Q: My doctor keeps lowering my goal blood pressure and just added another medication. What’s changed?
A: It wasn’t so long ago that high blood pressure in aging adults was called “essential hypertension.” The thinking was that high blood pressure was essential to deliver sufficient blood to the brain. With age, blood vessels become stiffer and less flexible. To reach the brain, the belief was that circulating blood needs an extra “push.”
That’s why most doctors previously considered a systolic blood pressure (the top number in the reading) was okay at 150 mm Hg for older people. Increasingly, however, doctors are reconsidering their approach to treating hypertension in people age 60 and older.
The results of a recent study added to the evidence showing the effectiveness of lower blood pressure. The study, in the Sept. 30, 2021, issue of The New England Journal of Medicine, included more than 8,500 people ages 60 to 80 with high blood pressure. Half were randomly assigned to a standard treatment group, with a target for systolic blood pressure of 130 to 150 mm Hg. For the other half, the intensive treatment group, the systolic target was 110 to 130 mm Hg.
After a year, the average systolic blood pressure in the standard group was 135 mm Hg, compared with 127 mm Hg in the intensive group. During a median follow-up of just over three years, researchers tracked the participants’ rates of serious cardiovascular problems, including stroke, heart attack, heart failure, and atrial fibrillation. The incidence of these problems was 4.6% among those who received standard treatment, compared with 3.5% in those who received intensive treatment.
Rates of adverse side effects, including dizziness, fainting, fractures, headaches, and cough, were similar in both groups. However, the intensive-treatment group did experience more episodes of abnormally low blood pressure (hypotension).
The findings support those from an earlier trial done in the United States that also documented fewer heart-related problems when doctors aimed for an even lower — 120 mm Hg — systolic blood pressure target. In fact, when researchers analyzed the results only from people ages 75 and older, the heart-related benefits were even more striking. And the rates of side effects were similar to those seen in people with a target of 140 mm Hg.
People often expect that a single medication will get them to their blood pressure goal, but that’s rarely feasible. Using lower doses of two different blood pressure medications is more effective than maximizing the dose of a single drug. High blood pressure can result from several different mechanisms, so combining drugs that target different mechanisms typically works better. The combination approach is also less likely to cause side effects.
(Howard LeWine, M.D., is an internist at Brigham and Women’s Hospital in Boston and assistant professor at Harvard Medical School. For additional consumer health information, please visit www.health.harvard.edu.)
