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Making Sense of Blood Pressure Guidelines

Dr. Jose Delgado on new blood pressure targets, home monitoring and more…

Guidelines are from the American Heart Association and American College of Cardiology

By Dr. Jose Delgado, MD
Internal Medicine Department
Boulder Medical Center

About Hypertension – The Silent Killer

About two out of three adults above age 55 will have hypertension (HTN).

Hypertension (HTN) — or high blood pressure — is the leading risk factor for death and disability worldwide. It is a major cause of stroke, heart attack, kidney failure, atrial fibrillation, vascular dementia, aortic aneurysm, and other life-threatening conditions. Hypertension is common — about two out of three adults above age 55 will have HTN.

The tricky thing about HTN is that for most people it is a silent condition, thus its nickname “The Silent Killer”. Hypertension can be a challenge to diagnose because blood pressure can vary significantly for each individual. For instance, up to 30 percent of people have white coat HTN, which occurs when a patient’s blood pressure reading is high in the doctor’s office but completely normal as soon as they walk out the door.

Identifying those who truly have high blood pressure and treating their condition with lifestyle modifications and medication is critical, as we can significantly reduce the risk of developing more severe health conditions and prolong life while we’re at it!

Measuring Blood Pressure – A History

The Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High Blood Pressure published the first medical guidelines for HTN in 1977. Back then, most of the research suggested that tracking diastolic blood pressure was most important. Diastolic blood pressure measures the pressure in your blood vessels when your heart rests between beats. At that time, high blood pressure was defined as a diastolic BP (blood pressure) of 105 mmHg (millimeters of mercury—the units used to measure blood pressure) or greater.

The next major guideline, the JNC 7, was published in 2003. Better randomized and controlled trials showed the importance of measuring systolic blood pressure, the pressure in your blood vessels when your heart beats. Hence, the new JNC 7 guidelines included both systolic and diastolic levels. Hypertension was defined as 140/90 mmHg or greater (140 denotes systolic and 90 is the diastolic measurement). In addition, a new category called “Pre-HTN” was defined as BP 130-139/80-89 mmHg. If you were in this Pre-HTN category, your doctor typically recommended lifestyle modifications and kept a closer eye on you. If you had chronic kidney disease or diabetes mellitus, your doctor would initiate more intensive treatment for BP 130/80 mmHg or greater.

An Updated View of High Blood Pressure

In 2014, the National Heart, Lung, and Blood Institute transferred responsibility for sponsorship of cardiovascular disease prevention guidelines to the American Heart Association and American College of Cardiology. These two organizations, along with nine other professional societies, worked together to develop the latest guidelines that were published in 2017. This multidisciplinary team met on a quarterly basis for three years and did not draw on relationships and influence from industries involved with diagnosis or treatment of HTN. As a result, the guidelines were extremely well done, objective, and extensive. Out of the 106 recommendations in the study, I will focus on four main themes in this article:

The new guidelines recommend measuring blood pressure both at home and at the doctor’s office.
  • The new BP targets
  • A risk-based approach to treatment
  • The importance of home blood pressure monitoring .
  • Emphasis on lifestyle modification

New Blood Pressure (BP) Targets

The new guidelines represent a significant change from how doctors managed patients with high blood pressure in the past. Here are the new BP targets in four categories:

  • Normal — Under 120/80 mmHg
  • Elevated — 120-129/under 80 mmHg
  • Stage I HTN — 130-139/80-89 mmHg
  • Stage II HTN — 140/90 mmHg or greater

If these numbers seem low it is useful to know that, based on a large observational database, blood pressure begins to increase the risk for cardiovascular disease and death at a systolic blood pressure of 115 and up.

A Risk-Based Approach to High Blood Pressure Treatment

Using the JNC 7 targets from 2003, there were about 72 million adults with HTN. The new guidelines raise that number to 102 million. However, of the new 30 million being diagnosed with HTN, only 4.2 million will actually need medication. The others fall under categories that require closer observation and lifestyle modifications.

For adults in the Stage I HTN category, we consider prescribing medication if there is clinical cardiovascular disease, chronic kidney disease, diabetes mellitus, or a 10-year risk of a cardiovascular event that is 10% or greater. To determine the risk for a cardiovascular event we incorporate the Atherosclerotic Cardiovascular Disease Risk Estimator that is also used for managing high cholesterol.

If you are in the Stage II HTN category, you definitely need to be on medication that will help you obtain a target BP of under 130/80 mmHg.

Home Blood Pressure Monitoring

The new guidelines emphasize monitoring your blood pressure at home – not just in the doctor’s office. This approach allows your physician to combine the average blood pressure readings in the office and at home to confirm an HTN diagnosis. The guideline also details a standard way of measuring blood pressure at home. Here are a few tools from the American Heart Association and American Stroke Association that can help you measure your own blood pressure:

Tracking your readings over time is critical to understanding and managing your blood pressure. Here is a Seven-day Blood Pressure Monitoring Procedure that I recommend to my patients:

  • Take two morning and two evening readings for seven consecutive days. Be sure to sit down and relax in the morning for five minutes before taking the first reading, then take the second reading one minute later. Do the same thing in the evening. After seven days, calculate the average of all of your readings.
  • If you tend to have high readings in the doctor’s office due to white coat HTN or if you have elevated Stage I or Stage II HTN, monitor  your blood pressure using this procedure for seven days prior an office visit.
  • If your blood pressure medication changes, wait two weeks then use this seven-day monitoring procedure to take new readings.
  • Measure your blood pressure before food, coffee, medication or any exercise.

High Blood Pressure and Lifestyle Modification

The DASH eating plan helps prevent and treat high blood pressure and can lower cholesterol.

The new guidelines also recommend lifestyle modifications to manage blood pressure. The following steps can lower blood pressure by 5 to 11 mmHg:

  • Exercise — 90 to 150 minutes of aerobic and/or resistance exercise each week
  • Lose weight if overweight — the target Body Mass Index (BMI) is under 25. There is about a 1 mmHg drop in blood pressure for every kilogram of weight loss
  • Reduce your sodium intake — less than 1,500mg of salt per day
  • Eat a heart-healthy diet — Dietary Approaches to Stop Hypertension (DASH) is an eating plan to lower or control high blood pressure. Rich in fruits, vegetables, low-fat and nonfat dairy, whole grains, lean meats, and heart healthy fats, the plan is flexible and requires no special foods. DASH has ranked as the best overall diet for eight years in a row by U.S. News and World Report.
    Click Here to learn more about the DASH Eating Plan
  • Include more potassium-rich foods in your diet (examples: avocado, acorn squash, spinach, sweet potato, wild-caught salmon, dried apricots, pomegranate, coconut water)
  • Drink alcohol in moderation. Two drinks or less for men and one drink or less for women per day.

About Dr. Jose Delgado, MD, FACP

Dr. Jose Delgado joined Boulder Medical Center in 2007 after owning a large internal medicine office and hospital practice in Miami for 10 years. As an internal medicine specialist, Dr. Delgado is trained in the prevention, diagnosis and treatment of adult diseases and has treated virtually every health condition imaginable. He is comfortable with the wide spectrum of internal medicine, from routine primary care to managing multiple, chronic diseases. Dr. Delgado enjoys treating patients from diverse backgrounds and cultures and is very experienced with the elderly population. He welcomes new patients to his practice at Boulder Medical Center on Broadway in Boulder.

Contact Dr. Jose Delgado

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