How low is too low? That’s what physicians are debating after new advice for treating hypertension was issued in December.
High blood pressure is defined as 140 mmHg over 90 mmHg, and for years, doctors have used that measure as the threshold for prescribing anti-hypertensive drugs. But based on the new recommendations, adults who are 60 or older can wait until their readings reach 150 over 90 or above to begin medication. After reviewing available evidence on the effects of blood pressure treatments, including adverse events, the Institute of Medicine’s Eighth Joint National Committee (JNC 8) concluded that aggressive treatment can lead to lightheadedness, falls and fainting in elderly populations — so they advised loosening the guidelines for starting medication.
The change only affects those over 60 years; for younger populations, the group recommended that doctors continue prescribing drug treatments if blood pressure climbed to 140/90 or above.
But days after the guidelines were published, heart experts raised concerns about how the advice would affect patients; uncontrolled blood pressure is a risk factor for heart attack and stroke, and according to the American Heart Association, 76.4 million American adults have high blood pressure, and about a third of them aren’t aware they are hypertensive, so aren’t receiving proper treatment. In an interview with the Associated Press, the American Heart Association’s (AHA) president-elect Dr. Elliott Antman, a cardiologist at Brigham and Women’s Hospital and a professor at Harvard Medical School in Boston, told the Associated Press the AHA was uneasy with the decision. “We are concerned that relaxing the recommendations may expose more persons to the problem of inadequately controlled blood pressure,” he said.
Members of the JNC 8 who voted against the recommendation felt the need to voice this view, and published an editorial in the Annals of Internal Medicine outlining their reasons for opposing the change. “We, the panel minority, believed that evidence was insufficient to increase the [target systolic blood pressure] goal from its current level of less than 140 mm Hg because of concern that increasing the goal may cause harm by increasing the risk for CVD [cardiovascular disease] and partially undoing the remarkable progress in reducing cardiovascular mortality in Americans older than 60 years,” they wrote.
Other doctors agree. Dr. Suzanne Steinbaum, the director of women and heart disease at Lenox Hill Hospital in New York said she has not changed the way she treats her patients over age 60. “I have been waiting. I have been waiting for this editorial,” she says. “As a preventive cardiologist, these new guidelines have made me insane. What we have learned is that blood pressure treatment even for a patient above 80 has been shown to be critical. It goes against everything we know as cardiologists.”
One of Steinbaum’s concerns, beyond the fact that research supports the need to treat high blood pressure to reduce health risks, is that people are living longer, often into their late 80s, and 60 is considered relatively young to not be treated if blood pressure reaches the 140 mmHg over 90 mmHg threshold. The small risk of falls and fainting, she and others say, is not enough to outweigh the benefits of lowering blood pressure and avoiding heart disease and stroke.
Defending the panel’s decision, Dr. Paul A. James, the chairman of the department of family medicine at the University of Iowa and co-chairman of the guidelines committee, said in an email to TIME, “I can assure you that the panel discussed the opinions of the minority members on three different occasions and the majority were not persuaded that the expertise of a few members should override the scientific evidence.”
James said that as with any medications, doctors will use the blood pressure recommendations as guidelines, and prescribe drugs based on their evaluation of each patient. “Medications prescribed by physicians all have the potential to be dangerous–over treatment, adverse effects, and drug interactions,” he wrote. “Educating doctors about the scientific evidence will help doctors make better decisions with patients. Physicians who practice based on scientific evidence usually subscribe to a simple rule–if the medicine cannot be shown to help the patient, then the medicine should not be prescribed.”
The editorial, and the backlash against the guidelines, isn’t likely to change them any time soon. But the concerns should prompt doctors to monitor their patients more closely, and tailor medications and their doses more carefully.