Blood Pressure Guidelines Call for Knowledge, Judgment (Video)

Patients now can have more individualized treatment

blood pressure cuff

By: Steven Nissen, MD

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About eight months ago, an expert panel issued new recommendations to guide how doctors in the United States treat tens of millions of patients with high blood pressure. There’s been a lot of controversy recently around these guidelines for control of high blood pressure, which physicians call hypertension.

Hypertension is a serious and widespread health concern in the United States. Nearly 78 million U.S. adults – or one in three people – have the condition, which is a major risk factor for stroke and heart disease. Half of those people do not have their hypertension under control.


Hypertension is more common among older adults. As people grow older and enter their 60s, 70s and 80s, the percentage of their age group with hypertension increases.

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New thresholds

The recent recommendations, written by the Joint National Commission (JNC), set blood pressure thresholds based on a patient’s age. Under the new guidelines, most people older than age 60 should start medication when their blood pressure reaches 150/90. The recommendations also say that most people younger than age 60 should begin medications if their blood pressure is 140/90 or higher.

Everyone seems to agree that blood pressure higher than 140/90 is undesirable, while blood pressure of less than 120/80 is desirable.

That leaves a large group of people whose blood pressure falls in-between. Under the former guidelines, these people were labeled “pre-hypertension,” and advised to make blood pressure-lowering lifestyle changes.

Expertise needed

So do we prescribe medications for people in this group? This is where the doctor will use his or her expertise and judgment.

For example, if your blood pressure is usually around 150/90 but you are basically in good health, you may still be able to make dietary or lifestyle changes to bring your blood pressure to an acceptable level without having to take medicine.

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If this approach seems right for my patients, I recommend the DASH diet – The Dietary Approaches to Stop Hypertension diet. This way of eating focuses on fruits, vegetables, whole grains and lean proteins. At the same time, people who eat this way greatly reduce the amount of high-calorie foods and limit their salt intake.

Every patient is different, and physicians will have to assess a patient’s complete medical picture in deciding whether to prescribe lifestyle changes or medicine to lower blood pressure for these patients who fall in the gray area between 140/90 and 120/80. Factors the doctor may weigh could include the patient’s weight, the patient’s other diseases and conditions, or other medications the patient is taking.


One very important factor is age. There is consensus among physicians to have more flexibility in high blood pressure thresholds for older people. Lower blood pressure often produces dizziness in older people and could lead to falls. For older adults, falls are a serious matter. They can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death.

Although the science is not as clear as we wish it were, the new standards offer the opportunity for a more tailored, individualized approach for many people with hypertension.

So talk to your physician. Your doctor, using experience, knowledge and judgment, will be able to guide you to the best treatment for your individual needs.

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