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Decoding the Latest High Blood Pressure Recommendations

By Susan Hardin Rocchini, PT, DPT

Based on the recently released new standards for blood pressure, half of Americans will be considered to have high blood pressure. Under the old guidelines, about one-third of Americans had high blood pressure. What has changed?  The recently published updated guidelines were based on new research that determined systolic pressure over 130 mmHg to be hypertensive, whereas 140 mmHg was previously considered hypertensive.

Based on the new standards, blood pressure is categorized into one of the 5 ranges:

Normal: Less than 120/80 mmHg (e.g., the higher blood pressure number is below 120 and the lower number is below 80).

Elevated: The top number is between 120 and 129 while the bottom number is below 80.

Stage 1 hypertension: The top number is between 130 and 139 or the bottom number is between 80 and 89.

Stage 2: The top number is at least 140 or the bottom number is at least 90.

Hypertensive crisis: The top number is above 180, the bottom number above 120, or both.

If you fall into one of the categories that isn’t considered normal, you do not need to fear that your doctor will immediately recommend that you begin taking blood pressure medication.  According to the American Heart Association and the American College of Cardiology, doctors will recommend lifestyle changes versus medication use to initially lower blood pressure, especially if you are in the elevated or stage 1 hypertension categories. Advice will often include losing weight, increasing exercise, managing stress, improving diet, discontinuing smoking, and limiting alcohol intake. The American Heart Association advises those with elevated blood pressure into the 120s and 130s to lose weight, exercise and eat plenty of fruits, vegetables and whole grains before trying medication. However, if you also have additional risk factors, such as a previous stroke, heart attack, diabetes or kidney disease, doctors may prescribe a medication along with lifestyle changes.

The new recommendations are based on a study that was federally funded and is known as SPRINT (Systolic Blood Pressure Intervention Trial). 1  The results were published in the New England Journal of Medicine in 2015 and demonstrated that that patients who took medication to lower systolic blood pressure from the 130s to 120 or lower had fewer heart attacks, strokes, and cardiovascular deaths. The study specifically found that between two groups of 4000+ patients with hypertension, the group that took higher doses of blood pressure medication to bring their systolic blood pressure to 120 had a 25% reduction in cardiac events, including stroke and heart attack, compared to the group who took medicine, but aimed for a systolic blood pressure below 140.  Simply put, higher blood pressures means the heart is working harder, which takes a toll over time, such as thickening of the heart which makes it difficult for blood flow to reach the innermost layers of the heart and the development of plaque formation on the walls of arteries, as well as other effects.

Monitoring blood pressure can be challenging. Does one high reading mean that one has hypertension?  The short answer is no, because blood pressure readings can be volatile and can fluctuate.   Blood pressure is affected by activity, stress and your surroundings, particularly the surroundings of a doctor’s office. Therefore, it seems wise to gather several measurements in different situations and times of day in order to establish an average. The new guideline emphasizes that an average should be based on at least 2 readings obtained on at least 2 occasions to estimate an individual’s level of blood pressure. Out-of-office and self-monitoring of blood pressure measurements are recommended to confirm the diagnosis of hypertension, as well as determine the appropriate dosage of medication.

Based on the new research, there are specific guidelines to manage the various scenarios. The guidelines recommend in low-risk adults with elevated blood pressure or stage 1 hypertension with low cardiovascular risk, blood pressure should be repeated after 3-6 months of nonpharmacologic therapy. Adults with stage 1 hypertension and high cardiovascular risk should be managed with both nonpharmacologic and antihypertensive drug therapy with repeated blood pressure measures in 1 month. Adults with stage 2 hypertension should be evaluated by a primary care provider within 1 month of initial diagnosis and be treated with a combination of nonpharmacologic therapy and 2 antihypertensive drugs of different classes with repeat blood pressure evaluation in 1 month. For adults with a very high average blood pressure (e.g., ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg), prompt evaluation and drug treatment followed by careful monitoring and upward dose adjustment is recommended.2

The new guidelines also offer advice on the types of medications that are most effective and what type of medicine should be used with each population depending on race and past medical history.  The bottom line that is every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals; effective management of comorbid conditions; and timely follow-up with the healthcare team. Effective behavioral and motivational strategies are recommended to promote lifestyle modification. A structured multi-disciplinary approach including a physician, nurse, and pharmacist collaborative model is recommended, along with integrating home-based monitoring and telehealth interventions.  2

If you are having difficulty starting an exercise program because of pain or limitation, consider consulting with a physical therapist to improve your ability to access the heart healthy power of exercise and physical activity.

Susan Hardin Rocchini is a physical therapist and board certified clinical specialist in orthopedic physical therapy.  She may be reached at susanhrocchini@physiopartners.com.

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1  http://www.nejm.org/doi/full/10.1056/NEJMoa1511939#t=article

http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults

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