Navigating the confusing blood pressure recommendations
The last few years have seen some big changes in formal medical recommendations for treatment of hypertension (high blood pressure) for older patients. In 2014, the Joint National Committee 8 (JNC) produced a lengthy report called, “2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults,” that got a large amount of attention. The JNC is a big panel of experts that get together, crunch data, and try to make big picture recommendations for the everyday front-line health care provider. In this case, they reviewed a few decades worth of randomized controlled trials and gave guidelines on when to start treatment for hypertension, and which drugs to choose for different population groups. The big excitement here was that the JNC recommended that adults over the age of 60 with uncomplicated hypertension not start treatment until their blood pressure (BP) was above either 150 systolic (top number) or 90 diastolic (bottom number).
The previous JNC 7 recommendation had kept the more traditional 140/90 number so having the extra ten points for wiggle room before initiating treatment in older adults was a fairly big shift. This allows for less stringent control of numbers and more careful tailoring of treatment to the patient. The big goal is to keep patients who are more vulnerable to falls from being slightly dizzy when standing up and taking a tumble that could result in a fracture. It’s a classic case of weighing what is more likely to be a concern for a 75-year-old – having a stroke or breaking a hip? To be clear, the JNC does not recommend reducing treatment in patients who are responding well to medication and are stable just to get them closer to 150/90. They also, bless them, state that “For all persons with hypertension, the potential benefits of a healthy diet, weight control, and regular exercise cannot be overemphasized. These lifestyle treatments have the potential to improve BP control and even reduce medication needs.”
Don’t confused with new BP guidelines. Lifestyle changes are still the first choice in treatment and save aggressive medication for numbers above 150/90 if you are over 60.
This was all moving along well until September 2015 when the Systolic Blood Pressure Intervention Trial (SPRINT) from the NIH was stopped 2 years earlier than planned because the data was so compelling. This trial looked as using medication to keep systolic blood pressure at or below 120 in patients over the age of 50. It found that by doing so (compared to a systolic number of 140 or less) the risk of a cardiovascular event such as a heart attack or stroke was reduced by a one-third and the risk of death was reduced by one-quarter. Potentially extremely compelling numbers, but we don’t have all of the information yet.
The formal results from the trial are being presented this month (November 2015) at the American Heart Association meeting. Hopefully soon after the final results will be published so we can analyze the data more carefully. Right now we don’t know even basic statistical information such as absolute vs relative risk, overall safety with using the multiple medications often required to achieve desired numbers, and whether or not there is a useful subgroup breakdown (example: do we know if there is differentiation between a 52-year-old and a 72-year-old patient?). It’s also good to keep in mind that this was one trial (albeit a large one), and the JNC recommendations come from analyzing many trials.
Bottom line for now: for patients over the age 60 with hypertension, save aggressive medication for numbers above 150/90 and continue to emphasize the lifestyle interventions we know work and work well.
Dr. Alethea Fleming, ND is a passionate advocate for naturopathic geriatric medicine. A 2007 Bastyr University graduate, she also earned a certificate in Gerontology from the University of Washington. Dr. Fleming is the owner and lead physician of the Vital Aging Clinic in Anacortes, Washington where she provides primary care to all adults as well as adjunctive geriatric care. Dr. Fleming is active in multiple community organizations as well as a member of WANP, AANP and OncANP. In her off hours, Dr. Fleming can be found hiking the beautiful trails of Fidalgo Island, spending time with her wonderful husband and son, or with her nose firmly in a good book.