Cho

Cho

The Cleveland Clinic Center for Medical Art & Photography

About 103 million Americans have high blood pressure, according to the American Heart Association – a figure that increased following the November announcement of a new guideline for diagnosing high blood pressure. 

The guideline, which lowers the minimum threshold from 140/90 mm Hg to 130/80, was agreed on by 11 medical groups, including the AHA and American College of Cardiology, and is the first update in nearly 15 years. While the change increases the percentage of U.S. adults diagnosed with high blood pressure, or hypertension, most adults diagnosed will not need medication. However, changes in lifestyle choices may be the solution.

Dr. Leslie Cho, director of Cleveland Clinic’s women’s cardiovascular center, and Dr. Jackson Wright, director of University Hospitals’ clinical hypertension program, provide insight into how significant this change is. 

“It’s a big change because we’re reclassifying so many millions of Americans into hypertension,” Cho said. “The prevalence of hypertension, with the new guideline, increased from 32 percent to 46 percent. So, it went from 82 million Americans to 103 million Americans.”

Nearly half of the U.S. adult population will be categorized as having high blood pressure, with the greatest impact expected among younger individuals, according to the ACC. In addition, the frequency of high blood pressure will triple among men under 45 years old and double among women under 45 years old. 

The new guideline also changed how patients measure their blood pressure. 

“There are some patients who are hypertensive in the office but not at home. Those patients have no greater risk of having an adverse event from high blood pressure than patients with normal blood pressure,” Wright said. “And by the same token, there are patients who are well controlled in the office whose blood pressure is much higher at home. And those patients have the same risk of high blood pressure.”

Those patients who experience an elevated blood pressure while at the office are experiencing white coat hypertension, which occurs when patients are nervous at the doctor’s office. 

“We may be missing patients who need treatment by relying on office readings,” Wright says. “We also may be treating patients who don’t need treatment.”

Because of white coat hypertension, Cho recommends patients take their own blood pressure measurements at home throughout the week but adds people should not overdo it because fixating on the measurements can affect the readings.

If it’s determined a patient’s blood pressure is between 130 and 140, identifying them as hypertensive, prescribing medication is not a doctor’s first step. Instead, Cho and Wright say more information is needed – like age, race, gender, history of diabetes and cholesterol levels – to estimate the chance a patient will have a cardiovascular event, like a heart attack, that can cause damage to the heart muscle. 

The additional information, along with blood pressure measurements, are put into a risk calculator, a tool utilized by physicians for years. If the risk is less than 10 percent and the patient hasn’t had a cardiovascular event, beginning treatment takes the form of healthy eating, increased exercise, responsible drinking and refraining from smoking instead of medication. 

If the risk is greater than 10 percent, Cho says “your goal of blood pressure treatment should be less than 130 over 80. ... We should target you to a lower blood pressure because your risk is higher.”

Treatment for a risk of greater than 10 percent will still include lifestyle changes, though medication may be prescribed. That said, older adults may not want to lower their blood pressure too quickly as it could result in adverse results. 

“As we get very, very old, it’s not so good to really lower your blood pressure because you may need a little bit of a higher blood pressure just for brain profusion,” Cho says. “Sometimes, when we try to lower blood pressure aggressively in the elderly, they get dizzy and fall down and break a hip, which is horrible.”

Cho adds, that the “very, very old” age depends on the patient as the health of older patients vary by case, which is when personalized medicine comes into play.

While the release of the new guideline may be seen as a way to scare patients into living a healthier lifestyle, being prescribed medication is easier than having people modify their behavior. Yet, Cho and Wright say over-prescribing can be avoided with more time in the doctor’s office and educating everyone involved.  

“It’s important to educate patients on the blood pressure target, educate physicians on the new blood pressure target and then also the use of the risk calculator to figure out where the patients sit on that risk calculator,” Cho says. “And I think the other important thing is the proactive part of taking the initiative and measuring at home.” 

Following the guideline will take both patients and physicians working together, and the results can be rewarding.

“The benefits (of the guideline) are there will be a reduction in patients dying as well as reduction in heart attacks. The major cause of people entering the hospital is heart failure, and the major cause of heart failure is high blood pressure,” Wright says. “It will reduce strokes, it will reduce kidney disease. There’s a huge benefit to both the patients who are being taken care of, as well as to the overall community, and the cost of health care in the country.”

 

This story originally appeared in Balanced Family magazine on March 16, 2018.

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