New normal reclassifies millions as having high blood pressure, so now what?

bp-300x169Did you feel yourself just get less well? U.S. heart experts have just issued new guidelines on what Americans’ optimal blood pressure should be—effectively and suddenly shifting just under half of the adults in the nation younger than 45 into an unhealthful status as hypertensive.

Doctors say there’s no doubting data that shows that blood pressure readings exceeding 130 over 80 can be detrimental to patients’ health. That’s down from the previous warning level of 140 over 90.

But what exactly has the medical establishment wrought with this sweeping metric? Have they deemed so many of us unwell in this way that we’re about to see public doubt and confusion—even profiteering—as has surrounded the description of tens of millions of Americans as “prediabetic?”

To be sure, hypertension, a so-called “silent killer,” is a serious concern, as the federal Centers for Disease Control and Prevention has noted. High blood pressure contributes to hardening of the arteries, which decreases the flow of blood and oxygen to the heart and leads to heart disease. Decreased blood flow to the heart also can cause: Chest pain (aka angina); heart failure, when the heart can’t pump enough blood and oxygen to other organs; and heart attacks, which occur when the blood supply to the heart is blocked and heart muscle begins to die due to insufficient oxygen. High blood pressure also can burst or block arteries that supply blood and oxygen to the brain, causing strokes that can be fatal and cause serious disabilities in speech, movement, and other basic activities. Adults with diabetes, high blood pressure, or both have a higher risk of developing chronic kidney disease, the CDC says. About 1 of 3 adults with diabetes and 1 of 5 adults with high blood pressure have chronic kidney disease.

But what’s to be done to lower that high blood pressure?

Stop if you’ve heard this from your doctor before: You should eat less and better. Get more healthful fruits and vegetables in every meal. Cut down on the alcohol. Lose weight. Exercise more. Figure if you can reduce the salt and sugar in your diet.

You’ve been there, done that, right?

If not, you do need to go there, and all the way if you can, no fudging, no rationalizing. Otherwise it’s daily pill-taking which has its own issues.

In my practice, I see the major harms that patients suffer while seeking medical services and their struggles and abundant confusion in trying to adhere to various medical care regimens. I understand doctors’ hypertension concerns. This health measurement, however, comes with its own challenges, which also need to be made clear to patients.

Blood pressure readings, though they have been around forever, aren’t easy to take in accurate fashion. They can vary greatly within just a few minutes of measure, and the devices used, and the takers’ skill matter a lot. In fact, a recently published study called out medical schools for failing to teach aspiring physicians adequately and properly how to measure blood pressure, saying:

[M]edical students do not attain mastery of the skills required to measure BP accurately. We believe the use of automated devices will reduce some common errors in measuring BP, but our study confirms that automated device use alone will not eliminate many common errors in BP measurement. If physicians continue to measure BP, as we expect they will, then medical school training in these skills should be revised and studied to ensure it is effective. We also expect that physicians, after achieving mastery in these skills, should undergo competency testing at similar intervals, a minimum of every 6 months throughout their careers, as is recommended for other healthcare professionals…

It’s also worth digging deeper into the research that swayed heart experts to toughen their blood pressure guidelines, the careful, 2015 “Sprint” study of just under 10,000 participants, focusing on randomly assigned high blood pressure patients age 50 and older to one of two treatment targets: systolic blood pressure of less than 140 or one of less than 120. A report on the work was published in the prestigious New England Journal of Medicine.

It’s worth reading about this study in a New York Times Op-Ed by H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, and the author of “Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care.” He summarizes and raises questions about the research, thusly:

The primary finding was that the lower [blood pressure] target led to a 25 percent reduction in cardiovascular events — the combined rate of heart attacks, strokes, heart failures and cardiovascular deaths. Relative changes — like a 25 percent reduction — always sound impressive. Relative changes, however, need to be put in perspective; the underlying numbers are important. Consider the patients in Sprint’s high target group (less than 140): About 8 percent had one of these cardiovascular events over four years. The corresponding number in the low target group (less than 120) was around 6 percent. Eight percent versus 6 percent. That’s your 25 percent reduction. The effect was small enough that The New England Journal used a special pair of graphical displays used for health events that occur rarely. One display focused on those participants suffering the cardiovascular events (8 percent versus 6 percent); the other shows the big picture — highlighting the fact that most did not (92 percent versus 94 percent). Oh, and did I mention that to be eligible for Sprint, participants were required to be at higher-than-average risk for cardiovascular events? That means the benefit for average patients would be even smaller.

Got it? Patients, of course, should consult closely with their own doctors about their individual situations. They may be at higher risk and need greater hypertension management because of a family history of stroke or heart disease or if they have diabetes. At present, the medications commonly given to control high blood pressure are readily available as low-cost generics. (That also was true for a long time of a common diabetes therapy—insulin, a product whose prices drug makers have sent soaring.) But, counter intuitively, it also needs to be noted that reducing blood pressure can carry some risks, particularly for older patients. They may suffer a drug side-effect that makes them dizzy and more susceptible to falls.

As Welch points out in his commentary, it may be that patients’ doctors will not only follow the heart experts’ guidelines on blood pressure but do so with thought, care, and moderation. Their front-line role in keeping Americans healthy won’t be made easier when half the folks who walk in their offices may be hyper “medicalized,” either deemed to be at worrisome risk of diabetes (again, a serious condition, not to be taken lightly) or hypertension.

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