The Shifting Guidelines for Blood Pressure Control

The patient initially came to see Dr. Mark Supiano in 2017 because her family was concerned about her short-term memory loss.

While taking her history and vital signs, Dr. Supiano, a geriatrician at the University of Utah, saw one disturbing signal: Her blood pressure was 148/86, above normal despite her taking two medications intended to lower it. “Clearly that was too high,” he said recently.

Several factors could have contributed to the high reading, including the anti-inflammatory drug the 78-year-old woman took for arthritis pain, a high-sodium diet and a lack of regular exercise. She had also told Dr. Supiano that she typically drank a couple of glasses of wine each evening.

After Dr. Supiano discussed ways to lower her risk, the woman and her husband joined a gym. She stopped taking the anti-inflammatory and cut back on salt and alcohol, bringing her systolic blood pressure readings into the 130 to 140 range — still hypertension, according to the guidelines issued by the American Heart Association and the American College of Cardiology later that year, but more acceptable. (Systolic is the top number in the blood pressure ratio, and the more clinically important number.)

By 2019, though, the patient had a diagnosis of mild cognitive impairment, and medical evidence was emerging about a connection between hypertension (the medical term for high blood pressure) and dementia. “I was not as aggressive as I should have been,” Dr. Supiano recalled. He added a third drug for hypertension to the woman’s regimen, and her readings fell to 120 or lower.

The shifting guidelines for blood-pressure control may remind those at advanced ages of a dance fad from their youth, the limbo. As Chubby Checker once intoned, “How low can you go?”

For more than 25 years, a reading of 140/90 or below was considered normal, according to the A.H.A./A.C.C. guidelines. But the 2017 update introduced major changes, backed by results from the landmark Sprint trial, which enrolled adults over 50 who were at high cardiovascular risk.

The Sprint trial found that intensive treatment aimed at bringing the systolic number below 120 reduced the risk of heart attacks, strokes, other cardiovascular illnesses and overall mortality so substantially that the investigators stopped the study early.

It was unethical, they decided, to deny half the trial participants the benefits of intensive treatment. The 2017 guidelines, therefore, recommended medication for those with a systolic blood pressure over 130.

The most recent revisions, issued late last year, encourage still tighter control. They call for patients at cardiovascular risk to strive for systolic readings below 120, and they also call that target “reasonable” even for those who are not at high risk. Readings considered normal not so long ago are now defined as hypertension.

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