New high blood pressure guidelines: Think your blood pressure is fine? Think again…

Monique Tello, MD, MPH
Monique Tello, MD, MPH, Contributing Editor

The American College of Cardiology and the American Heart Association certainly grabbed the attention of us busy primary care physicians with the recent release of their updated blood pressure guidelines. These organizations had piqued interest by declaring the release date and labeling it as “highly anticipated.” I pooh-poohed all that drama, but upon reading through the 114-page executive summary PDF with 21 authors and almost a thousand references, I have to say, I am duly impressed.

The definition of the diagnosis of high blood pressure and the decision-making process surrounding treatment have traditionally been quite individualized (read: all over the place). Personally, I invite these stricter measures, because they are accompanied by solid research, logistical guidance, and useful management strategies.

However, a whole heck of a lot of people just got pulled into a significant medical diagnosis.

Let’s review what’s new.

A new definition of high blood pressure (hypertension)

(Please note that all numbers refer to mm Hg, or, millimeters of mercury.) The guidelines, in a nutshell, state that normal blood pressure is under 120/80, whereas up until Monday, normal was under 140/90.

Now, elevated blood pressure (without a diagnosis of hypertension) is systolic blood pressure (the top number) between 120 and 129. That used to be a vague category called “prehypertension.”

Stage 1 high blood pressure (a diagnosis of hypertension) is now between 130 and 139 systolic or between 80 and 89 diastolic (the bottom number).

Stage 2 high blood pressure is now over 140 systolic or 90 diastolic.

The measurements must have been obtained from at least two careful readings on at least two different occasions. What does careful mean? The guidelines provide a six-step tutorial on how, exactly, to correctly measure a blood pressure, which, admittedly, is sorely needed. My patients often have their first blood pressure taken immediately after they have rushed in through downtown traffic, as they’re sipping a large caffeinated beverage. While we always knew this could result in a falsely elevated measurement, it is now officially poor clinical technique resulting in an invalid reading.

New recommendations on monitoring blood pressure

The new guidelines also encourage additional monitoring, using a wearable digital monitor that continually takes blood pressure readings as you go about your life, or checked with your own cuff at home. This additional monitoring can help to tease out masked hypertension (when the blood pressure is normal in our office, but high the rest of the time) or white coat hypertension (when the blood pressure is high in our office, but normal the rest of the time). There are clear, helpful directions for setting patients up with a home blood pressure monitor, including a recommendation to give people specific instructions on when not to check blood pressure (within 30 minutes of smoking, drinking coffee, or exercising) and how to take a measurement correctly (seated comfortably, using the correct size cuff). The home blood pressure cuff should first be validated (checked in the office, for accuracy).

If you now have high blood pressure, you may not need meds… yet

The guidelines also outline very clearly when a diet-and-lifestyle approach is the recommended, first-line treatment, and when medications are simply just what you have to do. Thankfully, the decision is largely based on facts and statistics. For the elevated blood pressure category, medications are actually not recommended; rather, a long list of evidence-based, non-drug interventions are. What are these interventions? Things that really work: a diet high in fruits and vegetables (such as the DASH diet, which is naturally high in potassium); decreased salt and bad fats; more activity; weight loss if one is overweight or obese; and no more than two alcoholic drinks per day for men, and one for women. Simply changing what you eat can bring down systolic blood pressure by as much as 11 points, and each additional healthy habit you adopt can bring it down another four to five points.

For people with stage 1 hypertension who don’t have cardiovascular disease and are at low risk for developing it (less than 10% risk of an event within 10 years), lifestyle changes are still the way to go. (Risk is determined using a well-researched, widely used formula available here.)

However, if a patient has any kind of cardiovascular disease and stage 1 hypertension (a blood pressure over 130 systolic or 80 diastolic), or no existing cardiovascular disease but a significant risk of developing it (over 10% risk within the next 10 years), then lifestyle changes plus medications are recommended. And, even if someone has less than a 10% risk, if their blood pressure is over 140 systolic or 90 diastolic, which is now stage 2 high blood pressure, they ought to be treated with medication as well.

Optimizing treatment of high blood pressure

The authors bring several evidence-based yet progressive concepts into the guidelines, the first of which is that high blood pressure should be treated using a team approach. This makes sense, as science supports more and better patient education around self-monitoring, nutrition, and lifestyle changes, as well as stress management. Telehealth is emphasized as a cost-effective method of ongoing monitoring that is more convenient for patients than frequent office visits.

And why should this all matter to you?

