Comprehensive Analysis of the New Blood Pressure Guidelines

Close-up of doctor checking blood pressure on the arm

If your blood pressure readings did not show you suffered from hypertension before, there are high chances you do now.

In the last quarter of 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) lowered hypertension diagnoses readings to 130/80 millimeters of mercury (mm Hg) after more than a decade.

This was from a previous threshold of 140/90 mm Hg and above. It means that if you have readings above 130/80 mm Hg, you’d be diagnosed with high blood pressure. The updated guidelines also provide new treatment recommendations, redefining hypertension. What was the criterion used to lower this number and why? Read on to find out.

blood pressure monitor and pill boxes

Why Blood Pressure Numbers Were Changed

Clinical trials are the prime lifeline of guidelines. The translation of the data into practical advice lays more emphasis on opinion and science. The recent reclassification of high blood pressure has attracted varying opinions. Individuals previously thought to be healthy have been classified as hypertensive. In the United States, the changes saw at least 30 million adults into the category of hypertensive individuals. AHA and ACC changed the systolic and diastolic numbers for 2 reasons:

  1. To target early intervention
  2. To account for medical complications that can occur at lower numbers

The changes shift how people view what’s now considered an elevated blood pressure. High blood pressure can quickly worsen and develop into a full-blown condition. It can especially be life-threatening for pregnant women. With the new changes, it means that more people, notably the elderly are now diagnosed with high blood pressure.

The researchers were convinced that hypertension starts at lower readings than was previously thought. They also felt that it was important to pay special attention to pressure levels before the condition starts to cause problems. This followed the high cases of stroke, heart disease, and deaths associated with a hike in blood pressure.

The new guidelines since 2003, stress on the need to use proper technique to measure hypertension, whether at home or in a clinical setting. Several factors can inflate readings. These may include slouching, full bladder, sitting with crossed legs, using a small cuff, not supporting the arm, or talking while taking measurements.  Accurate readings are critical for an accurate diagnosis. This silent killer accounts for the largest number of heart disease and stroke deaths, only second after smoking.

person wearing a nurse uniform taking blood pressure for himself

What’s New in Blood Pressure Readings?

High blood pressure occurs when the force pushing blood against the walls of the blood vessels is too strong. The pressure causes the heart to work harder. With time, the tissues in the blood vessels are then damaged, hurting the functioning of the heart and the circulatory system.

As part of the approval process, the 2 AHA and ACC together with other health experts and a panel of 21 scientists systematically reviewed over 900 studies. Their analysis projected a decline of fatal and non-fatal cardiovascular diseases by 3.3 million events over 10 years. Several contemporary population-based databases were used to reach this conclusion.

By lowering the definition of hypertension, the new guidelines recommend early intervention for detection, prevention, and management of the disease. 

In adults, blood pressure will now be categorized as normal, elevated, stage 1, stage 2, and hypertensive. The new guidelines are as follows:

  • 120/80 mm Hg or less – Normal
  • 129-129/80 – Elevated
  • 130-139/80-89 – Stage 1 hypertension
  • 140/90 – Stage 2 hypertension
  • 180/120 – Hypertensive crisis

In the new guidelines, the pre-hypertensive category has been eliminated. In this category, the systolic number (top) was initially 120-139 mm Hg while the diastolic number (bottom) was 80-89 mm Hg. People presenting these numbers will now be considered to have an elevated high blood pressure or stage 1 hypertension. The impact is bound to be felt especially among the young people. High blood pressure prevalence may triple in men below the age of 45 years, and double in women aged 45, the reports show.  

Other Recommended Changes in the New Guidelines

  • Prescriptions: According to the new guidelines, if the patient is at stage 1 of hypertension, medication should be prescribed if they have suffered from a cardiovascular disease such as stroke or heart attack. If there is also the presence of diabetes, chronic kidney disease, or the risk of atherosclerotic, based on age; the patient should be put under medication.
  • Plan of Care: The new guidelines brings to light the need to realize that psychological stress and socioeconomic status are risk factors and should be part of the patient’s plan of care.
  • Medication: Patients may need to take more medication types. Pills may also be taken severally if multiple drugs are combined into one pill.

A recent meta-analysis consisting of 140, 000 participants was done to analyze at least 42 randomized hypotension clinical trials. Most of the cardiovascular (CVD) events prevented were from patients who had a blood pressure of 140/90 mm Hg and above. They were believed to have developed a controlled blood pressure during simulation. The collected results offered the risk reduction predictions for cardiovascular cases and hypertension treatment targets. This landmark analysis coupled with epidemiological studies has altered the paradigm of the targets of blood pressure treatment.

The Recommendations of the New Blood Pressure Guidelines

The low BP numbers do not necessarily mean that antihypertensive agents must be used to control new and old cases. The emphasis according to the new guidelines is to modify lifestyle. This includes reducing the intake of sodium, having at least 6 hours of uninterrupted sleep, exercising regularly, and embracing other factors directed towards achieving healthy blood pressure goals.

Many observational and randomized studies show that reducing the intake of salt to 2300 mg/day is almost the same as giving the patient antihypertensive medications. The new guidelines suggest that adding more medication may be inappropriate and could potentially cause more harm. The new guidelines also do not recommend treatment for patients in the stage 1 of hypertension.

Should the predictions show that the patient has 10 percent or lower risk in 10 years; treatment may not be necessary. The recommended form of controlling high blood pressure would be a change in lifestyle as the initial form of treatment. Many patients in stage 1 are more likely to have a lower risk of cardiovascular events. Because physicians may be promoted to start treatment despite the low risk, they are advised to resist the urge and focus more on patients with a higher risk.

