Hypertension (high blood pressure), especially inadequately treated hypertension, increases one’s risk of having a stroke, heart attack, developing congestive heart failure, or progressing to various forms of dementia two- to four-fold.  There are an estimated 80 million Americans with high blood pressure, and that figure is expected to steadily rise in the next 15 years.  The good news is that these feared outcomes are potentially preventable. Aggressive treatment with lifestyle and dietary modifications, and medications, have been shown to be effective in a multitude of studies.  When analyzing and aggregating the results of numerous trials evaluating the treatment of hypertension, results support the estimation that for each successive lowering of the systolic blood pressure (SBP) and diastolic blood pressure (DBP) by 10/5 mmHg respectively, one can reduce their 5 year risk of stroke by 36%, of developing congestive heart failure by 43%, and of having a heart attack by 16%.

The seventh Joint National Committee (JNC 7) Hypertension guidelines, published in 2003, broadened high BP classification in an attempt to increase awareness about the need for interventions in patients who met these criteria, and those with specific cardiovascular risk factors such as diabetes and chronic kidney disease.  This classification is shown below:


The eighth Joint National Committee (JNC 8) updated its hypertension treatment guidelines in a document published last year.  The classifications above were not addressed; the focus instead was on which groups of individuals should be treated, and to what specific thresholds.  Many of these new thresholds were considered extremely controversial.  Specifically debated was a new recommendation that In the general population aged 60 years or older, medical treatment to lower systolic blood pressure should be started at levels of 150mmHg or higher and/or diastolic blood pressure at levels of 90mmHg or higher, and treatment to a point lower than these levels should be the new goal.  This less aggressive approach was questioned by many in the medical community involving multiple medical specialties.

Based on a recently performed NIH-sponsored clinical trial called SPRINT, these new thresholds for treatment are coming under fresh scrutiny for being too lenient.  This study evaluated approximately 9,300 people age 50 or older, with elevated systolic blood pressure and elevated cardiovascular risk, and randomly treated half of the patients to a target SBP of 120mmHg (more aggressive group), and the other half to the recommended 140mmHg (guideline treated group). In short, the results demonstrated an approximate 25% reduction in death over the study period in the more aggressively treated group.  This raises the obvious question: are physicians under-treating patients with high blood pressure?  The results of this study are due to be published shortly, and will likely impact updated hypertension treatment guidelines and practices.

I have always tended to treat my hypertension patients more aggressively than guidelines recommend, especially patients who have multiple risk factors for cardiovascular disease.  I also encourage my patients to get screened via multiple methods early in adulthood, so treatments that are potentially less aggressive can have greater effectiveness in preventing the ravages of high blood pressure down the road.  Of course, other than simply treating the BP to a certain level, the choice of medication used in the process, which is often based on coexisting risk factors, is of paramount importance and often unfortunately minimized as a trivial issue.  When the SPRINT study is actually published and fully scrutinized, further light will be shed on these issues.

I will close with practical lifestyle and dietary pointers that should be part of ALL high blood pressure treatment regimens, regardless of whether you are taking medications.  I encourage you to discuss all of these issues with your physician.

  1. If you are overweight, try to decrease your BMI to < 25 kg/m2
  2. Try to stick to a diet similar to the DASH (Dietary Approaches to Stop Hypertension) diet or similar regimen (high fruits and vegetables, low fat). http://dashdiet.org/default.asp
  3. Decrease your sodium (salt) intake to 1500-2400 mg/ daily (READ food labels!!).
  4. Get off your butt and walk! Briskly walking 30 minutes a day 4-5 days a week will have a significant blood pressure lowering effect.
  5. Drink alcohol only moderately (less than 2 drinks/day).

Lee S. Marcus, MD, MS, FACC