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Blood pressure goals: How low should you go?

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Lowering pressure to 140/90 is a reasonable goal for otherwise healthy men at any age.

As many as three-quarters of men over 65 have high blood pressure. Many end up taking medication to prevent heart attacks, heart failure, stroke, kidney failure, and erectile dysfunction.

For most people with blood pressure clearly in the red zone, getting their numbers below 140/90 millimeters of mercury (mm Hg) is a reasonable goal. However, in December 2013, a panel of experts convened by the National Institutes of Health (NIH) released a recommendation that people over age 60 with high blood pressure could settle for a goal of 150/90—not the more stringent standard of 140/90—and still get health benefits. The American Heart Association rejected the idea, and five of the 17 members on the NIH panel later publicly dissented with the majority opinion. The debate continues.

To bring blood pressure under adequate control, it may require taking one or more medications (in addition to exercising and eating a healthy diet). But taking multiple medications—besides being more expensive and inconvenient—multiplies the chance of side effects.

The risk of side effects depends only partly on your age. The older you are, the greater the chance that drug therapy could overshoot the mark and trigger blurry vision, confusion, dizziness, fainting, light-headedness, erectile dysfunction, and weakness. Given those risks, how low of a target pressure should you shoot for?

“It doesn’t depend on an arbitrary age,” says Dr. Lewis A. Lipsitz, chief of geriatrics at Harvard-affiliated Beth Israel Deaconess Medical Center. “In the end, the goal of treatment—the target pressure you should shoot for—depends on your overall health.”

A healthy man with high blood pressure may be able to tolerate more medication and therefore benefit more from the treatment.

Blood pressure: How low is healthy?

The “sweet spot” for blood pressure control in older adults is a systolic blood pressure between 130 and 150 mm Hg. This lowers the risk of heart attacks, strokes, and death from heart-related causes. But in men 70 and older, cardiovascular risk may begin to rise if medication reduces systolic blood pressure below 130 mm Hg.

Treatment pros and cons

Medication keeps both blood pressure measures in check. Systolic blood pressure—the upper number in a blood pressure reading—measures the force on the arteries when the heart contracts. Diastolic pressure (the lower number) measures the force between beats.

The ideal blood pressure is 120/80; as it rises above that threshold, the risk of heart attacks, strokes, and other health problems steadily rises. At 140/90, doctors generally recommend blood pressure medication. In an individual, the amount of disease-prevention bang you get for your medication buck depends on how high your pressure is to start. If your risk is high, you have more to gain from medication. If your risk is relatively low—well, not so much.

In older men, the main benefit of blood pressure control is preventing strokes. However, the older you are and the more health conditions you have, the greater the chance of medication side effects. “We do want to treat high blood pressure in people over 65—or in fact at any age,” Dr. Lipsitz says. “The question is how low do we want to reduce the blood pressure?”

The recent recommendations were based on evidence that if you take people with systolic blood pressures of 160 and higher and give them drugs to reduce it below 150, those people get more health benefits than the treatment “costs” them in side effects.

The evidence gets hazier for reducing blood pressure to 140 or below. Many doctors still believe that’s what the goal should be for those age 60 and older, but the quality of the evidence for it is not as strong as we would like it to be.

Age and treatment goals

Dr. Lipsitz says age is indeed an important consideration in decisions about treating high blood pressure, but a more personalized approach is best. “I would treat otherwise healthy 60- or 70-year-olds like everybody else,” Dr. Lipsitz says. “I would aim for a pressure below 140. It’s proven to be effective.”

However, he adds, “I wouldn’t go too low.” Forcing a blood pressure between 160 and 180 down to anywhere near 120 could require excessive amounts of medication and could cause dangerous side effects. But it’s not necessary to push everyone’s systolic blood pressure down to 120. “We get good results in people as old as 84 years by bringing pressure just below 150,” Dr. Lipsitz says.

Side effects from blood pressure treatment



ACE inhibitors causes a cough in some people.

Take an ARB instead.

Calcium channel blockers (CCBs) can cause swelling in the ankles.

Take an ACE inhibitor or an ARB


Diuretics or “water pills” can cause frequent urination if taken at night.

Take diuretics in the morning.

Beta blockers are associated with a small risk of fatigue or sexual dysfunction.

Ask your doctor if you can try different

kinds of blood pressure medication and see if your symptoms go away.

Alpha blockers, drugs used to treat urinary symptoms from an enlarged prostate, may lower blood pressure excessively, causing dizziness and fainting.

Don’t take alpha blockers with blood pressure medications or ask your doctor about alternative drugs for prostate problems.

ACE: angiotensin-converting-enzyme (ACE) inhibitor; ARB: angiotensin-receptor blocker;

CCB: calcium channel blocker

Who gets side effects?

Aggressive blood pressure lowering is not always best for men with other underlying health conditions, Dr. Lipsitz says. “It makes you more vulnerable to the side effects of blood pressure medication.” These higher-risk individuals would include:

  • men with impaired liver or kidney function

  • men with memory impairment

  • men already taking multiple other medications

  • older men with a slow walking speed, which indicates frailty

  • men with narrowed coronary arteries, which might not be able to channel sufficient blood to the heart if their diastolic blood pressure falls too low.

If you’ve been taking blood pressure drugs for a while without problems, it’s unlikely that you will start experiencing new ones out of the blue. Bad reactions tend to happen more often in the first few weeks of taking a new blood pressure medication, when the body is adjusting to it. If the drug overshoots its mark a bit, you could feel lightheaded or dizzy.

“It’s safest to start low and go slow,” Dr. Lipsitz says. “If you start at a small medication dose and you gradually increase it over time, the body adjusts better.”

Mealtime effects

Taking your pills together with breakfast can also cause problems. In some elderly men and men with diabetes or certain other health conditions, blood pressure can drop sharply in the hour or two after meals. “If people take a handful of medicines right before breakfast, the drugs take effect while the meal is also taking effect, and blood pressure can go quite low.”

In such cases, it helps to avoid large meals or meals high in carbohydrates. It would also be wise to take blood pressure medications before bed. There’s one exception: diuretics. They cause your body to excrete water, which lowers the blood pressure. But a diuretic taken at bedtime could end up sending you to the bathroom multiple times throughout the night.

Healthy lifestyle, too

Medication is only one part of the solution to high blood pressure; lifestyle changes should be the other. “You get a bigger bang for your buck by lowering salt intake, exercising more, and losing weight if you are overweight,” Dr. Lipsitz says. These changes can reduce the number of drugs you need to take, and pay many other health dividends.

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Posted by: Dr.Health

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