It’s an all-too-familiar drill to anyone visiting a doctor’s office for a checkup: Sit up straight in the chair, feet planted firmly on the floor, while an assistant wraps the cuff around your biceps. It inflates, and you feel the blood pulsing reliably beneath the pressure. Moments pass as you ponder your heartbeat. Then comes the whoosh of air leaving the cuff, a sound that may vaguely suggest relief.
If the resulting blood-pressure numbers exceed what’s considered the normal range, however, that reprieve could be short-lived. Your doctor may launch into a stern lecture on the dangers of hypertension, “the silent killer” that triggers strokes and heart attacks in millions of unsuspecting Americans each year. You agree that you probably should lose some weight and get more exercise but soon find yourself clinging to a scribbled prescription and wondering whether you should finally break down and apply for that rewards card at the local pharmacy.
At that point, you may also begin to wonder what “normal” means when it comes to the numbers your doctor’s sphygmomanometer produces. You would not be alone.
In 2017 the American College of Cardiology (ACC) and the American Heart Association (AHA) recommended a dramatically lower threshold for a hypertension diagnosis: 130/80 mm Hg instead of 140/90 mm Hg. These guidelines pushed nearly half of all American adults and 80 percent of seniors into the danger zone. Ever since, practitioners have been debating the merits of the more stringent standards, while patients weigh the convenience (and risks) of blood-pressure drugs against the challenge of lifestyle changes.
Dropping the hypertension ceiling from 140/90 to 130/80 mm Hg may seem insignificant, but it has proved a powerful talking point for functional-medicine cardiologist Mimi Guarneri, MD, with her patients. “There are a lot of people who say, ‘I’m 130; that’s close enough,’ but that’s now recognized as stage 1 hypertension,” she says. “I think it’s a public-service message and a public-health issue.”
Other frontline practitioners are less enthusiastic. The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) refused to endorse the new guidelines, and the American Medical Association (AMA) issued a neutral statement, instead renewing its call for diligent blood-pressure monitoring. Meanwhile, a host of respected analysts have criticized the controversial 2015 study used to justify the change, the Systolic Blood Pressure Intervention Trial, better known as SPRINT.
Cardiologist Harlan Krumholz, MD, director of the Yale New Haven Hospital Center for Outcomes Research and Evaluation, pointed to SPRINT’s limited range of participants, suspect methodology, and adverse outcomes. Writing in the New York Times, Krumholz advised patients to avoid overreacting. “For the many people treated for blood pressure who would not have qualified for this study, including those with diabetes, it is not clear that they should do anything different.”
For Guarneri and her functional-medicine peers, the guidelines simply offer an opportunity to improve patient education. The numbers are important, she notes, but only if they encourage health-supportive behavior change. “We haven’t empowered our patients with enough good information,” she says. “A lot of conflicting information from the media perspective confuses people.”
When Hypertension Was “Essential”
Hypertension — excessive amounts of blood coursing through too-narrow arteries — comes in two forms: primary hypertension, which develops gradually as a byproduct of aging, and secondary hypertension, which appears more suddenly as a result of genetic defects or certain conditions, including sleep apnea, kidney dysfunction, adrenal gland tumors, and thyroid problems. Some pharmaceuticals can also spike blood pressure.
High cholesterol can be a trigger as well, because it may produce plaque that narrows the arteries. Too much sodium can also inhibit the kidneys’ capacity to remove water from the blood, leaving extra fluid to put more strain on arterial walls.
As recently as the mid-20th century, hypertension was considered a nontreatable malady, a natural result of aging and hence “essential.” President Franklin Roosevelt reportedly had blood-pressure readings of 210/110 mm Hg and higher; his death from a stroke in 1945 was a pivotal event in the U.S. campaign to identify and treat the condition.
The 1948 National Heart Act sparked a flurry of research, including the Framingham Heart Study, which established a credible link between high blood pressure and cardiovascular disease. But a lack of safe, reliable treatment options hampered efforts well into the 1960s.
“Attempts to treat hypertension, with the few drugs that were available at the time, often caused more misery and earlier demise for the patients than leaving them untreated,” reports Mohammad Saklayen, MD, in Frontiers in Cardiovascular Medicine.
