New hypertension guidelines - Lucy Nicholson, Reuters

New hypertension guidelines could lower use of blood pressure medications By Deborah Kotz / Globe Staff 12/18/2013 | 3:42 PM

http://www.boston.com/lifestyle/health/blogs/daily-dose/2013/12/18/hypertension-guideline-could-lower-use-blood-pressure-medications/POayoqD5C5aAyy7Q32rkIP/blog.html

REUTERS

A participant's blood pressure is measured at an event to inform people about the Affordable Care Act in Los Angeles, California, November 25, 2013. REUTERS/Lucy Nicholson

A smaller number of older Americans with hypertension could be put on blood pressure-lowering medications if doctors follow new advice from a panel of experts. The guidelines, published online Wednesday in the Journal of the American Medical Association, raise the threshold for treating those over age 60, recommending that doctors don’t prescribe medications until levels reach 150/90 mmHg instead of the previous recommendation of 140/90 mmHg that was issued 10 years ago.

Older patients with hypertension also shouldn’t be treated with additional medications or higher doses to drive down their blood pressure levels to below 150/90 mmHg—a change from previous advice.

“We did not find evidence for additional health benefits in achieving a level of 140 instead of 150 in those over age 60,” said Dr. Paul James, co-chair of the guideline committeee and chair of family medicine at the University of Iowa Carver College of Medicine. “We were particularly concerned about medication side effects in the elderly population like light-headedness and dizziness, which increases the risk of falling and broken bones.”

Anyone with diabetes or kidney disease, regardless of their age, should now aim for blood pressure levels of below 140 mmHg instead of the previous recommendation of below 130 mmHg. The recommendations didn’t change for younger folks with high blood pressure: treat when their levels go above 140/90 mmHg and use drugs to lower elevated levels down to that point.

Hypertension remains one of the biggest factors involved in stroke and heart disease deaths, and the guideline emphasizes the importance of controlling high blood pressure through lifestyle changes like weight loss, reduced salt intake, and exercise in addition to using medications. About one-third of Americans currently have high blood pressure, and 90 percent develop it at some point after age 55.

James said the guideline was intended to simplify the old recommendations, which had differing advice for specific groups of patients like those who had a previous heart attack or stroke. “We wanted to get advice out to the primary care community of doctors, not just cardiologists, since family doctors are often the ones treating hypertension.”

In terms of treatment, the panel recommended any of the four classes of drugs: diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers. African Americans, however, should be prescribed calcium channel blockers or ACE inhibitors first because those medications are more effective at lowering their blood pressure.

Hypertension experts who weren’t involved in the guideline development applauded the panel for basing their recommendations on clinical trials, disclosing any financial relationships with drug manufacturers, and not allowing panel members with financial conflicts to vote on the recommendations. But some also pointed out that the guideline was likely to generate controversy and could lead to unintended consequences.

“It has taken a decade to teach clinicians and patients that high BP is defined as levels higher than 140/90 mmHg, so how long will it take to teach them that these targets need to be altered to 150/90 mmHg for patients who reach 60 years of age?” wrote the authors of an editorial that accompanied the study. They pointed out that only half of those with hypertension have reached the 140 mmHg treatment goal, and it’s likely the new recommendation will mean fewer than half will now reach the new 150 mmHg goal.

Dr. Randall Zusman, director of the division of hypertension at Massachusetts General Hospital Heart Center, said he would have preferred a more detailed set of recommendations that pertained more to patients with a mix of medical conditions beyond simple hypertension.

“What about people with congestive heart failure, coronary artery disease, heart arrhythmias? There are lot of individual characteristics that these guidelines don’t address,” said Zusman, who was not involved with the guideline. He also would have like to have seen more emphasis placed on lifestyle modifications specific to lowering high blood pressure like a relaxation techniques. (The authors referred doctors to a new guideline issued by the American Heart Association recommending lifestyle measures to prevent heart disease.)

A number of cardiologists also complained that the new guideline was not issued by any major medical group or government entity. The National Heart, Lung, and Blood Institute previously endorsed guidelines outlining treatment for hypertension, high cholesterol, and heart disease prevention, but they decided, for unexplainable reasons, to remove themselves from this process earlier this year.



High Blood Pressure Goals for 60 and Older Lowered by Physicians By Michelle Fay Cortez December 18, 2013
   
http://www.businessweek.com/news/2013-12-18/high-blood-pressure-goals-for-60-and-older-lowered-by-physicians

People 60 and older don’t need to be treated as aggressively for high blood pressure, according to new physician guidelines that may help lower the number of medicines taken by Baby Boomers.

The recommendations, published in the Journal of the American Medical Association, suggest treatment goals for older people should be set at 150-over-90 mm Hg, based on studies showing these patients fare just as well over time at this higher level. The goal for other groups is 140 over 90, according to the new guidelines by a panel convened by the U.S. National Heart, Lung and Blood Institute.

