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High Blood Pressure

Growing Body of Evidence for Benefits of Lower Blood Pressure Targets

The table below shows the American Heart Association’s blood pressure categorization thresholds.8

Table 1  

While we at Life Extension agree that “normal” blood pressure levels are below 120/80—with an optimal target being 115/75 for most adults up to age 80—we feel that assigning blood pressures of 120‒139/80‒89 mm Hg the current seemingly benign moniker “prehypertension” is a mistake.

A diagnosis of “prehypertension” may not be taken seriously by patients, and many physicians may not emphasize the importance of aggressive lifestyle and dietary changes for these patients. “Prehypertension” is far from benign.

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, cardiovascular disease risk doubles for each increment of 20 mm Hg systolic and 10 mm Hg diastolic above 115/75 mm Hg.3 These findings become even more concerning when considering the staggering prevalence of higher-than-normal blood pressure: up to half of adults worldwide have “prehypertension,” or blood pressure levels ranging from 120/80 to 139/89 mm Hg.9

A recent meta-analysis of observational studies showed that having prehypertension correlates with a nearly 20% increased risk of declining kidney function; the association was especially strong in older individuals.10

In 2006, an analysis of 8960 middle-aged adults in the Atherosclerosis Risk in Communities (ARIC) study demonstrated that pre-hypertensive individuals with blood pressure levels ranging from 120/80 to 139/89 mm Hg had about double the risk of cardiovascular disease compared with people whose blood pressure was below 120/80 mm Hg.1

A meta-analysis of 61 prospective trials evaluated the relationship between blood pressure and cardiovascular-related mortality rates for one million individuals with no known history of cardiovascular disease. Researchers noted that at least down to 115/75 mm Hg, there is no threshold where lower blood pressure is not directly associated with lower mortality rates due to cardiovascular events. In addition, among people 40 to 69 years old, each 20 mm Hg difference in systolic blood pressure was associated with at least a twofold difference in overall mortality due to stroke, ischemic heart disease, or other cardiovascular events.2

With the recent publication of the SPRINT trial results, the evidence base supporting more aggressive blood pressure treatment targets in select populations continues to broaden.

Is Lower Blood Pressure Always Better?

The concept that “lower is always better” in the context of aggressive blood pressure reduction can be a recipe for disaster, in particular for elderly, frail patients.

Often told is the story of the young intern fresh from medical school graduation starting their residency. The intern aggressively treats their older patients to achieve rapid blood pressure reduction, yet is dismayed when their kidney function and cognitive abilities deteriorate rapidly.

Wiser, more experienced physicians know that older patients with significant pre-existing vascular disease and other medical problems often require higher blood pressure to perfuse critical organs like the kidneys and brain. These patients require a higher perfusion pressure to allow blood to reach critical organs and tissues throughout the body.11

Some older patients simply do not tolerate aggressive blood pressure reduction to a predefined value that requires careful monitoring of kidney function and blood tests for BUN (blood urea nitrogen), creatinine, cystatin-C, and electrolytes like potassium and sodium, as well as assessment of cognitive function. These tests are necessary to facilitate appropriate titration of antihypertensive medication to a blood pressure tolerated by these patients.