Veteran’s Administration studies in the 1970s focused on diastolic hypertension — the lower number in a reading, which reflects the pressure exerted on the vessels between heartbeats — and recommended treatment for levels above 90 mm Hg. But that approach applied to only about a third of Americans with high blood pressure.
Isolated systolic hypertension (the force of blood against vessels when the heart is pumping) is far more common and was not considered treatable until 1991. That’s when a major study demonstrated the salutary effects of lowering systolic levels with a pharmaceutical regimen.
The consensus on healthy diastolic levels has remained relatively consistent over time, but researchers have continued to haggle over optimal systolic numbers — and nothing has raised their blood pressure quite as reliably as the 2015 SPRINT study, which inspired the guideline change in 2017.
By the time Paul Whelton, MB, MD, PhD, presented the SPRINT findings at a November 2015 AHA conference, the news had already made global headlines.
Results from the randomized controlled study of more than 9,000 participants showed that lowering systolic blood pressure below 120 mm Hg with an intensive drug regimen reduced rates of heart attack, stroke, and other fatal and nonfatal cardiovascular events by 25 percent compared with a control group receiving a standard treatment with a target of 140 mm Hg.
The response from the broader medical community was cautiously pessimistic. While cardiologists hailed the results, a wide swath of scientists questioned the study’s methodology and its conclusions. Many expressed concerns about the adverse effects of overmedication, while several respected experts suggested that the greatest risk for the vast majority of Americans comes not from hypertension but from rushing to get it treated.
University of Victoria drug-policy researcher Alan Cassels argued in a 2016 journal article that early media reports had mostly overlooked SPRINT’s flaws. The trial was concluded two years earlier than planned when early results looked promising; truncated studies, he explained, often lead to overestimating treatment effects. Cassels also noted financial ties between some of the study’s investigators and drug companies. Plus, he stressed its outlier standing.
“SPRINT is one study, and it is dangerous to look at a single trial in isolation,” he wrote. “Clinicians and patients should consider how the results of SPRINT compare with other trials that have asked similar questions.”
Most important, Cassels questioned the relative benefits of SPRINT’s protocol for hypertensive patients. Calculating the outcomes per 1,000 patients treated with the more intensive therapy, he found that the risks outweighed the benefits:
- Eight heart failures and six deaths from cardiovascular causes were prevented.
- 18 acute kidney injuries or renal failures, 10 cases of low blood pressure, six cases of fainting, and eight electrolyte abnormalities were caused.
If you or a loved one happen to be one of the patients saved from heart failure or death, the risks may seem reasonable. But those with kidney dysfunction and fainting spells might feel differently. Either way, Cassels’s analysis shows that intensive blood-pressure-reduction efforts come with risks of their own.
His view is shared by the Cochrane Collaboration, a global network of scientists known for its meticulous analysis of medical research. Seven years earlier, its Hypertension Review team had concluded that treatment lowering systolic levels below 140 mm Hg yielded no overall health benefits. When Cassels asked the head of that team whether patients should seek treatment to lower their blood pressure to the levels SPRINT recommends, the response was unambiguous: “Definitely not.”
A Victory for Cardiologists
Despite mixed reviews, SPRINT bolstered the argument for stricter blood-pressure standards that some cardiologists had been making since 2003, when the National Heart, Lung, and Blood Institute established the previous set of guidelines. And two years after SPRINT was released, a panel of 21 health experts announced the new ACC/AHA standards of 130/80 — a compromise of sorts emerging from what experts described as the “highest standards” of research.
The lower threshold for treatment now means nearly half of the U.S. adult population qualifies as hypertensive — triple the number of men and double the number of women under the age of 45.
“We want to be straight with people — if you already have a doubling of risk, you need to know about it,” Whelton, the lead author of the guidelines, said in a statement announcing the new standards. “It doesn’t mean you need medication, but it’s a yellow light that you need to be lowering your blood pressure.”
Conventional practitioners, however, are often unprepared to counsel their patients on lifestyle changes that will effectively lower their numbers without drugs. Even under the less rigorous guidelines, a National Health and Nutrition Examination Survey found that only about half of all patients were able to reach the goal numbers.
“This is a big change that will end up labeling many more people with hypertension and recommending drug treatment for many more people,” Krumholz told the New York Times.
