When headlines about new blood pressure guidelines pinged across my phone recently, I remembered a man my inpatient team had admitted to the hospital not long ago.
He had gotten up in the middle of the night to use the toilet and passed out, hitting his head on the floor. The first people to find him described him twitching, so he initially got a battery of tests to determine whether he was having seizures. All were negative. But when he got out of bed and stood up, his blood pressure dropped from 137/63 to 98/50 — a sign of a condition called orthostatic hypotension.
His wife told us he had been having symptoms of lightheadedness for several months, a period that happened to coincide with his beginning a new blood pressure pill. We told him and his wife that he needed to stop that drug and to reduce the dose of one of his other blood pressure medicines. Two days later, I spoke with the man's wife, who reported that he was doing much better. "See?" I told the team's intern. "Big work-up for a simple problem."
So when I saw the headlines — "Blood pressure of 130 is the new high" and "Millions more Americans will need to lower blood pressure," I grimaced. How many people would experience symptoms like our patient's as a consequence of overzealous medication? And how many would injure themselves as a result?
I also thought: "Not again!"
The latest hypertension recommendations were issued by a committee convened by the American Heart Association and the American College of Cardiology, and while they aren't the only expert guidelines out there, they're arguably the most influential in the United States.
The panel that penned the guidelines is the descendant of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of Blood Pressure, a group of experts that originally was convened by the National Institutes of Health in 1977. Since then, that committee and its successors have issued nine reports. Each one has adjusted recommendations in light of new research. From a practitioner's point of view, the repeated changes can be a bit discombobulating.
The headlines focused on the new guidelines' dropping the cut-off for a diagnosis of hypertension to 130/80 from 140/90. (The top number is called the systolic blood pressure, which measures the pressure in a person's arteries when the heart pumps out blood; the bottom number, the diastolic blood pressure, measures arterial pressure when the heart relaxes between beats). But that's only one of many recommendations in the report.
Before going into detail about medication, the report advocates that people be encouraged to adopt proven blood pressure-lowering behaviors, such as eating foods rich in potassium (meaning fruits and vegetables), reducing salt and alcohol consumption, and doing aerobic, isometric and dynamic resistance exercises. (Isometric resistance exercises involve contracting muscles while staying in one position, like certain yoga poses; dynamic resistance exercises involve movement against a force, such as lifting weights). It also spells out the expected effect of each behavior on blood pressure.
Of those newly classified as hypertensive as a result of the changes, "70 percent will not need medical therapy if they eat right and exercise," said Joaquin Cigarroa, a professor at Oregon Health & Science University who served on the task force that oversaw the report. "Our clinical practices need to be developed so that they have an opportunity to lower their risk through natural means."
Before deciding to prescribe blood pressure medication, doctors are supposed to use an online calculator to compute a person's risk over the next 10 years of a cardiovascular event such as a stroke or myocardial infarct. If that risk is 10 percent or more, the guidelines recommend medication if the patient's average blood pressure is 130/80 or higher. If the risk calculation is lower than 10 percent, then a doctor should prescribe medication only if the patient's average blood pressure is 140/90 or higher.
The word "average" is important. To a greater extent than its predecessors, the new guidelines stress that decisions on whether to treat blood pressure shouldn't be based on a single number, but ideally should incorporate lots of readings done not only in a doctor's office but also by people checking themselves at home. The guidelines link to the heart.org Web page with easy-to-understand details about how to do that measuring correctly. They also state that ideally, readings should be done daily.
"I don't think one can manage hypertension without a patient and their family being educated on how to measure blood pressure [at home] with a machine," Cigarroa said. He added that a single blood pressure reading "every three to five months is woefully inadequate."
Many busy practices and clinics check people's blood pressure when they arrive, before they're seen by the doctor. Because people may feel stressed or have rushed to get to their appointment, these readings are often higher than their usual blood pressure. Relying on these numbers alone may result in the person being overtreated and leading to orthostatic symptoms similar to what my patient experienced when he hit his head. People shouldn't have exercised, consumed anything caffeinated, nor smoked for a half-hour before getting a blood pressure check, and they should relax in a chair for at least five minutes before the measurement.
Unfortunately, a physician's first instinct may be to jump and treat that initial blood pressure reading, without giving a patient time to relax for a second reading. Our health system usually doesn't reward physicians for spending time to make sure patients know how to correctly measure blood pressure at home, never mind counseling them about healthy eating and exercise.
It can seem easier to simply write a prescription. And our bizarre insurance system makes it lucrative to perform interventions, such as cardiac catheterizations, after a person has had a complication from high blood pressure. In general, most insurance plans don't cover the cost of a good home blood pressure monitor for routine tracking, either. Most run about $50.
The report also urges clinicians to be aware of patients' health literacy, the barriers they face in getting healthy food and how they budget for medical care. It concludes with a plea that doctors engage social and community services when taking care of lower-income patients who may "skip a doctor's appointment to pay a residential utility bill."
These recommendations didn't make the headlines, but they're among the report's most important points.
Marcus is a general internist at the University of Miami and has a grant from the Ford Foundation to support her reporting on health-related topics.