Hypertension increases the risk of heart disease, the leading cause of death worldwide. Studies show about 90 percent of people may eventually develop it. While the changes probably won’t reduce how many people are treated for hypertension, the new goals may help reduce the number and types of pills taken by older patients, doctors suggested.




For the Very Old, a Surprise in Blood Pressure Readings By PAULA SPAN August 8, 2012

http://newoldage.blogs.nytimes.com/2012/08/08/for-the-very-old-a-surprise-in-blood-pressure-readings/?_r=0

Joe Raedle/Getty Images

It’s such a routine thing: A nurse wraps the cuff around your elderly relative’s arm, squeezes the bulb, listens with a stethoscope and says: “120 over 60. Very good.” Smiles all around (this was my 89-year-old father’s latest reading), because everyone knows that high blood pressure is a risky proposition.

Or is it? Reading a study and an editorial just published in Archives of Internal Medicine, I was startled to learn that in the very elderly — those over 85, say — high blood pressure may indicate better health while lower numbers could mean trouble ahead. For a layperson, this was such a through-the-looking-glass moment that I called Dr. James Goodwin, a geriatrician at the University of Texas Medical Branch in Galveston who wrote the editorial, and asked, in essence, does everyone know this but me?

“These are very well-kept secrets,” he said. “That high blood pressure in those over 85 predicts longer survival would probably be news to 95 percent of practicing physicians.” Which was not entirely reassuring.

Dr. Goodwin has been writing for years about the way blood pressure readings and other indicators of health, like weight and cholesterol, take on different meanings in advanced age. What sparked this latest discussion was a new study, bluntly titled “Rethinking the Association of High Blood Pressure With Mortality in Elderly Adults,” that examined whether walking speed might identify which older people are more at risk from high blood pressure, as hypertension is commonly known.

An Oregon State University epidemiologist, Michelle Odden, and a team at the University of California, San Francisco, reviewed data from the National Health and Nutrition Examination Survey, following 2,340 people over age 65 for an average of five years. The researchers divided the participants into categories based on the pace at which they walked a 20-foot corridor. Among fast walkers, who averaged a pace of 1.8 miles per hour or better, those with elevated blood pressure had a 35 percent higher risk of dying — the same risk seen in younger adults. But in slower walkers, hypertension did not increase mortality.

And in a small group of participants who didn’t complete the walk, those with high blood pressure had a 60 percent lower risk of death.

If these were the only data suggesting that hypertension’s effects begin to reverse in old age, we could shrug them off. In this study, those who didn’t or couldn’t walk 20 feet offered a variety of reasons: many had physical limitations or felt unsafe, but “some just showed up late for their appointments,” Dr. Odden acknowledged. Hard to draw conclusions from that.

But this isn’t the first study showing an inverse association — hypertension equals longer life — in the very old. “It expands on a fairly substantial amount of research on the relationship between blood pressure and survival,” Dr. Goodwin said. What doctors should do about hypertension in the very elderly – treat it or leave it alone? – has generated controversy for decades, particularly since clinical drug trials often exclude the elderly, leaving doctors with scant evidence to go on.

The medical guidelines for treating hypertension, set by a Joint National Committee in 2003 (and about to be updated) established a goal of 140/90; the systolic reading, the first of the two numbers, is the more important measure in people over age 50. The guidelines recommend medication for people who have higher blood pressure (as more than two-thirds of those over age 65 do) because of the well-established risk of heart attack and stroke. The recommendations don’t differ for the very old, but perhaps they should.

“The paradigm in medicine is, high blood pressure is bad, treating it is good,” Dr. Odden said. “We’re saying, maybe we need to look more closely at the guidelines and tailor them more to older adults.” Her study shows that “it’s not just age, it’s your physiology, your functional status, frailty” that matters.

What do we do with this? For younger people, the decisions are clear-cut: Reducing high blood pressure is a priority, and our increasing success at it represents a major public health victory, one reason we’ve become an aging nation.

In the very old, however, lower readings could mean good health, or they might also indicate that a patient’s heart isn’t pumping efficiently, while higher readings may mean robustness. “It can make you quite a bit less aggressive in treatment,” Dr. Goodwin said, especially since hypertension drugs can cause falls and dizziness.

Dr. Ken Covinsky, a geriatrician at the University of California, San Francisco, and senior author of the new study, said he’d probably recommend treatment for an 80-year-old tennis player with high blood pressure, but would be less worried about a frail 80-year-old with a systolic reading of 160, especially if she was already prone to falling.

“Do we really want to give her a ninth medication?” he asked. “I’d feel a little queasy about that.”

It’s a conversation worth having with a doctor, though hypertension treatment has become so reflexive that it could be a tough discussion. “Few physicians are aware of these findings, and they’re going to be suspicious,” Dr. Goodwin said.


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