It’s a concern shared by many physicians. Neither the AAFP nor the ACP endorsed the new guidelines, and the ACP’s Clinical Guidelines Committee stated its opposition quite clearly: “Are the harms, costs, and complexity of care associated with this new target justified by the presumed benefits of labeling nearly half the U.S. [adult] population as unwell and subjecting them to treatment? We think not.”
Lifestyle changes are the ideal treatment, but drugs are often the reality — and the new guidelines are a boon to Big Pharma. The vast majority of people diagnosed with hypertension turn to diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), calcium channel blockers, beta blockers, or renin inhibitors.
In 2016, for example, doctors wrote more than 110 million prescriptions for a single ACE inhibitor, lisinopril; more than 49 million for assorted ARBs; and more than 43 million for various hydrochlorothiazide diuretics. These drugs can effectively lower blood pressure, but they also pose risks, including kidney and liver damage, dizziness, and fainting.
A Clinical Conundrum
At the La Jolla, Calif., clinic where Guarneri practices, the new guidelines seldom come up in her conversations with patients. Most of them, she says, think 120/80 mm Hg has been the standard. As a cardiologist, Guarneri is fine with that.
“It’s really important to recognize that hypertension is a silent killer,” she says, “because some people are running around with a heart condition they don’t know about.”
She is concerned, however, that most physicians won’t focus on lifestyle changes. Pharmaceuticals are often the default solution in clinics where overscheduled doctors have little time to explore possible reasons behind a patient’s high numbers.
“A practitioner who is seeing 25 to 30 people a day will say, ‘Here’s a pill,’ because that’s what they can do in 10 minutes. There’s no real counseling that’s happening,” Guarneri says.
She prefers to focus on root causes for high blood pressure. “Maybe it’s a micronutrient issue, maybe it’s sleep apnea, maybe it’s stress and anxiety. These are not going to be addressed with a blood-pressure pill.”
Patients can fall into the same trap, says Shilpa Saxena, MD, a Tampa-area functional-medicine practitioner. “To some extent, patients enjoy this idea of a quick fix — until they start realizing there are side effects to their sexual function or whatever,” she says.
Before long, she adds, that first “magic bullet” leads to a second and third, as the causes for their hypertension remain unexplored.
That’s not to say pharmaceuticals have no place in their practices. Both Guarneri and Saxena prescribe them when necessary. But “preventive cardiology” focuses first on educating patients about how exercise, stress management, sleep, and dietary modifications help control blood pressure.
Guarneri counsels patients to limit sodium intake to less than 1,500 mg per day and boost potassium consumption, which helps the body process excess salt. She also runs lab tests to ensure they’re getting enough magnesium, vitamin D, and zinc, all of which play a role in regulating hypertension.
The guidelines matter, Saxena notes, but they don’t govern her treatment choices. She may encourage her younger patients to pursue lower numbers than her older patients. It’s never one-size-fits-all.
“These guidelines are for the masses, but we don’t treat the masses,” she says. “We treat one person at a time.”
Hypertension isn’t a disease, she explains. It’s simply a clue that something’s not functioning properly in the body. When you begin to understand that premise and realize that lowering the numbers isn’t the end goal, you’re in a better position to work with your physician to find the real sources of the trouble.
Saxena often recommends an elimination diet of four to six weeks for patients with high blood pressure. It can help reduce the inflammation that may ultimately contribute to cardiovascular disease as well as rebalance the gut microbiome. She also focuses on improving liver function to help the body shed toxins more effectively — another factor in chronic inflammation.
Many doctors claim they prescribe drugs because patients refuse to change their habits, but Guarneri says that has not been her experience — even though there are usually obstacles on the way to behavior change. Combating the food industry’s relentless marketing of unhealthy products, for instance, is a major challenge.
“There are millions of dollars invested in making salty potato chips so you can’t only eat one,” she notes. “Money is spent on making food addictive.” So she counsels her patients to think critically about these messages, as well as to read food labels, know what vegetables deliver the best balance of micro- and macronutrients, and understand how stress, sleep, and weight affect blood pressure.
Both Guarneri and Saxena believe it’s possible to respond calmly to the dire warnings raised by the new blood-pressure guidelines, and Saxena is encouraged by what she sees in her clinic every day. “People already recognize that there are things they can do to help themselves; they just don’t know what they are yet,” she says. “They have more interest, and they’re open to being empowered.”