New guidelines caution use of certain meds for treating high blood pressure

Physicians received new guidelines this month for treating high blood pressure in patients age 65 and older.

The guidelines, released by the American Heart Association and the College of Cardiology, advise physicians to monitor whether hypertension medication results in a dangerous drop in blood pressure when elderly patients stand up. The medical groups say a sudden drop in blood pressure can cause fainting, which could result in serious injuries for older patients.

MPR medical analyst Jon Hallberg discussed the recommendations this week with All Things Considered host Tom Crann. Hallberg is a physician in family medicine at the University of Minnesota and director of the Mill City Clinic.

Tom Crann: So first, what are the changes in guidelines?

Dr. Jon Hallberg: Well, for the first time ever we've really got some information to go by that lets us look at our older patients, people who are 65 and older, and even those who are 80 and older, and (gives) us some recommendations.

What we've realized is that there's no one-size-fits-all for blood pressure anymore. I think we all know that 120/80 is the upper range of what is considered normal, and therefore for treating blood pressure, you should be shooting for that, but that is not true when people get to be 65 and older.

Crann: And so why this change now?

Hallberg: For years, high blood pressure has been called essential hypertension. I think the thinking decades ago was that it was essential that the blood pressure be elevated as we got older because it was harder to profuse the brain and organs. And then for years that thinking has been revised, and we realized that no, having really high pressure is not a good thing.

So in 2008, there was a study that was concluded, and it looked at high blood pressure in people over 80. And they found that if you treat them gently, treat their blood pressure gently and bring it down, that you actually have a major reduction in heart disease. And so it got everyone thinking, these cardiologists and others, that maybe we should have some guidelines to help us determine how best to treat blood pressure in the elderly.

Crann: So is this an admission that perhaps it isn't as risky as once thought in older patients, to have a little bit of elevated blood pressure?

Hallberg: That's right. The biggest problem we have in people is if we are going to treat their blood pressure, that frankly, we overshoot the mark, that we do too good of a job of bringing it down. And when we do that, and older people get something called orthostatic hypotension — hypotension, not hypertension. As they stand, sometimes blood pressure drops.

So we need to be really careful because one of the biggest risks is that a person falls or faints, and they could break a hip, for example, or get some kind of injury, so we have to really walk that fine line between treating, doing the right thing, but not overshooting it.

Crann: So right now, how has it been detected and treated? I imagine it's a regular part of most office visits for anyone of any age, right?

Hallberg: Absolutely. It's one of the vital signs. So between checking someone's weight and your blood pressure and pulse virtually every visit, that's been included, but there's a little twist now. They're actually saying that, especially the older folks, we should actually have them stand when we're checking their blood pressure for one to three minutes.

And that's a complete change, and I feel like I've really missed the boat on that one. I wasn't aware of that, and I think it's going to take a long time before that becomes the standard of care, but it makes sense to have people stand and see if their blood pressure's dropping. That might give us a better sense of how aggressive we need to be with treating their blood pressure.

Crann: Do these new guidelines give you any advice on how aggressive you should be about prescribing medicine, for example?

Hallberg: They sure do, and they're now saying that rather than that mark of 120/80 for most people, when people are 65 and older, maybe we really need to be looking at 140/90 as our goal. And that's a big, big change, and I think a lot of people are going to be surprised to hear that, patients and providers alike.

And then they're saying that perhaps 150 in some people, if they can't tolerate a blood pressure lower than that — they're just getting too light headed when they stand up, they just feel funny, the meds are too much for them — that maybe 150 is the new cutoff. And the fact is if you keep it less than that, there's a big reduction in heart disease and seemingly stroke.

Crann: So moving forward on this, will people, especially patients 65 and older, likely see changes in the way blood pressure's detected and treated?

Hallberg: Yes, I think so. I think what we're going to do first of all, we'll probably detect their blood pressure differently. We'll probably actually have them stand at some point to see what kind of a difference we get with that.

I think we'll be very careful about the medications that we choose. They've given us some specific guidelines about starting with a low dose and slowly, slowly adding, which isn't really new, but it's giving us some guidelines, and I think that we'll be much more flexible in what we are shooting for. We're going to be much more okay with people having higher blood pressure. And that's a pretty big change. We've had it pounded into our heads for so long that it needs to be lower that this is going to, I think, make it easier in some ways to treat this condition, but not treat it too aggressively.

(Interview edited and transcribed by MPR reporter Madeleine Baran)

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