Aggressive Treatment of High Blood Pressure

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At the American Heart Association Scientific Sessions (November 13, 2023), researchers presented the results of the 11,255 patient ESPRIT trial of patients who also had diabetes and/or a past history of a stroke. When they were treated very aggressively for three years to drop their high systolic blood pressures below 120 mm Hg (compared to the old standard of 140 mm Hg), they had:
• a 12 percent lower incidence of heart attacks
• a 39 percent lower incidence of deaths from heart attacks

This is an important study because the same group also showed that high blood pressure medications increase blood flow to the brain to help prevent strokes (JAMA Neurol, March 7, 2022;79(4):380-389). One of every two North American adults has high blood pressure, and only 40 percent of those taking medications have their hypertension well-controlled (Int J Cardiol Hypertens, July 31, 2020;6:100044). Ideal blood pressure would be below 120/80, but it can often take three or more medications to reach that ideal level, which increases risk for side effects such as fainting from low blood pressure. In this study, only three patients in the aggressively-treated group suffered from the side effect of passing out from the blood pressure medications.

Controversy Over Treating to 120 mm Hg Rather Than 140 mm Hg
• The American Academy of Family Physicians (AAFP) recommends that you get your systolic blood pressure below 140/90 mm Hg (Am Fam Physician, Nov 10, 2022;106(6):721-722). They cite literature showing that taking medication to reduce blood pressure below 140 mm Hg did not further reduce your chances of dying overall or from heart disease, even though it did lead to a 16 percent reduction in heart attacks. The AAFP guidelines apply to adults with high blood pressure with and without heart disease. To reduce high blood pressure from 140/90 to 120/80, a person often has to take at least three medications.

• The American Heart Association based its recommendation of treating blood pressure to 130/80 on the SPRINT Trial which included only patients who were at very high risk for heart attacks, while the recommendation for allowing a higher blood pressure was based on studies on patients who were either at high risk or low risk for heart attacks (Circulation, 2018;137(1):1097-1099).

• The International Society of Hypertension recommends an “essential” blood pressure target of <140/90 for most individuals, and for those under 65, they provide the option of an “optimal” blood pressure of <130/80 (Hypertension, 2020;76(5):1391-1399).

• The American Diabetes Association this year revised its target blood pressure to <130/80 for people with diabetes (Diabetes Care, 2022;45(Suppl 1):S144-74).

• The AHA/American Stroke Association in 2021 recommended blood pressure of <130/80 (Stroke, May 2021;52(7):e364-e467).

• The International Society for Hypertension and the American Heart Association recommend a blood pressure of <130/80 for those with established atherosclerotic cardiovascular disease (Hypertension, May 2020;76(5):1391-1399).

Medications to Treat High Blood Pressure
It is established that high blood pressure markedly increases a person’s chances for heart attacks, strokes, kidney damage, dementia and premature death (JAMA, 2019;321(6):553-561). However, high blood pressure treatment often requires more than three drugs. Significant side effects can come from getting high systolic blood pressure down to 120 mg Hg, so at this time most doctors treat high systolic blood pressure down only to below 140 or 130 mm Hg.

Common side effects of blood pressure medications include:
Diuretics: frequent urination, weakness, leg cramps, fatigue, foot pain
Beta-Blockers: asthma, cold hands and feet, depression, erection problems, insomnia
Angiotensin Converting Enzyme Inhibitors (ACI): cough, skin rash, loss of taste
Angiotensin II Receptor Blockers (ARBs): dizziness
Calcium Channel Blockers (CCBs): constipation, dizziness, headache, irregular or rapid heartbeat, swollen ankles
Alpha-Blockers: dizziness, lightheadedness, or weakness when standing up, rapid heart rate
Alpha-2 Receptor Agonists: sleepiness or dizziness
Alpha-Beta-Blockers: dizziness, weakness
Central Agonists: anemia, constipation, dizziness, drowsiness, dry mouth, impotence, fever
Peripheral Adrenergic Inhibitors: dizziness, erection problems, stomach burning, stuffy nose, nightmares
Vasodilators: excessive hair growth, swollen ankles, headaches, irregular heartbeat, joint pains
Renin Inhibitors: cough, diarrhea, stomach pain, rash

Lifestyle Changes to Lower Blood Pressure
The primary treatment for high blood pressure should be lifestyle changes, whether or not you are taking any of the blood pressure drugs. Everyone can help to prevent and control high blood pressure by:
• Eating a plant-based diet that is heavy in fruits, vegetables, whole grains, beans, nuts and other seeds. Restrict mammal meat and processed meats, sugar-added foods and drinks, and fried foods.
• Making sure that you are not using extra salt. Limit use of a salt shaker and restrict processed foods because they often have added salt and sugar.
• Exercising. Try to do aerobic and resistance exercise for at least 30 minutes daily. If you have heart-attack risk factors, check with your doctor.
• Trying to get 7-8 hours of sleep every night.
• Trying to avoid habits and exposure to everything that increases cell damage such a smoke, alcohol, recreational drugs, herbicides, insecticides, air pollution, and so forth.

My Recommendations
I recommend buying a blood pressure cuff (arm, not wrist) and take your own blood pressure. You can buy one at your drugstore or on Amazon or ebay for about $25. If it repeatedly shows that your blood pressure is above 120/80, check with your doctor. You and your doctor together will decide whether you need to take medication. Meanwhile, you may be able to control your blood pressure by following the listed lifestyle guidelines.