It is clear that avoiding high blood pressure is very important to health, but medical
scientists are far from total agreement about what the healthiest blood pressure
target should be at differing ages and in the presence or absence of CVD, diabetes,
or kidney disease. Since the selection of an appropriate blood pressure goal is an
important life-long consideration for most of us, the following discussion considers
what optimal blood pressure targets are.
A long-standing and standard of high blood pressure was a systolic pressure of 140
mm Hg or higher and/or a diastolic blood pressure of 90 mm Hg or higher. But in
2014, a committee of experts, the Joint National Committee (JNC 8), suggested less
stringent goals for blood pressure and concluded: “There is strong evidence to support
treating hypertensive persons aged 60 years or older to a BP goal of less than
150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic
goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive
persons younger than 60 years for a systolic goal, or in those younger than 30 years
for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for
those groups based on expert opinion. The same thresholds and goals are recommended
for hypertensive adults with diabetes or nondiabetic chronic kidney disease
(CKD) as for the general hypertensive population younger than 60 years.”
Many studies raised questions about the JNC 8 blood pressure guidelines that set
higher blood pressure goals. They include epidemiologic studies demonstrating a
linear relationship between blood pressure and cardiovascular risk. For each 20 mm
Hg increase in systolic blood pressure (SBP), or 10 mm Hg increase in diastolic
blood pressure (DBP), or both, greater than 115/75 mm Hg, there was a two-fold
increase in mortality associated with stroke and coronary artery disease. This suggests
that the lower the blood pressure, the lower the CVD risk.
Evidence against accepting the new higher targets for blood pressure came from the
SHEP study that found that over five years, lowering of average SBP from 155 mm
Hg to 143 mm Hg resulted in a 32% reduction in cardiovascular events. Some
randomized controlled trials have found that lowering blood pressure by as little
as 10 mm Hg in patients with hypertension can reduce a person’s lifetime risk for
cardiovascular and stroke death by 25% to 40%.
Among the studies cited for choosing lower blood pressure targets are those that
show benefits from treating what was called “prehypertension,” a systolic blood
pressure of 120 to 139 mm Hg, and a diastolic blood pressure of 80 to 89 mm Hg.
Treatment of patients with CVD and with prehypertension is associated with a decreased
risk of cardiovascular morbidity and mortality. It is less clear if there are
benefits from treating those with prehypertension who do not have CVD.
Additional evidence supporting low blood pressure targets comes from the Systolic
Blood Pressure Intervention Trial (SPRINT). The trial compared the benefit of
intensive treatment of systolic blood pressure to a target of less than 120 mm Hg
with standard treatment to a target of less than 140 mm Hg among persons age 50
or older who had an increased risk of cardiovascular disease but without diabetes.
Participants treated to achieve a systolic blood pressure of less than 120 mm Hg, as
compared with less than 140 mm Hg, had a 25% lower relative risk of heart attack,
stroke, and heart failure; a 43% lower rate of death from cardiovascular causes; and
a 27% lower risk of death from any cause. An analysis of the older participants in
the SPRINT trial with a SBP target of less than 120 mm Hg found a one-third lower
rate of cardiovascular events and all-cause mortality, and the overall rate of serious
adverse events was not different between treatment groups.
The intensive treatment did have some drawbacks. There were significantly (30%)
higher rates of some adverse events (falls, low blood pressure, fainting, electrolyte
abnormalities, and acute kidney injury or acute renal failure) in the intensive-treatment
group. Furthermore, even with intensive lifestyle modification and medical
therapy, blood pressure will remain above target in many patients. This suggests
the need for population-level initiatives such as reduced sodium content in food.
Similar to the findings of the SPRINT trial, the Hypertension in the Very Elderly
Trial (HYVET) evaluated patients over age 80 who lowered their blood pressure
with an angiotensin-converting–enzyme (ACE) inhibitor. They reduced their risk
of stroke by 30%, their risk of death from cardiovascular causes by 23%, their risk
of death from any cause by 21%, and they had a 64% reduction in the rate of heart
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