Mountains of research over time have shown a very clear link between high blood pressure and cardiovascular disease. A 20-point higher systolic blood pressure or a 10-point higher diastolic blood pressure is associated with double your risk of death from a heart attack, stroke, or other cardiovascular complication (like abdominal aortic aneurysm or heart failure). What many people don’t realize is that those who survive these events find their lives permanently altered by disability and medical complications.

Much is being made of the fact that the new definitions of high blood pressure will mean roughly half of all US citizens will be considered to have high blood pressure, but when you really look at the numbers, as cardiologists already have, not that many more people will actually be advised to take medications. Although the public has good reason to be suspicious of “big pharma,” that’s not what this is about.

Diet and lifestyle changes are powerful medicine. Even if your blood pressure is normal now, you can help to prevent it from becoming elevated starting today. Eat more fruits, veggies, and whole grains, and limit foods high in sodium and unhealthy fats. Be as physically active as possible.

There is a lot more in the very long, detailed executive summary, including specific guidance for various populations, myriad diseases, and special circumstances, but this is the gist of it. The document is free, and available here.

Related Information: Starting to Exercise

Comments:

  1. Liz Feinauer

    The American Heart Association recommends using up the amount of calories you consume with aiming for 150 minutes per week of moderate intensity exercise or 75 minutes of vigorous activity-or a combination of both. Dietary guidelines recommend eating a variety of nutritious foods from all food groups including a variety of fruits and vegetable, whole grains, low-fat dairy products, skinless poultry and fish, nuts and legumes, and non-tropical vegetable oils. It is also recommended to limit the amount of saturated fats, trans fats, and sodium. In order to lower blood pressure, it is recommended to consume more than 2,400 mg of sodium (approximately 1 tsp of salt). Reducing sodium down to 1,500 mg of sodium can reduce blood pressure even further, but reducing sodium intake by even just 1,000 mg per day can help reduce blood pressure. Also it is recommended to not smoke and avoid secondhand smoking (American Heart Association, 2015). As a registered dietitian, these new guidelines and the emphasis on a healthy diet and lifestyle seem to me that it will lead to increased need for dietitians who specialize in hypertension. Do you think that this will increase the job market for dietitians and wellness coaches in this health area?

    American Heart Association. (2015). The American Heart Association’s diet and lifestyle recommendations. Retrieved from http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutrition/The-American-Heart-Associations-Diet-and-Lifestyle-Recommendations_UCM_305855_Article.jsp#.WhbRcbS9-QA.

  2. azure

    “While we always knew this could result in a falsely elevated measurement, it is now officially poor clinical technique resulting in an invalid reading.” So what? Does that mean that someone’s actually going to visit clinics all over the US to make sure that BPs are taken several times during the visit? Is that going to be added to the skin inspections (that aren’t done by the health care providers I have access to) done at every “wellness” exam? And the questions regarding mental health/depression that aren’t asked that are “now required”?

    My BP gets taken once, when I arrive. Occasionally the top number is over 120. No health care provider has ever said anything to me about it. Only ONCE in the past 5 years, has any health care provider or assistant taken my BP again during the course of the exam to see if there’s been a change. So by your defintion, I’m getting poor clinical care. And that means what? As in, what will make that change? It sure won’t change for me raising the issue, I’m lucky if the provider even speaks to me. Providers spend more time staring at monitors then looking directly at the client/patient in the examination room.

  3. Char barton

    We live on hype daily about many things. Goalsetters we are. This is just another one, designed to raise our blood pressure about yet another thing. We gotta live/work harder-better -smarter. Sleep the same way. Dam. I feel my blood pressure rising already! Maybe less driven work, play, judgment; more relaxing, letting it go, loving what we are and have- is a better answer.

  4. Stavros

    Not only table salt adds sodium to our food but also sodium glutamate, a flavor enhancer used in processed foods and restaurants. Does someone knows if this is as bad as adding salt?

  5. Elaine Shiner

    High-blood-pressure medications used to have a reputation for causing symptoms that were worse than the disease. I hope that situation has changed. I’m sure that you’re sincere when you write that this is not about more medications, but, having observed the evolution of our health-care system for many decade now, I’m skeptical.

  6. Sanjay

    Normal BP level (130/80) may not be uniform across all the regions of the world owing to different life style and eating habbits. What is experts’ opinion on this?

