’s hard to get an exact number,” so it’s important to monitor blood pressure in more than one setting and look at the overall pattern, which requires help from the patient. “The clinician is there to provide advice and make recommendations for treatment,” he says, “but at the end of the day, the patient is the most important person on that team.”