NEW YORK – New guidelines suggest that people older than 60 can have a higher blood pressure than previously recommended before starting treatment to lower it. The advice, criticized by some physicians, changes treatment goals that have been in place for more than 30 years.
Until now, people were told to strive for blood pressures below 140/90, with some taking multiple drugs to achieve that goal. But the guidelines committee, which spent five years reviewing evidence, concluded that the goal for people older than 60 should be a systolic pressure of less than 150. And the diastolic goal should remain less than 90.
Systolic blood pressure, the top number, indicates the pressure on blood vessels when the heart contracts. Diastolic, the bottom number, refers to pressure on blood vessels when the heart relaxes between beats.
Essentially, the committee determined that there was not strong evidence for the blood pressure targets that had been guiding treatment, and that there were risks associated with the medications used to bring pressures down.
The committee, composed of 17 academics, was tasked with updating guidelines last formulated a decade ago. Their report was published online Wednesday in the Journal of the American Medical Association.
Hypertension experts said they did not have a precise figure on how many Americans would be affected by the new guidelines. But Dr. William White, president of the American Society of Hypertension, said it was “a huge number for sure.”
He estimated that millions of people are over 60 and have blood pressures between 140 and 150. Under the old guidelines they would need medication. With the new ones they would not.
Dr. Paul A. James, chairman of the Department of Family Medicine at the University of Iowa and co-chairman of the guidelines committee, said, “If you get patients’ blood pressure below 150, I believe you are doing as well as can be done based on scientific evidence.”
The group added that people older than 60 who are taking drugs and have lowered their blood pressure to less than 150 could continue taking the medications if they were not experiencing side effects.
But, it cautioned, although efforts to lower blood pressure have had a remarkable effect, reducing the incidence of strokes and heart disease, there is a difference between lowering blood pressure with drugs and having lower pressure naturally.
Medications that lower blood pressure can have side effects that counteract some of the benefits, said Dr. Suzanne Oparil, a co-chairwoman of the committee and director of the vascular biology and hypertension program at the University of Alabama at Birmingham School of Medicine. For that reason, maximum benefits may occur with less intense treatment and higher blood pressure.
“The mantra of blood pressure experts in the past has been that lower is better,” Oparil said. “Recent studies don’t seem to support that.”
The guidelines committee’s paper is accompanied by three editorials, two of which praise the process and note the rigor with which the group assessed evidence.
The third – by Dr. Eric D. Peterson of Duke University, Dr. J. Michael Gaziano of the VA Boston Healthcare System and Brigham and Women’s Hospital, and Dr. Philip Greenland of Northwestern University – said the committee should have considered evidence that fell short of randomized, controlled clinical trials.
“We’re not starting from square one,” Gaziano said in a telephone interview. “We’ve got a history of how to manage patients. The bar for changing that should be pretty high.”
Half of people taking drugs do not achieve the current goal of blood pressure under 140/90, and the writers expressed concern that with the new, more lenient target, patients’ blood pressures would edge even higher.
The guidelines had a difficult history. The committee began its work under the auspices of the National Heart, Lung and Blood Institute, a division of the National Institutes of Health. Then, when the group was almost done, the institute said it was getting out of the guidelines business and handed the task over to the American College of Cardiology and the American Heart Association.