Nearly a third of the US population has high blood pressure, so the release of new guidelines on how doctors should treat high blood pressure (hypertension) is a very big deal, potentially affecting millions of people. The new guidelines announced by the Eighth Joint National Committee have therefore attracted a lot of media attention.
The committee’s recommendations address three questions:
- At what point should patients begin taking blood pressure medication?
- What is the blood pressure goal patients should aim for in order to know they are benefiting from their medication?
- When beginning hypertension treatment, what are the best medications?
Here, boiled down to their essence, are the 2014 evidence-based guidelines for managing high blood pressure:
- The goal of treatment for people 60 and older has been increased from 140/90 to 150/90. This decision is not based on new evidence, but rather on a reconsideration of previous studies–in particular, two studies from Japan that showed no significant difference in outcomes such as heart disease and stroke in participants whose systolic blood pressure (the top number in blood pressure measurements) was between 140 and 160, and those below 140.In addition, there are risks associated with lowering blood pressure too much, particularly in older people: Dizziness can lead to falls and resultant fractures and head trauma; drug interactions are more likely as we age because we often end up on more medications; and sensitivity to side effects increases as we get older.
- For those over 60 who are already being treated for high blood pressure, and whose pressure is already in the lower range, there is no need to alter their medication as long as they are tolerating it well without side effects.
- For people younger than 60, the target remains 140/90.
- People at least 18 years old with diabetes or kidney disease should also aim for a target of 140/90.
What’s New in the 2014 Guidelines
Previous guidelines stressed that the initial drug of choice for treating hypertension should be a diuretic (aka water pill), but many health care providers have been using other medications as well because they are just as effective and often better tolerated than a diuretic. The new guidelines accede to this logic and now broaden initial treatment options to include medications from many different classes.
Not everyone agrees with the new treatment goal for people over 60, but in the absence of compelling data showing benefits from the lower target, caution makes sense. Hypertension treatment works–it’s one of the major reasons why the incidence of strokes, heart attacks, and heart failure has declined–and it represents one of the great triumphs of modern medicine. Identifying the proper drugs and proper targets for therapy impacts millions of people, and these guidelines help bring us closer to maximizing benefit while minimizing harm.