Since 2017, when guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) were published, most experts in the United States have considered a systolic blood pressure of 130 millimeters of mercury (mmHg) or higher or a diastolic pressure of 80 mmHg or greater as hypertension. Yet, although the ACC/AHA thresholds are supported by scientific evidence, the definition of hypertension is not universal, as some medical organizations continue to recognize the previous hypertension mark of 140/90 mmHg.
Regardless of the definition, just keep in mind that your blood pressure reading is more than a set of numbers. It reflects your cardiovascular risk, and it also forms the basis of decisions about initiating or modifying antihypertensive treatment, as well as the target blood pressure you should aim for if you have hypertension.
It seems only logical to get your blood pressure as far below the hypertensive range as possible, and some research suggests that driving blood pressure lower with more intensive medical therapy may further decrease your cardiovascular risk. However, the benefits you gain from reaching more ambitious targets also can come with risks associated with lowering blood pressure too drastically. As a result, not everyone agrees on how greatly blood pressure should be reduced, and some experts call for more relaxed systolic blood pressure goals among older adults, who may be more susceptible to drug side effects and are more likely to be taking other medications that might adversely interact with their blood pressure medications.
So, as you and your health-care team map out a plan to manage your blood pressure, it’s important to understand all the expert recommendations, identify what your blood pressure goal should be, and weigh the benefits and potential risks of achieving and maintaining that goal.
The ACC/AHA Guidelines
Under the revised ACC/AHA definition of hypertension, nearly half of Americans have hypertension, but only a fraction of patients newly classified as hypertensive would require medical therapy to control their blood pressure, the organizations explained. Instead, the majority—including people in the normal and elevated blood pressure categories—can reduce their blood pressure with nonpharmacologic approaches, such as a heart-healthy diet and exercise regimen.
For people with normal blood pressure (less than 120 mmHg systolic and less than 80 mmHg diastolic), physicians should encourage patients to follow a heart-healthy lifestyle to maintain a normal blood pressure, the ACC and AHA recommend. People with elevated blood pressure (120 to 129 mmHg systolic and less than 80 mmHg diastolic) should be encouraged to make healthful lifestyle changes and should have their cardiovascular risk re-evaluated in three to six months.
Hypertension Stage 1
You can calculate your 10-year risk of heart disease and stroke using the atherosclerotic cardiovascular disease (ASCVD) risk calculator available at tools.acc.org/ASCVD-Risk-Estimator-Plus.
For people with a 10-year risk below 10 percent, the recommendation is to make healthy lifestyle changes and re-evaluate their cardiovascular risk in three to six months.
For those with a 10-year risk of 10 percent or greater or who have known cardiovascular disease, diabetes, or chronic kidney disease (CKD), the recommendation is lifestyle changes, prescribe one blood pressure-lowering medication, and reassess in one month. Patients who achieve their blood pressure goal in one month should be re-evaluated in three to six months. For those who don’t, physicians should consider increasing the medication dose or switching to a new drug.
Hypertension Stage 2
The recommendation is healthy lifestyle changes, prescribe two blood pressure-lowering medications from different drug classes, and re-evaluate in one month. Image may be NSFW.
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Patients who achieve their blood pressure goal in one month should be reassessed in three to six months. For patients who don’t meet the goal, physicians should consider increasing the medication doses or switching to new drugs, and then continue following the patients monthly until they reach their blood pressure goal.
For patients with no history of cardiovascular disease and a 10-year cardiovascular risk less than 10 percent, antihypertensive therapy should be initiated when blood pressure exceeds 140 mmHg or higher systolic or 90 mmHg or higher diastolic, with a target blood pressure goal of less than 130/80 mmHg, the guidelines state.
Among those with a history of cardiovascular disease, a 10-year cardiovascular risk of 10 percent or higher, or the presence of diabetes or CKD, the guidelines recommend a threshold of 130/80 mmHg to begin antihypertensive treatment, with a goal of reducing blood pressure below that level. Treatment also is recommended for any adults over age 65 with systolic blood pressure of 130 mmHg or higher.