The new guidelines also show the need to obtain accurate blood pressure measurements. This follows the high risk of rushing into treatment through the guidance of inappropriate white coat hypertension readings.  Home blood pressure monitoring is suggested for proper decision making. For this method to work, patients ought to be taught how to take accurate readings. Wrong positioning of the hand while taking the readings or using the wrong cuff sizes may attract undeserved therapy.

Patients with normal kidney function are advised to add more potassium rich foods into their meal plan. Those with a glomerular rate of not more than 45 Ml/MIN/1.73m should avoid this diet. The new guidelines have reduced the number of antihypertensive medications to 4 including angiotensin converting enzyme inhibitors, thiazide diuretics, calcium channel blockers, and angiotensin receptor blockers. In the previous years, Beta blockers have been considered the first line of high blood pressure treatment. In the new guidelines, these should be avoided unless there is evident risk of coronary artery disease myocardial infarction, arrhythmias, or heart failure. Atenolol dosage has also been raised to an intake of twice daily and not once as prescribed before.

doctor taking blood pressure for lady

Top 5 Highlights of the Guidelines

Based on the new guidelines, how blood pressure is defined and managed has changed. Here are the top highlights:

1. High blood pressure cut points have changed. Research analysis show that people with BP readings previously determined to be hypertensive are at a high risk of major cardiac events. The research reveals that lowering the systolic readings of a high blood pressure patient offers major cardiovascular benefits in high risk cases.

2. Only a small number of those in the elevated and stage 1 hypertension will need medication. However, patients in these two categories are advised to make major lifestyle modifications to get the blood pressure levels to a stable position. The research conducted shows that being in the 2 categories means the patient is a high-risk case and must make several lifestyle changes to protect heart health and lower blood pressure. These include:

  • Weight loss: Overweight patients are advised to cut their weight down to the recommended benchmark.
  • Healthy diet: The first guideline is to reduce the intake of salt to a tablespoon a day. They are also advised to follow hypertension dietary approaches. That includes increasing the intake of potassium rich foods such as bananas, sweet potato, avocado, beans, spinach, and wild-caught salmon
  • Limiting or avoiding alcohol intake: The recommended amount of alcohol intake is 2 drinks a day for men and one for women.
  • Observing regular physical activity: Many activities count, including cycling, brisk walking, dancing, housework, and more.

Regardless of how high or low your blood pressure is; making healthy lifestyle changes is a positive way towards managing hypertension. Making healthy lifestyle changes can positive impact your health and lower your risk of heart problems.

3. The risk of developing heart disease or stroke should guide the treatment method applied: The new guidelines show that gauging the risk of heart and vascular conditions can help to determine the best blood pressure management technique. It means the risk should guide the physician on whether to task the patient with lifestyle changes alone or prescribe them with medication. The physician is guided by the ASCVD risk calculator to assess how likely the patient is to suffer from heart disease in the next 10 year. The following are taken into account:

  • Gender
  • Age
  • Systolic blood pressure
  • Total and HDL cholesterol
  • Smoking habits and presence of diabetes

This calculator determines the patients likely to benefit most from hypertension medications. If the risk of suffering from heart disease is 10 percent or more, blood pressure medication should be started followed by lifestyle modification. This is because it would mean the patient could easily develop cardiovascular disease. Patients in stage 2 however, must get a high blood pressure prescription.

4. Patients are encouraged to learn how to take their blood pressure at home for proper management of hypertension: These new guidelines show that blood pressure varies. Office readings are not always accurate meaning they could be falsely elevated prompting inappropriate treatment. However, for home measurements, the readings must be taken correctly. Several notable mistakes include:

  • Taking just one reading: Patients are advised to take at least 2 readings slightly apart.
  • Positioning the cuff incorrectly on the arm
  • Sitting with feet dangling or taking the measurements while seated on the bed. Sit upright on a firm seat with feet stepping on the floor
  • Exercising or taking caffeine before checking the readings

5. Hypertension can be successfully treated: Several lifestyle changes can be adopted to reverse blood pressure. For the more serious cases, medication can also be prescribed to successfully manage the disease.

It is worth noting that high blood pressure is a silent killer because it does not present any obvious symptoms. People are advised to have a regular high blood pressure screening to catch the disease before it can cause havoc. The focus on risk according to these guidelines is the most crucial step towards treatment. Low risk individuals may reap great benefits from an optimal lifestyle program while high risk patients may benefit from pharmacological intervention. It means that physicians will need to perform a risk assessment on their patients for a more aggressive therapy. High blood pressure is a leading cause of death from stroke and heart disease and therefore requires immediate intervention.

New Guidelines Gaps

Although the new guidelines have laid emphasis on the need to manage hypertension early, several medical critics feel there are gaps. For instance, they feel that hypertension in elderly patients may be difficult to treat without developing side effects.  Various reviews also find the new guidelines to only address caution while treating the elderly but do not give guidance on how to treat those with isolated systolic blood pressure.

According to the critics, the new guidelines also do not give guidance on how to handle patients with low diastolic wide pulse pressure. Critics feel that focusing on the systolic blood pressure below the recommended 130 mm Hg alone would consequently lower the diastolic pressure to dangerous levels exposing the patient to the risk of renal insufficiency or ischemic heart disease.

Several studies have revealed a continuum of rising cases of heart disease risk as systolic blood pressure rises above 115 mm Hg. As a way of managing the risk, blood pressure down to 130/80 mm Hg should record improvement in most treatment trials. With the changes recorded in the new guidelines, high blood pressure and its complications are expected to come to a swift decline.