Guidelines for Blood Pressure Targets

For managing high blood pressure, the ideal target number has changed over the years. In 2017, the American Heart Association and American College of Cardiology released updated guidelines.

They recommended that the level considered to be hypertension (high blood pressure) be lowered to 130/80 millimeters of mercury (mm Hg) for all adults. The previous guidelines defined hypertension as 140/90 mm Hg and higher for people younger than 65 and 150/80 mm Hg and up for people older than 65.

This article discusses the guidelines for blood pressure measurements. It also covers the different stages of hypertension and how they are treated.

Updated Blood Pressure Categories

Blood pressure is the amount of pressure when your blood pushes against the arteries. If the pressure stays high, it can cause damage to the heart and blood vessels. Having high blood pressure, or hypertension, can put you at risk for stroke and heart disease, the two top causes of death in the United States.

With the updated AHA/ACC guidelines, the number of people considered to have hypertension has gone up. According to the Centers for Disease Control and Prevention, almost half (47%) of people have hypertension under these new definitions.

The guidelines outline the following blood pressure categories:

• Normal: Less than 120/80 mm Hg
• Elevated: Systolic (the higher number) 120 to 129 and diastolic (the lower number) less than 80
• Hypertension stage 1: Systolic 130 to 139 or diastolic 80 to 89
• Hypertension stage 2: Systolic at least 140 or diastolic at least 90

Why the Guidelines Were Updated

The updated guidelines are partly based on a landmark study called the SPRINT (Systolic Blood Pressure Intervention Trial). This trial was conducted between 2010 and 2013, involving 9361 patients from 102 different locations throughout the United States.

All participants were diagnosed with hypertension and had systolic blood pressure between 150 mm Hg and 180 mm Hg at the start of the study.

The study volunteers were divided into two groups: one group with a target systolic pressure of 140 mm Hg (the standard treatment group) and another group with a target systolic pressure of 120 mm Hg (the intensive treatment group.) The initial plan was to monitor the participants approximately every three months for five years.

However, the intensive treatment group did so much better than the standard treatment group that investigators ended the study after a little over three years instead of completing the five-year project.

The standard treatment group had a 43% higher rate of death than the intensive treatment group. The intensive blood pressure control with the goal of systolic blood pressure below 120 mm Hg resulted in fewer deaths from stroke, heart disease, and other medical causes.

In addition to SPRINT, the updated AHA/ACC guidelines were also based on a three-year comprehensive review of hundreds of research studies pertaining to blood pressure.

How to Measure Blood Pressure

When your healthcare provider measures your blood pressure, it may be higher than it is when you're at home. Blood pressure can rise if you get nervous or stressed during an appointment. This is known as "white coat hypertension."

The AHA/ACC guidelines recommend monitoring your blood pressure at home if you get an abnormally high reading at your healthcare provider's office. This helps you know whether the blood pressure reading was a good estimate of your usual measurement.

In addition, the guidelines recommend the following for an accurate reading:

• Avoid smoking, caffeine, or exercise for 30 minutes before taking your blood pressure.
• Sit quietly for five minutes before the measurements.
• While taking your blood pressure, support your arm that's being used to take measurements.
• Keep the blood pressure cuff at heart level.
• Roll up your sleeve if possible so the cuff has contact with your bare arm.
• Take about two to three measurements on two or three separate days to help get an accurate estimate.

For home blood pressure measurements, your healthcare provider can give you recommendations on the best monitor to get. They'll likely ask you to get one that goes around your upper arm since wrist and finger monitors are not as accurate. They may also ask that you get a monitor with a cuff that inflates automatically.

For home measurements, your healthcare provider will have you write down the readings from home to discuss at your appointment. They may ask you to bring in the monitor so you can take measurements with your equipment at their office.

How Hypertension Is Treated

According to the updated guidelines, treatments vary for the different blood pressure categories, depending on whether it's elevated or hypertension stage 1 or 2. These recommendations are the same for all age groups, whether you're younger or older than 65.

The new guidelines increase the number of people diagnosed with hypertension. However, most of these new patients will be advised to make lifestyle changes before taking medications.

Elevated

Your healthcare provider will likely recommend healthy lifestyle changes if your blood pressure is elevated. This may include:

• Following a healthy diet, such as the DASH diet
• Increasing physical activity
• Reducing sodium in your diet
• Limiting alcoholic drinks
• Losing weight if you fall into the overweight or obese categories

Your healthcare provider will ask you to follow up with them in three to six months to reassess your blood pressure.

Hypertension Stage 1

In this stage, treatment will depend on any existing health conditions and your risk of heart disease and stroke.

The 2017 guidelines recommend calculating your 10-year risk for heart disease and stroke with the Pooled Cohort Equations CV Risk Calculator. This calculator helps estimate your risk based on information including blood pressure, cholesterol, your health history, and factors such as age and race.

If your 10-year risk for heart attack and stroke is greater than 10%, your healthcare provider may recommend antihypertensive medication. They may also recommend medication if you have clinical cardiovascular disease, diabetes mellitus, or chronic kidney disease.

This initial therapy may include classes of medications like thiazide diuretics, calcium channel blockers (CCBs), or ACE inhibitors.

If your 10-year risk for heart disease and stroke is less than 10%, your healthcare provider may recommend lifestyle changes instead of medication.

Hypertension Stage 2

The updated guidelines for stage 2 hypertension recommend healthy lifestyle changes as well as two blood-pressure-lowering medications.

Your healthcare provider will likely recommend two medications of different classes and reexamine your blood pressure numbers in one month. If the medications aren't lowering blood pressure enough, your healthcare provider will have you try different medications.

Summary

Updated guidelines from the American Heart Association and American College of Cardiology define hypertension as 130/80 mm Hg or higher. Because the previous numbers were 140/90 mm Hg, more people will be diagnosed with hypertension.

Healthcare providers recommend healthy lifestyle changes for people with elevated or stage 1 hypertension. Some who are stage 1 but with higher health risks will also need medication. The guidelines recommend two blood-pressure medications for those with hypertension stage 2.