Controlling High Blood Pressure

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The American Academy of Family Physicians (AAFP) recommends that you get your blood pressure below 140/90 mm Hg (Am Fam Physician, Nov 10, 2022;106(6):721-722). Taking medication to reduce blood pressure below that 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. It also did not reduce the incidence of strokes, and it increased risk for multiple side effects from medications. After blood pressure is reduced below 140/90, the doctor and patient can make a shared decision whether to add medication to reduce blood pressure below 130/80. The AAFP guidelines apply to adults with high blood pressure with and without heart disease. To reduce high blood pressure from 140/90 to 130/80, a person often has to take at least one additional medication.

One of every two adult North Americans 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 or low blood pressure.

What Other Medical Societies Recommend
• The American Heart Association based its recommendation of treating blood pressure (BP) 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” BP target of <140/90 for most individuals, and for those under 65, they provide the option of an “optimal” BP of <130/80.
• The American Diabetes Association this year revised its target BP to <130/80 for people with diabetes.
• The AHA/American Stroke Association in 2021 recommends BP <130/80.
• The International Society for Hypertension and the American Heart Association recommend a BP of <130/80 for those with established atherosclerotic cardiovascular disease.

Tight Blood Pressure Control May Help to Prevent Dementia
High blood pressure increases risk for brain damage, strokes, and dementia by damaging blood vessels in the brain, leading to a type of dementia known as vascular dementia (Hypertension, 2022;79:218–229). Recent research showed that getting blood pressure to and below 120/80 can help to improve blood flow to the brain (International Stroke Conference, Feb 8, 2023 in Dallas, Texas). This study included 658 people, average age 67, with high blood pressure but none had previously been diagnosed with diabetes, dementia, or stroke.
• 243 people received high-intensive treatment for high blood pressure with a target of 120 mm Hg systolic pressure.
• 199 people received standard treatment, with a target of 140 mm Hg.
All participants had pre-and-post-study MRIs that analyzed the perivascular spaces, the areas of space around blood vessels in the brain that are filled with cerebro-spinal fluid. These spaces help to eliminate water and metabolic waste from the brain and enlarge with aging, inflammation, or nerve and brain damage.

At the start of the study, the volume of perivascular spaces was similar in both groups. After four years of high blood pressure treatment, the volume of perivascular areas decreased significantly in the intensive-treatment group, but did not change in the standard-treatment group. This suggests that intensive blood pressure lowering may help to protect a person who has high blood pressure from brain damage or dementia. Reducing the enlargement of the perivascular space in the brain is associated with increased clearance of toxins and breakdown products of metabolism in the brain that could help to protect the brain from further damage. Furthermore, another recent study from China found that tight blood pressure control (<120/80) does not increase dementia risk even in people who have diastolic blood pressures significantly below 80 mm Hg (Hypertension, January 23, 2023).

My Recommendations
The same rules for helping to prevent and treat high blood pressure also help to prevent dementia. I recommend that you buy a blood pressure cuff and take your own blood pressure. If it is repeatedly 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 these lifestyle guidelines:
• Eat an anti-inflammatory 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.
• Make sure that you are not loading on extra salt. Limit use of a salt shaker and restrict processed foods because they often have added salt and sugar.
• Exercise. Try to do aerobic and resistance exercise for at least 30 minutes daily.
• Try to get 7-8 hours sleep every night.
• Try to avoid habits and exposure to everything that increases cell damage such a smoke, alcohol, recreational drugs, herbicides, insecticides, air pollution, and so forth.