When is High Blood Pressure Considered Hypertension?

by Dominic Dizon, MD

This is a conundrum that has baffled physicians and cardiologists in the US and in Europe over the past 5 years. Typically, a new guideline on hypertension comes around every 10 years.

Truly enough, the Joint National Committee (JNC) last published guidelines in May of 2003. This was called JNC 7. Then in 2014, JNC 8 was published in the Journal of the American Medical Association (JAMA) calling for restraint in labeling and treating patients with hypertension based on age. It said that any patient above age 60 can have an upper threshold of 150/90 blood pressure (BP) before they need to be treated for hypertension with medications unless they have diabetes or chronic kidney disease. For these patients, goal should be less than 140/90. Everybody else less than 60 years old should have a goal of less than 140/90.

The main rationale for this more lenient threshold is the fact that too aggressive control of blood pressure in patients above 60 can lead to symptoms of dizziness and lightheadedness, putting them at risk for falls.

However, in 2017, the American College of Cardiology and American Heart Association (ACC/AHA), the same agencies which published the cholesterol management guidelines we talked about in the last Health issue, came up with new guidelines on hypertension. Citing a significant increase in risk of adverse cardiovascular and renal outcomes in patients with uncontrolled high blood pressure, they considered someone with Stage 1 Hypertension if blood pressures are above 130/80 and Stage 2 Hypertension for above 140/90, regardless of age.

Then in 2018, the European Society of Cardiology and European Society of Hypertension (ESC/ESH) published their own guidelines defining hypertension as an office-based systolic pressure ≥140 mmHg or diastolic pressure ≥90 mmHg.

These 3 new guidelines have divided a lot of physicians and we are now faced with how to use them prudently. My personal take is to still use 140/90 as a starting goal and threshold, and to be gentler and more careful with my patients above age 60 when I am already treating them with medications to lower their BP. With patients who are not yet on BP meds, we will try our best to keep BP < 130/80 using a mutually decided strict exercise regimen, weight loss and maintenance program and diet that is high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, and nuts and low in sweets, sugar-sweetened beverages, and red meats..

Questions? Please contact:
Dominic Dizon: [email protected]