  7. Bhupender Kataria

    Hi
    What about our continued evolution? Are we saying that homo sapiens are stuck in time ? Being a science student I am totally puzzled. Our stomach was never made to digest wheat and rice and so many grains and pulseswe eat now but then this how we evolved from the cave dwelling and flesh eating beings to what we are today. Does any doctor estimated the systolic and diastolic of our ancestors ?

  8. Arnold Baise

    It wasn’t long ago (2013) that those over 60 were advised to aim for blood pressure below 150/90. Now, as a result of a single large trial, the numbers are being revised in a major way. But as Dr. Gilbert Welch has pointed out at https://www.nytimes.com/2017/11/15/opinion/blood-pressure-guidelines.html , there are problems with this study. First, about 8% of patients aiming for 140 systolic (or less) had “cardiovascular events,” whereas only 6% of those in the 120 systolic group did. This is only a 2 point reduction, but as a percentage it’s a 25% reduction. This is the misleading use of percentage change instead of actual change. Second, the participants were already at higher than average risk for cardiovascular problems, so it was a study of a selected group and not of the general population.

    • Doc Mil

      A reduction from 8% to 6% of cardiovascular events is known as an absolute risk reduction of 2%. This may seem small, but the translation is not small when applied to real world people. This can be understood more easily as something called “number needed to treat” which is calculated by 1 divided by the absolute risk reduction. In this case, an absolute risk reduction of 2% translates to a “number needed to treat” of 50 (1 divided by 0.02 = 50). This means that 50 people need to have a BP down to < 120/80 in order for 1 cardiovascular event to be prevented. In the context of many other things we do in our life (medical treatment or not), this is really good!

      For example, did you know it takes 10,000 mammograms done yearly for 10 years, in order to just prevent 10 breast cancer deaths?
      https://jamanetwork.com/journals/jama/fullarticle/2040228

      Of note, I am a primary care doc.

  9. Grace Williams

    Grace Williams
    I’m just turn 56 years and for the past 8 month my blood pressure was high, now it is even dangerously high. Was 154 over 82 now it’s 189 over 82 or 92 . It really scares me, I know that I can have a stroke or heart attack. My weight is 191 and my height is 5’7. Eats health. No meat or dairy. Just stress out from work. Need some help.

    • Nita

      Exercise may help. Walking at a brisk pace for 1/2 hour most days, then adding 15 minutes to the walk every week. It doesn’t have to be done all at once-walk 15 minutes in the morning, 15 at lunch, and 15 after supper. Get a friend or neighbor to walk with you and the time will go by quickly.

  10. Ghpkap

    What about the food industry? I cook almost all my meals, when I go out to eat, if I do not specify no seasoning, I can’t even take one bite due to the excessive amount of salt added to the food.
    I think at this point any restaurant or food industry that adds excessive salt should be taxed commensurately to help defray the cost for health care. The salt is killing us.

    I travel extensively, and our country by far uses too much salt in processed and restaurant food.

    Perhaps you can can help educate people and force the food industry to change! One can only hope.

    • John O

      Give me a break. Most people don’t use restaurants for their every-day eating— it’s a special occasion intended to be more indulgent than a normal meal. Your distaste for salt shouldn’t affect the level of seasoning in my Birthday dinner.

      • Brenda

        salt it yourself, john o

      • azure

        Or, restaurant meals could be prepared with less salt, and if you like more, you could ADD salt from the salt shakers I’ve always seen on the table of every restaurant I’ve eaten in.

        That way everyone is accomodated–you can add as much salt as you like, those who don’t like or need to cut back on salt can do so.

        Seems like an easy solution to me.

    • Nita

      I agree. Eating at home is the only sure way to keep your bp down. Way too much salt in restaurant meals.

  11. Jeanne Miller

    Why do I get up in the AM with enormously high B P? Usually 180 over 85 with a 53 pulse?

  12. Monique Tello, MD, MPH
    Monique Tello, MD, MPH

    Excellent point! I can’t speak for anyone specifically, but I can say that generally, doctors make the worst patients. We don’t always follow the textbook guidelines nor abide by health recommendations. Then, there’s genetics, a pretty powerful force, and one over which we have little control. And, of course, there is just plain bad luck (or fate, finger of God, however you choose to describe it). So, many factors can come into play when a doctor gets diagnosed with what can otherwise be considered a preventable disease.

  13. Sara Shannon

    Please stop saying “unhealthy fats.” Tell people what the sources of those unhealthy fats are specifically.

  14. Sotirios

    If you and your colleges at AHA are right about cvd, how come their president got a heart attack recently? Get real and level with us tha you do not know what is the cause and next u don’t know how to prevent or treat it right ,

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