‘How low can you go?’ The shifting guidelines for blood pressure control

The patient initially came to see Mark Supiano in 2017 because her family was concerned about her short-term memory loss.

While taking her history and vital signs, Supiano, a geriatrician at the University of Utah, saw one disturbing signal: Her blood pressure was 148/86, above normal despite her taking two medications intended to lower it. "Clearly that was too high," he said recently.

Several factors could have contributed to the high reading, including the anti-inflammatory drug the 78-year-old woman took for arthritis pain, a high-sodium diet, and a lack of regular exercise. She had also told Supiano that she typically drank a couple of glasses of wine each evening.

By 2019, though, the patient had a diagnosis of mild cognitive impairment, and medical evidence was emerging about a connection between hypertension (the medical term for high blood pressure) and dementia. "I was not as aggressive as I should have been," Supiano recalled. He added a third drug for high blood pressure to the woman's regimen, and her readings fell to 120 or lower.

The shifting guidelines for blood pressure control may remind those at advanced ages of a dance fad from their youth, the limbo. As Chubby Checker once intoned, "How low can you go?"

It was unethical, they decided, to deny half the trial participants the benefits of intensive treatment. The 2017 guidelines, therefore, recommended medication for those with a systolic blood pressure over 130.

But recent revisions could "define a lot more people as having high blood pressure," said Rita Redberg, a cardiologist at the University of California-San Francisco.

Nearly all major medical associations, including the American Geriatrics Society (Supiano is the chair of the organization's board), have endorsed the latest guidelines.

"I used to be lenient in many of my older patients," said John Dodson, a cardiologist and researcher at NYU Langone Health. "If I overtreated high blood pressure, bad things were going to happen."

Blood pressure that drops too low — hypotension — can cause dizziness and fainting or injuries from falls.

Another significant change: The new guidelines recommend at-home monitoring.

"Blood pressure is tricky," Spatz pointed out. "It varies throughout the day, depending on whether a person is just waking up or just ate or it's hot outside." Systolic readings can bounce around by 30 points or more in a single day.

And they're almost always higher in a doctor's office. "I don't want to put much stock in one reading," Spatz said.

"Maybe the patient has white-coat syndrome," she added, referring to anxiety about doctors and testing, "or they had a fight with the parking attendant" on the way in.

She asks patients to record their blood pressure twice a day for a week or two before their appointments. Some doctors prescribe a 24-hour home monitor.

Will patients adopt home monitoring and more aggressive treatment? Cardiologists argue that high blood pressure, almost always asymptomatic, remains undertreated despite the newer guidelines.

Although some side effects are serious — a fall can be life-altering — most complications "thankfully are transient and reversible and rather mild," he said.

Yet the guidelines have skeptics, too. Redberg, for example, counsels older patients about diet, exercise, and weight loss but does not urge them to start medication to reduce a 135 systolic reading to below 120.

They already seem overanxious about their blood pressure, she said, adding, "I encourage them to go out and enjoy themselves."

"Take a class! Go to a museum!" she said. "You can't do that if you're at home taking your blood pressure five times a day."

For people with other serious illnesses — cancer patients or frail nursing home residents with dementia, for instance — controlling blood pressure may be far down the list of concerns.

Reducing very high blood pressure is simpler and more important than trying to lower a 130 reading to below 120, Lee added. "You'd have to work a lot harder, add a third or fourth medication, and the risk of side effects is higher."

Supiano's 78-year-old patient did hit that target and did well for six or seven years. Then, as happens with many patients with mild cognitive impairment, she began to decline and eventually received an Alzheimer's diagnosis.

Given what researchers are reporting about the cognitive benefits of treating high blood pressure, "maybe it gave her another couple of good years," he mused. "Maybe it delayed the progression." Or maybe, he added, he should have started intensive treatment earlier.

The New Old Age is produced through a partnership with The New York Times.

Source:

KFF Health News