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Your blood pressure goal: A personalized balancing act

Experts are divided on optimal blood pressure targets but agree that an individual approach is the best strategy.

There’s no debate about the dangers of high blood pressure. Dubbed the “silent killer,” high blood pressure usually has no symptoms. Yet this common condition damages blood vessels throughout the body, raising the risk of heart attack, stroke, kidney disease, and other problems.

But exactly when to start drug therapy for high blood pressure and how aggressive that treatment should be — especially in older people — has been a matter of some dispute in recent years. Some studies suggest that aiming for a stricter (that is, lower) blood pressure target than the current guidelines recommend can substantially reduce a person’s risk of cardiovascular complications (see: “Blood pressure research and guidelines: A moving target?”). Other studies offer evidence that a more relaxed (that is, higher) target makes more sense for most people, given the potential harms of drug side effects such as fatigue and coughing, as well as low blood pressure, which can cause lightheadedness and fainting.

A personalized approach

“My approach is to individualize treatment to each person’s unique needs, goals, and risks,” says Dr. Randall Zusman, a cardiologist with the Corrigan-Minehan Heart Center at Harvard-affiliated Massachusetts General Hospital. Still, he notes, he and other blood pressure experts are moving toward a “lower is better” strategy. “I certainly aim for a systolic blood pressure under 140, and if that’s easy to achieve, we might push for an even lower goal.” But lower does not mean so low that you’re lightheaded or dizzy, he notes, adding that low blood pressure can be especially challenging for people in their mid-70s and older.

Confounding factors

Of course, age is just one consideration when it comes to choosing a blood pressure target and the best way to achieve it. Everyone has other potentially confounding issues, from factors that affect your cardiovascular risk (like high cholesterol or diabetes) to medical problems such as acid reflux disease, an overactive bladder, or an enlarged prostate, for example.

Ask your doctor what blood pressure goal makes sense for you and why, advises Dr. Zusman. Do your part by watching your weight, avoiding salt, and getting regular exercise. If those strategies don’t cut it, discuss your medication options and consider both the benefits and side effects of each. With more than 200 different blood pressure drugs to choose from, you can usually achieve a safe blood pressure without affecting your quality of life, says Dr. Zusman.


Image: © AndreyPopov/Thinkstock

Blood pressure research and guidelines: A moving target?

For decades, the general consensus on when to take drugs to treat high blood pressure has been to start when a person’s systolic measurement (the first number in blood pressure reading) is at or above 140 millimeters of mercury (mm Hg) or the diastolic measurement (the second number) is at or above 90 mm Hg. Both the American Heart Association and the American College of Cardiology remain committed to these recommendations, despite recent arguments calling for both lower and higher targets.

In late 2015, the widely publicized SPRINT study (which included people ages 50 or older who were at risk of heart disease) fueled enthusiasm for lower blood pressure targets. It documented a 25% lower incidence of heart attack, stroke, and heart failure among people who were assigned to a systolic blood pressure goal of 120 mm Hg compared with people who were assigned to a 140 mm Hg target. But fainting and kidney problems were more common in the group with the lower target.

In early 2017, two leading medical groups, the American College of Physicians and the American Academy of Family Physicians, released guidelines that recommend a systolic target of less than 150 mm Hg for people ages 60 or older who are otherwise healthy. For those who have had a stroke or transient ischemic attack (when the blood supply to part of the brain is briefly blocked), or who have risk factors such as high cholesterol, obesity, or diabetes, they suggest a target of less than 140 mm Hg. Published in the Jan. 17, 2017, Annals of Internal Medicine, the guidelines are based on 21 randomized controlled trials, including SPRINT.

Yet another study, in the February 2017 American Journal of Medicine, pooled results from SPRINT plus 16 other trials. Those researchers concluded that the middle ground — a target of less than 130 mm Hg — offered the best balance of efficacy and safety.

Posted by: Dr.Health

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