Other Recommendations
The ACC/AHA guidelines—specifically, the lower threshold of hypertension—differ from those of other medical organizations. Here’s a look at various recommendations:
Eighth Joint National Committee
In 2013, experts appointed to the Eighth Joint National Committee (JNC 8) released guidelines that maintained the 140/90 mmHg treatment threshold/goal for adults up to age 59 and for anyone with chronic kidney disease or diabetes.
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However, for people ages 60 and older without diabetes or kidney disease, the panel established 150/90 mmHg as the blood pressure level at which to begin antihypertensive drug therapy, and below 150/90 mmHg as the new treatment goal. The panel also noted that treatment need not be adjusted in patients 60 and older who have already achieved systolic blood pressure below 140 mmHg without adverse effects from medications.
The new guideline raised concerns among some experts that the more relaxed systolic blood pressure target would result in less-intensive treatment in some high-risk patients who need it. And, although the JNC 8 panel was almost unanimous in their agreement about nearly all of the recommendations, five of the members disagreed with the 150-mmHg target systolic blood pressure in adults over age 60. However, some recent evidence suggests that aiming for a less stringent blood pressure target may be more appropriate for elderly people (see “Study Suggests Caution in Lowering BP in the Elderly”).
American College of Physicians/American Academy of Family Physicians
Guidelines from the American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) endorse the same 150 mmHg systolic blood pressure treatment target for hypertensive patients ages 60 and older proposed by the JNC 8. The ACP and AAFP also recommended that physicians consider aiming for a systolic blood pressure of less than 140 mmHg for people ages 60 and older with a history of stroke or transient ischemic attack, as well as those at higher risk due to factors such as cardiovascular disease, kidney disease, diabetes, and cholesterol abnormalities.
Also, in 2017, the AAFP formally decided not to endorse the ACC/AHA guidelines and instead continued to support the JNC 8 recommendations.
American Diabetes Association (ADA)
In its 2019 standards of care, the ADA recommended that blood pressure targets should be individualized for people with diabetes and hypertension. For those at higher cardiovascular risk (10-year risk greater than 15 percent, according to the ASCVD risk calculator), a blood pressure goal of less than 130/80 mmHg “may be appropriate, if it can be safely attained,” the guidelines state. For those with an ASCVD risk of less than 15 percent, treatment to a blood pressure target of less than 140/90 mmHg is recommended, according to the ADA (Diabetes Care, January 2019).
European Society of Cardiology (ESC)/European Society of Hypertension (ESH)
Guidelines from the ESC and ESH classify blood pressure levels above 140 mmHg systolic and/or 90 mmHg diastolic as hypertension (European Heart Journal, Aug. 25, 2018). They also categorize blood pressure ranges of 120 to 129 mmHg systolic and/or 80 to 84 mmHg diastolic as normal and 130 to 139 mmHg systolic and/or 85 to 89 mmHg diastolic as “high-normal.”
The European guidelines differ from others in proposing that the first goal of treatment should be to reduce blood pressure to below 140/90 mmHg in all patients; then, if treatment is well tolerated, the blood pressure goal should be 130/80 mmHg or lower for most patients. A diastolic goal of less than 80 mmHg should be considered for all hypertensive patients, and systolic blood pressure should be treated to a target range of 120 to 129 mmHg in most people under age 65, and 130 to 139 mmHg for people ages 65 and older (but only if tolerated for people over age 80). Additionally, except for frail older adults and people at low risk and with grade 1 hypertension (especially those with systolic blood pressure below 150 mmHg), blood-pressure-lowering therapy should begin with a two-drug combination, the ESC and ESH recommend.
More Aggressive Goals
The lowering of the blood pressure treatment targets in the ACC/AHA guidelines was prompted, in part, by publication of Image may be NSFW.
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the Systolic Blood Pressure Intervention Trial (SPRINT). The government-sponsored study included 9,361 people, ages 50 or older, with systolic blood pressure between 130 and 180 mmHg. The study participants were at increased cardiovascular risk based on the presence of cardiovascular disease, chronic kidney disease, or other factors, but had no history of diabetes, stroke, or heart failure.
