Additional caution about aggressive blood pressure lowering comes from a study of
nearly 400,000 Kaiser healthcare system patients with hypertension, 19% of whom
had ischemic heart disease, and 30% of whom had diabetes. The study compared
blood pressures with the risk of mortality and end-stage renal disease (ESRD) and
found that the optimal BP for the lowest risk in this population was a SBP of 137
mm Hg and a DBP of 71 mm Hg.
The Kaiser study authors concluded that both higher and lower treated BP compared
with 130 to 139 mm Hg systolic and 60 to 79 mm Hg diastolic ranges had
worse outcomes and that their study adds to the growing uncertainty about BP treatment
targets. The Kaiser study showed a significant J-shaped association between
actual treated BP levels and adverse outcomes, that is to say, increased mortality at
very low blood pressure levels. Individuals with very low blood pressures might
be sicker and hence have higher mortality. An editorial commentary on the study noted that this study provides more support for relaxing BP treatment targets.
A commentary in the JAMA concerning blood pressure targets for people with diabetes
and hypertension noted that a recent meta-analysis including 74 trials and
more than 300,000 participants found no benefit to antihypertensive therapy in trials
with mean baseline systolic BP less than 140/90 mm Hg but strong evidence supporting
treatment of patients with diabetes and BP of 140/90 mm Hg or higher with a goal to lower BP to less than 140/90 mm Hg.
A 2018 article assessing the new guidelines in the New England Journal of Medicine
was in favor of some elements of the new ACC/AHA guidelines, including
increased use of home monitoring of blood pressure and individualized risk assessment. The authors are less sanguine about one-size-fits-all blood pressure goals. In particular, they note that many elderly have stiff non-compliant blood vessels that
elevate peak blood pressure readings, and they may have dizziness and poor mentation
if their SBP approaches 140 mm Hg. They concluded that while a blood-pressure
treatment target of less than 130/80 mm Hg makes sense for high-risk patients,
for everyone else, it seems more reasonable to continue defining hypertension as a
blood pressure of 140/90 mm Hg or higher.
This target was supported by a 2019 study published in the JAMA that considered
the cardiovascular outcomes of having systolic BP less than 130 mm Hg, diastolic
BP 80 mm Hg or greater compared to having the older definition of high blood
pressure systolic BP less than 140 mm Hg, diastolic BP 90 mm Hg or greater.
The study goal was to determine if lowering the diastolic threshold for hypertension
from 90 mm Hg to 80 mm Hg (the new 2017 ACC/AHA definition of isolated diastolic
hypertension, IDH) was associated with improved cardiovascular outcomes.
The study found that there was no significant association between IDH as defined
by the 2017 guideline and atherosclerotic cardiovascular disease, heart failure, or
chronic kidney disease.
This blog presents opinions and ideas and is intended to provide helpful general information. I am not engaged in rendering advice or services to the individual reader. The ideas, procedures and suggestions in that are presented are not in any way a substitute for the advice and care of the reader’s own physician or other medical professional based on the reader’s own individual conditions, symptoms or concerns. If the reader needs personal medical, health, dietary, exercise or other assistance or advice the reader should consult a physician and/or other qualified health professionals. The author specifically disclaims all responsibility for any injury, damage or loss that the reader may incur as a direct or indirect consequence of following any directions or suggestions given in this blog or participating in any programs described in this blog or in the book, The Building Blocks of Health––How to Optimize Your Health with a Lifestyle Checklist (available in print or downloaded at Amazon, Apple, Barnes and Noble and elsewhere). Copyright 2021 by J. Joseph Speidel