Eric Goulder, MD, FACC
Heart Talk - October 2020
Stopping a Silent Killer: Lifesaving Facts Everyone Needs to Know About High Blood Pressure
Heart-healthy and Stroke-free Living with Eric A. Goulder, MD, FACC
More than 105 million Americans have hypertension (high blood pressure), a leading risk factor for heart attacks, strokes and dementia. Often called “the silent killer,” high blood pressure is also a major risk for developing severe or fatal illness from COVID-19. Moreover, deaths linked to hypertension have increased by 66 percent over the past decade. Yet only 19 percent of those with hypertension have their disorder under control, according to an alarming new study published in Journal of the American Medical Association (JAMA).
Earlier research has found that most people with uncontrolled high blood pressure have health insurance and visit a healthcare provider at least twice a year but remain undiagnosed and untreated. In our practice, we frequently see patients who don’t know what their blood pressure is but tell us they have always been assured that it’s “in the healthy range.” Very often, however, their numbers actually fall into the danger zone. Here’s a look at the latest guidelines and discoveries about blood pressure — and the facts you need to safeguard your heart, brain and arterial wellness.
What is normal blood pressure?
In 2018, the American Heart Association (AHA) and American College of Cardiology (ACA) issued updated blood pressure guidelines that set a lower threshold for hypertension. Under the old guidelines, only one in three Americans were deemed to have high blood pressure, which was defined as a reading of 140/90 mmHg or higher. The updated guidelines define hypertension as 130/80 mmHg or higher, putting an additional 30 million Americans in the danger zone.
Previously, people with blood pressure between 120/80 and 129/89 were often told that their pressure was “a little high, but nothing to worry about.” Actually, studies show that having prehypertension doubles the risk for cardiovascular events, such as heart attacks and strokes. Recognizing that serious or fatal complications of high blood pressure can occur at lower numbers, and to encourage earlier treatment, the current guidelines create the following blood pressure categories:
Normal: Less than 120/80 mmHg.
Elevated: Systolic blood pressure (the top number) between 120-129 and diastolic pressure (the bottom number) less than 80.
Stage 1 hypertension:
Systolic between 130-139 or diastolic between 80-89.
Stage 2 hypertension: Systolic at least 140 or diastolic at least 90 mmHg.
What is the optimal blood pressure goal for people with hypertension?
Until recently, a commonly recommended treatment target for systolic blood pressure (SBP) was 140. The landmark SPRINT clinical trial compared outcomes in people treated to this goal (with an average of two medications) to those who treated a more intensive therapy (with an average of three medications) to lower their SBP to 120.
The researchers found that the more intensive therapy lowered rates of cardiovascular (CV) events, such as heart attacks, strokes and heart failure, by nearly one-third. What’s more, the intensive treatment also saved lives, reducing all-cause mortality during the study period by 25 percent. That’s an extremely impressive benefit from taking one additional medication! The study included about 9,300 people ages 50 and older of diverse ethnicities with high blood pressure and at least one other risk factor for heart disease.
However, not everyone can handle such low pressures. Research has linked lower blood pressure with worse outcomes in patients who have hypertension and heart failure, particularly among those with preserved ejection fraction, a condition in which the lower left chamber of the heart is unable to fill properly with blood during the diastolic (filling) phase. For people with this disorder, a recent study found that a SBP treatment goal of >130 was linked to improved survival, compared to a goal of >120.
This study and similar findings for patients with other comorbid conditions, such as diabetes, confir m a longstanding BaleDoneen Method recommendation: “Optimal” treatment means individualized treatment, instead of treating all patients according to the average results of large, randomized studies. We advise patients to work in collaboration with their healthcare provider to determine the best personalized therapies and treatment goals.
Is mildly elevated blood pressure a big deal in people who are otherwise healthy?
A large body of research has shown that even slightly abnormal blood pressure can be more dangerous than obesity or smoking. For example, a 2017 study that examined data from 8.69 million people from 154 countries found that SBP of 110 or higher is one of the top risks for health problems, including coronary artery disease (plaque buildup in the vessels that feed the heart), stroke and chronic kidney disease. The researchers also reported that 30% of the disease burden fell on those with SBP of 110 to 135.
While SBP of 110 to 119 is not cause for concern, you may want to discuss natural ways to reduce blood pressure with your medical provider. These include mindful meditation to reduce stress (an important contributor to elevated blood pressure); beet juice (which has been shown to reduce SBP by 4-5 points within hours of drinking it); eating foods such as dark green leafy vegetables that are rich in magnesium (which helps regulate blood pressure), unrefined grains, and legumes; and getting 7 to 8 hours of sleep a night (skimping on slumber is linked to increased risk for hypertension).
What’s the best way to check your blood pressure?
Your morning blood pressure may be the best predictor of heart attack and stroke risk. A 2016 study of 21,591 people with hypertension found that morning measurements (when blood pressure tends to be highest) were more accurate for predicting which participants might be headed for a heart attack or stroke, compared to readings taken at home in the evening or those performed by clinicians in medical settings. The rate of CV events was significantly higher in people whose morning SBP was 145 or higher, compared to those with a reading below 125.
While home blood pressure readings are an important way for people with hypertension to monitor their health, it’s crucial to know the right technique, When using a wrist blood-pressure cuff, the reading will be inaccurate unless the device is positioned at heart level. A good way to tell if the device is correctly positioned is to hold the arm with the BP cuff across your chest as you would if the national anthem were playing.
What else should I know about high blood pressure?
Early detection and treatment save lives! What’s more, getting the disorder under control reduces your risk for a wide range of serious complications, including stroke, heart attack, dementia, heart failure, chronic kidney disease, aortic abdominal aneurysm and vision changes or blindness. Even though high blood pressure ranks as one of the world’s leading causes of disability, the JAMA study cited above found that awareness among Americans about its dangers has plummeted, compared to statistics from 2013 to 2014.
“The reversal in hypertension awareness is a real setback in the fight to reduce heart disease and stroke,” said Paul Muntner, Ph.D., the lead study author who also is professor and Associate Dean for Research in the School of Public Health at the University of Alabama at Birmingham. “While lifestyle factors are big contributors to hypertension, awareness and appropriate treatment are key to lowering blood pressure and keeping it in a healthy range to greatly reduce the risk for heart disease and stroke.”
Have your blood pressure checked at least once a year by your medical provider. Discuss your numbers, and if they are 120/80 or above, ask about the best ways to lower them. Therapies typically include lifestyle changes and, for many patients, medications. Very often, as the SPRINT trial demonstrated, it is necessary to take more than one medication to achieve the optimal blood pressure level. The good news is that once you do, your risk for serious complications decreases dramatically. For example, a study involving nearly 500,000 people found that for a 10 mmHg drop in blood pressure, heart attack risk falls by 50 percent!
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