The participants were assigned to either a systolic blood pressure treatment goal of 135 to 139 mmHg (standard therapy) or an intensive treatment goal of less than 120 mmHg. Patients on standard therapy took, on average, about two blood-pressure-lowering medications, while those in the intensive treatment group required an average of about three drugs to reach the lower blood pressure target.
Compared with the standard-therapy group, patients who reached the lower systolic blood pressure goal with intensive therapy had a 25 percent lower relative risk of multiple endpoints that included heart attack and other acute coronary syndromes, stroke, heart failure, and death from cardiovascular causes, the study found. However, the intensive therapy was associated with an increased risk of low blood pressure (hypotension), acute kidney injury or failure, syncope (fainting), and electrolyte imbalances, compared with standard therapy.
A follow-up analysis, involving 2,636 SPRINT participants ages 75 and older, found that rates of cardiovascular events and death from any cause were significantly lower in the intensive-treatment group compared with the standard-therapy group after about three years. Although the intensive treatment was associated with a slightly higher risk of low blood pressure, acute kidney injury, syncope, and electrolyte imbalances, the researchers reported that the overall rate of serious adverse events was no different between the treatment groups. Another SPRINT follow-up study found that after about three years, rates of major cardiovascular events were lower among the participants with resistant hypertension who received intensive treatment than those assigned to standard treatment (Hypertension, February 2019).
It’s important to note that SPRINT did not include people with diabetes, a history of stroke, or more severe or difficult-to-control hypertension, so the results cannot necessarily be extrapolated to these populations. However, a more recent study suggests that people with type 2 diabetes indeed may benefit from more aggressive blood pressure lowering (see “Intensive Blood Pressure Treatment Beneficial in Diabetes”).
Recent research into the effects of aggressive blood pressure-lowering therapy on cognitive health has produced mixed results. In a sub-study of the SPRINT trial (SPRINT-MIND), researchers reported that, after a median follow-up period of about five years, treating to a systolic blood pressure of less than 120 mmHg versus less than 140 mmHg was associated with significant reductions in the risk of mild cognitive impairment, a potential precursor to dementia, but it did not significantly lower the risk of probable dementia (Journal of the American Medical Association, Feb. 12, 2019). In another study, researchers reported that lowering systolic blood pressure to even less than 130 mmHg among older adults may contribute to cognitive problems, especially among those with complex health problems (see “Research Links Lower Treated BP to More Cognitive Decline”).
The Implications of SPRINT
The potential ramifications of SPRINT are considerable. An estimated 16.8 million people in the United States, or 7.6 percent of the population, meet the eligibility criteria of the SPRINT study participants, including 8.2 million adults undergoing treatment for hypertension, one analysis found.
In a separate analysis, researchers calculated that treating all U.S. adults who met the SPRINT eligibility criteria to the more ambitious systolic goal of 120 mmHg would prevent about 107,500 deaths per year. On the downside, the more aggressive treatment would give rise to 56,100 excess episodes of hypotension, 34,400 episodes of syncope, 43,400 serious electrolyte disorders, and 88,700 cases of acute kidney injury annually.
Making Your Decision
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In simplest terms, lower blood pressure is better than higher blood pressure. But what’s right for someone else might not be right for you. Your blood pressure management should be based on your individual health history, any family history of high blood pressure or cardiovascular disease, your weight, age, diet, exercise level, smoking history, and whether you have any other medical conditions, such as diabetes or kidney disease.
The benefits of aggressive blood pressure treatment must be carefully weighed against the potential risks. Remember that more treatment means more costs and more risks. If you take multiple medications every day for other health problems, adding additional antihypertensive drugs daily to get your blood pressure down a few more points may lead to side effects and drug interactions that put you at greater risk than an elevated blood pressure.
Ultimately, you and your doctor should determine if and when you require hypertensive drug therapy, how intensive that treatment should be, and what your target blood pressure level should be based on your individual profile and factors such as the presence of comorbid medical conditions, your risk of medication side effects, the costs of treatment, and your willingness to adhere to your treatment regimen.
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