Blood pressure guidelines raised for patients 60-and-over

Staff Writer — The Greenville NewsApril 13, 2014 

MICHAEL MCCLOSKEY/ISTOCKPHOTO.COM

— New guidelines that relax blood pressure levels for people over 60 came as welcome news to Tanis Bryan.

The retired college professor watched her blood pressure inch up after losing her husband and, though she discussed it with her doctor, she wasn't interested in taking more medication.

"The new guidelines give a little more leeway and a little less stress about this particular indicator," the Greenville woman said.

"The data have accumulated to indicate that hitting 140 didn't mean 'Crisis Ahead — Beware,' " she said. "That was something else I had to worry about that increased stress levels."

Until recently, the control goal for people 60 and older was 140/90. Now, it's 150/90.

According to Duke University researchers, that could mean that 5.8 million people considered uncontrolled under the old guidelines wouldn't need blood pressure medication under the new guidelines.

While the new guidelines should result in fewer medication side effects, some say it could increase the risk for heart disease, stroke and kidney disease.

About one in three adults in the U.S. has high blood pressure, or hypertension, according to the U.S. Centers for Disease Control and Prevention. But only about half are under control.

African Americans are disproportionately affected by high blood pressure, and at an earlier age, according to CDC. And hypertension costs the nation $47.5 billion a year.

While everyone agrees that hypertension can lead to strokes, heart disease and kidney disease, just how low blood pressure levels should be to reduce the risk is controversial.

Out with the old

One in four adults in the over-60 group is on hypertension drugs to meet the old guidelines, according to the researchers from Duke Clinical Research Institute, who collaborated with McGill University researchers.

According to the study, 13.5 million adults — most over 60 — would no longer be classified as having poorly controlled blood pressure, including 5.8 million who would no longer need blood pressure pills under the new guidelines, lead author Ann Marie Navar-Boggan, a cardiology fellow at Duke University School of Medicine, told The Greenville News.

"These adults would be eligible for less intensive blood pressure medication under the new guidelines, particularly if they were experiencing side effects," she said. "But many experts fear that increasing blood pressure levels in these adults could be harmful."

The American Heart Association advocates that health care providers continue to follow the 140/90 guideline, saying there's not enough evidence to justify such "a major change."

But Dr. Andrea Bryan of Carolina Cardiology Consultants with Greenville Health System said the new guideline for the top, or cystolic number, is good news.

"For quite a while, the goal, especially for older patients, has been much too low," she said.

"They get calcified arteries, so it's harder to get blood pressure control overall. Adding more and more medications, and driving their cystolic pressure down makes the diastolic (bottom) number way too low for them. It can cause a lot weakness and dizziness."

That can affect quality of life, she said, and cause falls, which can mean dangerous hip fractures among other injuries.

"I don't know if we've ever seen long-term benefits from very low blood pressure in patients over 60," she said. "I think this will help a lot. They will have higher pressures to be able to move more blood, and that's a good thing."

And internist Dr. Adam Scher of Cypress Internal Medicine in Greer said the guidelines were changed because there were no proven benefits from the stricter limits and more adverse effects when patients were more aggressively treated.

"From the older population I see, we try so hard with so many medications to get it perfectly controlled," he said. "But it makes patients feel better when it's higher and they can take fewer pills and medications. And all these medications have side effects."

Dizziness and falls

Those side effects include headaches, dizziness, fatigue, leg swelling and falls, he said.

And in addition to side effects from the antihypertension drugs, doctors need to keep an eye on drug-drug interactions, Bryan said, because elderly patients are often on a number of medicines.

"A lot of these patients, especially women over 60, get dizziness from changing position from having too low blood pressure," she said. "Improving those symptoms will help them feel better. And their wallet will feel better, too."

Scher said he will adopt the new guidelines, but will still treat each patient as an individual.

"If I have a 65-year-old patient with diabetes or heart disease who is walking around with a blood pressure of 130/80 and no side effects, I won't withdraw his blood pressure medications," he said.

"But if ... the blood pressure is 148/84 and we can't get it to 140, and some medications are affecting his head or his energy, that 148 is great. Too low is not good, either."

Dr. Bryan said she's been able to reduce medications in her own practice and that patients have been "thrilled."

"We will see down the road what long-term impact this has, but for now it's very beneficial," she said. "When you're talking about stroke from high blood pressure ... it has to be pretty high for that to happen. This is only 10 points, so it's not going to rise out of control."

And while a higher blood pressure does put more strain on the heart, these numbers aren't high enough to do that, she said.

Dr. Edward Stewart, a cardiologist with Upstate Cardiology of Bon Secours Medical Group, said the new guidelines are a good change for patients over 60 who don't have a lot of other health issues, but should be individualized.

A good thing for some

"It depends on how many medicines they're on, the patient's functional status, family history of heart disease or stroke," he said. "But I would say as a general rule, if I have an elderly patient who has a cystolic blood pressure around 145-155, I'm not going to be as aggressive with that patient as I would with somebody of a younger age."

"I think it allows for more relaxed blood pressure control in the elderly," he said, "which is a good thing for some people."

And Dr. Andrew Freeman, of National Jewish Health in Denver and chair of the American College of Cardiology's Early Career Professional Section, said the guidelines are a step in the right direction and likely to result in better compliance and improved outcomes overall.

"I think it's a great idea. As the population ages, one of the major issues is polypharmacy, or way too many pills," he said.

"And that may not improve outcomes, it could worsen them," he added. "A big fall in an older person versus blood pressure control – avoiding the fall is better because trauma and falls in the elderly can be life-ending."

Dr. Bryan said the goals for patients with diabetes or heart disease won't change, and that more research is needed to see whether the rate can be increased in people younger than 60.

The change came after a review of the research found no difference in adults treated at the higher level versus the lower level, Navar-Boggan said, though the vote on the guidelines by the Eighth Joint National Committee wasn't unanimous.

"A lot of experts fear it could cause harm," she said. "It's important that older adults talk to their doctors before making changes."

Instead of taking medication to lower her blood pressure, which had only hit 140, Tanis Bryan chose to exercise to control it.

"I was clearly in a period of great stress and was not anxious to take another medication," said the 77-year-old mother of two and grandmother of seven. "Because of the new guidelines, I don't have to."

LEARN MORE

Want to know more about high blood pressure? Go to www.cdc.gov/bloodpressure/about.htm.

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