Revised Approach to Hypertension

New government guidelines for controlling high blood pressure establish for the first time clear recommendations on prescribing drugs to treat people with this common condition.

“The new guidelines are more practical, they emphasize more classes of blood-pressure medications and point out how you may very well avoid side effects with some of the medications,” said Roger Blumenthal, director of the Ciccarone Preventive Cardiology Center at Johns Hopkins Medical Institutions in Baltimore.

The guidelines also “individualize the care of patients with high blood pressure,” said Samer H. Ellahham, director of the exercise and pharmacological stress imaging laboratory at Washington Hospital Center. “It will mean better treatment.”

An estimated 50 million Americans have high blood pressure, a condition that places them at increased risk of stroke, heart problems and kidney disease. These diseases are among the leading causes of illness and death in the United States, and account for more than $260 billion annually in direct and indirect costs, according to the National Heart, Lung and Blood Institute, which released the guidelines last month.

Blood pressure is the amount of force generated against the walls of the arteries as the heart pumps blood. It is measured in millimeters of mercury and consists of two numbers: a higher (systolic) reading, which measures the pressure while the heart pumps, and a lower (diastolic) number, which measures the force while the heart rests between beats.

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The guidelines define high blood pressure as 140 / 90 and above. Optimal blood pressure is 120 / 80, and there are categories of “high normal” blood pressure (130 / 85 to 139 / 89), stage 1 high blood pressure (140 / 90 to 159 / 99); stage 2 (160 / 100 to 179 / 109) and stage 3 high blood pressure (180 / 110 or higher).

“Our goal for everybody is to have systolic blood pressure less than 140 and diastolic blood pressure less than 90,” said Sheldon Sheps, chairman of the committee that wrote the guidelines. “But we’d like to get blood pressure as low as possible.”

The guidelines underscore that detection of high blood pressure begins with proper measurement. They recommend that patients should be sitting in a chair with good back support and the arm being used to take the measurement should be bare and at heart level. The patient should also avoid ingesting caffeine and smoking cigarettes for at least 30 minutes before having blood pressure measured. Both can raise blood pressure.

The reading should be taken only after the patient has been at rest for at least five minutes, and two readings should be taken and then averaged. Only half of those people with elevated blood pressure receive treatment for the condition, and only about half of those treated have their elevated blood pressure under control, according to the latest figures from the National Health and Nutrition Examination Survey.

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The new guidelines urge renewed vigilance in diagnosing high blood pressure and in treating it aggressively once the condition has been detected. For the first time, there are detailed recommendations to help doctors tailor care to the individual patient and minimize the risk of drug side effects.

Among the changes is a recommendation to use angiotensin converting enzyme (ACE) inhibitor drugs as the first line of treatment to control blood pressure in diabetics who already have evidence of kidney damage. Studies have shown that ACE inhibitors help prevent the progression of kidney damage.

ACE inhibitors cost more than the diuretics and beta-blocker medications that have been the standard of care.

“This will be a help because it affirms that people with diabetes and high blood pressure are in a higher risk category [for complications],” said Richard Kahn, chief scientific officer of the American Diabetes Assn.

The new guidelines also underscore the importance of behavior in preventing high blood pressure and controlling it. The last set of guidelines, published in 1993, directed doctors to first try to control hypertension by prescribing lifestyle changes. Among the recommendations were weight loss, quitting smoking, daily exercise and reducing dietary sodium.

Diet is a key part of the latest guidelines, which for the first time include specific food recommendations.

More information about high blood pressure is available by calling the institute’s information line, (800) 575-9355, or checking its Web site at https://www.nhlbi.nih.gov/nhlbi/nhlbi.htm.