New thresholds for blood pressure drugs sought

by Delthia Ricks

Fewer people could be prescribed high blood pressure medications in light of new guidelines published this week, which also call for raising the threshold to initiate drug therapy in people 60 and older.

The new recommendations - the first in a decade - were produced by the Eighth Joint National Commission on Hypertension and posted online by the Journal of the American Medical Association.

Panelists reviewed reams of new clinical trials and agreed overwhelmingly on this point: Lower is not necessarily better in terms of health outcomes.

Guidelines now recommend prescribing medications to people 60 and older at a reading of 150/90, or higher. Prior set the threshold at 140/90.

The new recommendations also raise the threshold for starting therapy at 140/90 for people between ages 20 and 59 who have diabetes or kidney disease. That is up from 130/80.

Health benefits were no greater at the lower readings for any group, panelists found.

"There has been a mantra out there that the lower the blood pressure, the better," said Dr. Paul A. James of the University of Iowa, who co-chaired the conclave of experts.

"That notion has been ingrained in physicians and many hold it as a core belief. But when your core belief is challenged, there are only two things you can do. You can cling to your core beliefs or change in accordance with the new data."

High blood pressure is a so-called silent killer underlying heart attack, stroke and . Lowering blood pressure has helped patients avoid those fates.

Nonexistent in the new guidelines is the notion of "pre-hypertension," a term coined by the seventh joint commission. Pre-hypertension, the new panel said, is not a disease and therefore was not considered.

James said panelists were mindful that doctors should prescribe medications with an eye on consequences, especially among the elderly.

"Let's say we get an older patient's blood pressure down to 120. How good is that if they're lightheaded every time they try to stand up," he said of a key side effect.

At the heart of the new recommendations are methods of controlling blood pressure without drugs, such as an emphasis on exercise, eating a healthy diet, weight loss, obesity avoidance and limiting salt intake.

Arriving, however, on the heels of last month's controversial new cholesterol-treatment recommendations - which also retreated from the "lower is better ideal" - the new hypertension guidelines are already drawing fire.

"This will definitely ruffle some feathers in the (medical community) regarding when to start blood pressure medications, especially in the older community," said Dr. David Friedman, chief of heart failure services at Franklin Hospital in Valley Stream, N.Y. Friedman labeled the guidelines "a bit controversial."

Dr. George Petrossian, director of interventional cardiovascular procedures at St. Francis Hospital in Flower Hill, N.Y., sees the guidelines as going against the grain of current practice.

"Looking at the 150/90 is currently not what we do in cardiology," he said. "My colleagues and I would aim for 140/90."

Dr. Donna Denier of South Nassau Communities Hospital in Oceanside, N.Y., said patients are also concerned about blood-pressure readings.

"Patients do get caught up in the numbers," Denier said. "They ask: 'Isn't it normal for blood pressure to go up as you get older?'"

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