DALLAS, April 29, 2021 -- Health care professionals should consider prescribing medication for patients with slightly elevated blood pressure if levels do not decrease after six months of healthy lifestyle changes, according to a new scientific statement from the American Heart Association. The statement, published today in the Association's journal Hypertension, fills a gap in guideline recommendations by addressing how to manage untreated, stage 1 high blood pressure - levels of 130-139/80-89 mm Hg - that was not fully addressed in the 2017 treatment guidelines.
The 2017 American College of Cardiology/American Heart Association Blood Pressure Management Guidelines' recommendation for patients with stage 1 hypertension and a low (<10%) risk for having a heart attack or stroke within 10 years is to first treat with healthy lifestyle changes and then repeat the blood pressure check in six months. For patients with stage 1 hypertension and a high (>10%) 10-year risk for heart attack or stroke, the guidelines recommend anti-hypertensive medication in addition to healthy lifestyle.
Today's scientific statement suggests clinicians should consider medication for patients with a low ten-year risk if the blood pressure goals (<130/80 mm Hg) are not met after six months of sustained healthy lifestyle changes. This new guidance would apply to nearly 10% of American adults with high blood pressure.
"There are no treatment recommendations in current guidelines for patients who are at relatively low short-term risk of heart disease when blood pressure does not drop below 130 mm Hg after six months of recommended lifestyle changes," said Daniel W. Jones, M.D., FAHA, chair of the statement writing group, professor and dean emeritus at the University of Mississippi School of Medicine in Jackson, Mississippi, and a past president of the American Heart Association. "This statement fills that gap."
Many patients who have stage 1 high blood pressure are adults under the age of 40. Randomized controlled trials following these patients for cardiovascular disease risk are lacking, therefore, the statement writing committee relied on other forms of evidence including observational studies focused on the relationship between blood pressure and cardiovascular disease.
"We know that people with blood pressure lower than 130/80 mm Hg have fewer markers of cardiovascular risk like elevated coronary calcium, enlargement of the heart, or buildup of fatty deposits called atherosclerosis in arteries of the neck. There is strong evidence that treating high blood pressure saves lives by reducing the risks for heart attack and stroke," Jones said.
Healthy lifestyle changes to lower blood pressure include achieving ideal body weight, exercising (30 minutes on most days of moderate to vigorous physical activity, if possible), limiting dietary sodium, enhancing potassium intake and following the Dietary Approaches to Stop Hypertension (DASH) diet (combination diet of fruits and vegetables with low-fat dairy products and reduced saturated fat and total fat). In addition, patients should be recommended to limit alcohol and not smoke. These remain the cornerstone of cardiovascular disease prevention.
"If after six months with lifestyle changes, blood measure does not improve, clinicians should consider adding medications to control blood pressure," said Jones. "That's an important message for patients to hear as well because they should check their blood pressure regularly to monitor progress. If they don't achieve average daily systolic blood pressure less than 130 mm Hg, it's probably time to initiate a conversation with their doctor about practical next steps, which may include adding medication, to manage their blood pressure."
For people who took blood pressure-lowering medication as adolescents, there is evidence that, without intervention, these individuals are likely to develop markers of cardiovascular disease in young adulthood. The statement suggests the original indication for beginning treatment, usually to ward off organ damage from long-term high blood pressure, should be considered in assessing the need to continue medication.
The statement writers acknowledge that the goals of lifestyle change are difficult to achieve and maintain over time. "It is very hard in America and most industrialized countries to limit sodium sufficiently to lower blood pressure," said Jones, "and it is difficult for all of us to maintain a healthy weight in what I refer to as a toxic food environment. We want clinicians to advise patients to take healthy lifestyle changes seriously and do their best. We certainly prefer to achieve blood pressure goals without adding medication; however, successfully treating high blood pressure does extend both years and quality of life."
This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association's Council on Hypertension; the Council on the Kidney in Cardiovascular Disease; the Council on Arteriosclerosis, Thrombosis and Vascular Biology; the Council on Cardiovascular Radiology and Intervention; the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and the Stroke Council.
Additional members of the volunteer writing group are Bonita Falkner, M.D., FAHA, vice chair; Paul K. Whelton, M.B., M.D., M.Sc.; Norrina Allen, Ph.D., M.P.H.; Donald Clark III, M.D., M.P.H.; Samuel S. Gidding, M.D., FAHA; Paul Muntner, Ph.D., FAHA; Shawna Nesbitt, M.D., FAHA; Nia Schwann Mitchell, M.D., M.P.H.; and Raymond Townsend, M.D., FAHA. Author disclosures are in the manuscript.
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