The New Normal:
New Guidelines Lower Threshold
for High Blood Pressure

Published in December Issue             

High blood pressure begins with a reading of 130 over 80, not 140 over 90, according to sweeping new guidelines from the American Heart Association (AHA), American College of Cardiology (ACC) and nine other health professional organizations. These lower systolic and diastolic measurements mean 30 million more Americans have high blood pressure, bringing its prevalence to nearly half (46 percent) the U.S. adult population.

The new AHA/ACC guidelines, the first update since 2003, were published in the journal, Hypertension, and the Journal of American College of Cardiology in November. Still, the upper threshold for high blood pressure has been 140 since 1993.

With the lower measures, an additional 14 percent will be diagnosed with high blood pressure and recommended earlier intervention to prevent further increases in blood pressure and its complications. However, the guidelines note there will only be small rise in the number of people who require antihypertensive medications. Most will be counseled about lifestyle changes, including alterations to diet and exercise regimens.

In a news release, Paul K. Whelton, MD, M.Sc., lead author of the guidelines, noted the dangers of blood pressure levels between 130-139/80-89 mm Hg.

“You’ve already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure,” Dr. Whelton said. “We want to be straight with people – if you already have a doubling of risk, you need to know about it. It doesn’t mean you need medication, but it’s a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches.”

In the United States, hypertension, which increases the risk for heart disease and stroke, accounted for more cardiovascular deaths than any other modifiable risk factor and was second only to cigarette smoking as a preventable cause of death. Risk estimates from the Nurses’ Health Study suggest that obesity may be responsible for about 40 percent of hypertension, and the Framingham Offspring Study, puts it even higher at 78 percent in men and 65 percent in women.

The new guidelines also eliminate the category of prehypertension, which was used for blood pressures with a top number between 120-139 mm Hg or a bottom number between 80-89 mm Hg. People with those readings now will be categorized as having either Elevated (120-129 and less than 80) or Stage I hypertension (130-139 or 80-89).

Samer Mattar, MD

The impact of the new guidelines is expected to be greatest among younger people, with the prevalence expected to triple among men under age 45, and double among women under 45. ery serves to underscore the safety, durability and efficacy of this life-saving therapy.”

Damage to blood vessels begins soon after blood pressure is elevated, said Dr. Whelton. “Risk is already going up as you get into your 40s.”

Other changes in the new guidelines include:

  • Only prescribing medication for Stage I hypertension if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease or calculation of atherosclerotic risk (using the same risk calculator used in evaluating high cholesterol).

  • Recognizing that many people will need two or more types of medications to control their blood pressure, and that people may take their pills more consistently if multiple medications are combined into a single pill.

  • Identifying socioeconomic status and psychosocial stress as risk factors for high blood pressure that should be considered in a patient’s plan of care.

First Randomized Study Compares Gastric Bypass Plus Medical Therapy to Medical Therapy Alone for Hypertension

On the same day, the new AHA/ACC guidelines were released at the American Heart Association annual meeting in Anaheim, CA, the first randomized study on the impact
of bariatric surgery on hypertension was presented there and published in the
journal, Circulation.

The Gastric Bypass to Treat Obese Patients With Steady Hypertension (GATEWAY) study found bariatric surgery may reduce or eliminate the need for high blood medications in patients with obesity, often within one month. The study was funded by a grant from Ethicon, part of the Johnson & Johnson Medical Devices Companies and a manufacturer of devices used in bariatric surgery.

Within 30 days of surgery, 83.7 percent of gastric bypass patients controlled their blood pressure (140/90 mm Hg) with at least 30 percent fewer medications. Within a year, more than half (51%) showed remission and required no medications at all. The medical therapy group wasn't as successful with only 12.8 percent of them reducing their use of high blood pressure drugs by 30 percent and none achieving remission over 12 months.

After a year, a third (33%) of patients normalized their blood pressure to less than 120 mm Hg, and 69 percent of them did so without medication. A little more than a quarter (26%) of the medical therapy alone group achieved normalized blood pressure with an average of 2.8 medications per patient.

"This study suggests that cardiologists treating obese patients with hypertension, mainly those with severe obesity and using more than two drugs, can consider referring these patients for bariatric surgery, which is consistent with the American Heart Association, American College of Cardiology and The Obesity Society Clinical Practice Guidelines," said lead study investigator Carlos Aurelio Schiavon, MD, a bariatric surgeon at Hospital do Coracão (HCor) in Brazil, in a news release, "Fewer or no medications means better compliance and weight loss with an improved metabolic and inflammatory profile combine to reduce the risk of major cardiovascular events for these patients."

According to the news release, obesity and hypertension are independent risk factors for cardiovascular disease and stroke, and when someone has both risk factors, the risk for cardiovascular mortality doubles.