House call: New study points to new goals for blood pressure

When I was in medical school one of my professors once said, “The dogma of today is the dog doo of tomorrow.” That is not exactly what he said, but you get the picture. He was right. About a lot of things. And his saying may apply to our evolving treatment goals for hypertension, or high blood pressure.

Earlier this month in this column I talked about the basics of blood pressure and hypertension. This week I am going to talk about how the treatment goals for hypertension are evolving, based on high-quality studies of treatments and outcomes, or evidence-based medicine.

For all of the years that I have been practicing medicine, the guidelines for blood pressure treatment have for the most part been pretty simple. Anything over 140/90 was considered to be hypertension, and the treatment goal was essentially a blood pressure less than 140/90.

That goal shifted in 2014, when the Eighth Joint National Committee to set treatment recommendations did an exhaustive review of well-designed scientific studies on blood pressure. The committee concluded that the evidence supported a goal of blood pressure below 150/90 for healthy patients over age 60, and the old goal of under 140/90 for those younger than 60. To many of us that recommendation seemed like heresy because we had been being more aggressive in our treatment goals for years. But that’s the point of evidence-based medicine: basing our treatment decisions on high-quality studies of treatments and outcomes, and not on tradition or the opinions of doctors who are “experts.”

Now we have a new, large, well-designed study called “A Randomized Trial of Intensive versus Standard Blood-Pressure Control,” which is available on the New England Journal of Medicine’s website, http://www.nejm.org/.

The participants in the study were divided into two groups. One group had a standard treatment goal of getting their systolic blood pressure below 140 mm Hg. The other group had the intensive treatment goal of getting their blood pressure below 120 mm Hg.

The study was stopped early because the more intensely controlled group had such “lower rates of cardiovascular events and death from any cause” that it was decided that it would be unethical not to tell the participants and health care providers in the standard treatment group about the results. The bottom line is that deciding whom to treat and how aggressively to treat them is complicated. We know that high blood pressure over time increases the risk of heart attacks, strokes, and other related bad things. We also know that treatment to lower blood pressures lowers the risk of those things.

You might be wondering what this means for you. Should you rush out to your health care provider to discuss getting your blood pressure below 120 mm Hg? My answer is, “Not yet.” At least not if it involves taking more medication. If you can lower your blood pressure through exercise, weight loss and a healthy diet, the evidence is that the lower it is (within reason) the lower your risk for bad things like heart attacks, strokes and heart failure. Things that raise blood pressure are being overweight, consuming too much salt and alcohol, not getting enough sleep, and, in the short term, pain or emotional distress.

For now I am mostly staying in the under 140/90 camp for most of my patients, and for those who are older and have a hard time getting to the lower goal without multiple medications and their side effects, I can relax a little. I will be waiting for the recommendations to get clearer before making major changes in the way I care for my patients.

Dr. Bob Riggs is a family medicine physician practicing at Group Health’s Riverfront Medical Center.