More than 7 in 10 older adults in the United States who need more intensive treatment for high blood pressure don’t get it, according to a new Harvard study. The findings, published on September 16, 2022, in the American Heart Association journal Hypertension, suggest that millions of people are being undertreated, putting them at increased risk of heart attack and stroke.
"We haven't been doing well, despite robust evidence demonstrating the strong benefits of good blood pressure control in older adults," said the lead study author, Nicholas Chiu, MD, a clinical fellow at Beth Israel Deaconess Medical Center in Boston, in a press release. "This is a major public health gap that needs to be tackled."
Nearly Half of American Adults Have High Blood Pressure
Blood pressure is simply a measurement of the pressure of blood pushing against the walls of the arteries, according to the MedlinePlus. Systolic blood pressure is the top number in a blood pressure reading and indicates how much pressure the blood is exerting against the artery walls with each contraction. Diastolic blood pressure is the bottom number in a blood pressure reading, indicating how much pressure the blood is exerting against the artery walls while the heart is resting, between contractions.
If blood pressure stays high for a long time, it can cause damage to organs, including your heart, brain, kidneys, and eyes, and increases the risk of heart attack and stroke. According to the Centers for Disease Control and Prevention (CDC), nearly half of adults in the United States — 47 percent or 116 million people — have high blood pressure, also known as hypertension. In 2020, more than 670,000 deaths in the United States had hypertension as a primary or contributing cause.
The Threshold for High Blood Pressure Was Lowered in 2017
The old definition of high blood pressure was 140/90 and higher, but the guidelines were updated in 2017 when the American Heart Association (AHA), the American College of Cardiology (ACC), and nine other health organizations issued a joint statement that lowered the threshold for high blood pressure to 130/80 millimeters of mercury (mmHg) and higher for all adults, regardless of age.
To discover whether adults older than 60 whose readings indicated hypertension received more intensive blood pressure treatment, researchers looked at a decade of national data, focusing on individuals who visited their primary care provider and previously had been diagnosed with high blood pressure.
Using those records, investigators identified which patients underwent "appropriate antihypertensive intensification," defined as the addition of an anti-hypertensive drug to their care for high blood pressure.
Three different guidelines were used to define blood pressure targets — those published by ACC/AHA, the European Society of Cardiology, and the American College of Physicians/American Academy of Family Physicians (ACP/AAFP). The researchers also came up with their own all-inclusive measure that met all three guidelines.
Based on office blood pressure measurements, treatment intensification was warranted in as many as 7,404 primary care visits in the sample during the study period from 2008 to 2018, a number that could be extrapolated to 293 million visits throughout the population, according to researchers.
Key findings of the study included:
- Fewer than 3 out of 10 patients (27.5 percent) who had hypertension (according to the most liberal “all-inclusive” measure) who hadn't previously been taking drugs for high blood pressure were prescribed a medication.
- By that same measure, just 15.3 percent of patients already on hypertension drugs had an additional medication prescribed.
- The percentage of patients receiving appropriate treatment intensification declined over the study period. Most dramatically, under ACP/AAFP targets, appropriate treatment intensification decreased from nearly 25 percent of patients in 2008–2009 to about 15 percent in 2015–2018.
Side Effects Concerns and Time Constraints May Be Why People Don’t Get the Blood Pressure Treatment They Need
Although the study wasn’t designed to find out why many people weren’t getting the recommended high blood pressure treatment escalation, the authors offered a few different theories.
Both doctors and patients may be concerned about potential side effects of the drugs, said the senior author, Kenneth Mukamal, MD, an associate professor of medicine at Beth Israel Deaconess Medical Center in Brookline, Massachusetts.
It’s also difficult for primary care providers to treat high blood pressure aggressively in a typical 15-minute visit, he said. "We're trying to control not just blood pressure, but cholesterol and diet and weight, and the documentation burdens have grown bigger as well. Speaking from my own experience, it's harder than ever to be a primary care doctor," said Dr. Mukamal.
He said future studies are needed to learn which strategies will motivate medical professionals to better treat high blood pressure among older adults. For example, medical record systems could be retooled to automatically alert doctors to add a medication when a person's blood pressure is above the recommended level, he said.
Medications Used to Treat High Blood Pressure
It often takes more than one medication to control blood pressure. According to MedlinePlus, the most common types of medications used include the following:
Diuretics, also known as “water pills,” help the kidneys remove some salt (sodium) from your body, which helps reduce the amount of fluid in the blood vessels, causing blood pressure to go down.
Beta-blockers make the heart beat at a slower rate and with less force, which can lower blood pressure.
Angiotensin-converting enzyme inhibitors (ACE inhibitors) reduce the production of angiotensin II in the body, which helps relax the blood vessels, thereby lowering blood pressure.
Angiotensin II receptor blockers (ARBs) reduce the action of angiotensin II in the body, which helps relax the blood vessels and lowers blood pressure.
Calcium channel blockers reduce the amount of calcium entering cells in the wall of the blood vessels, which helps relax blood vessels.
High Blood Pressure Often Has No Obvious Symptoms
Because hypertension is often a silent disease with no obvious symptoms, many patients are surprised when they are told they have it, says Laxmi Mehta, MD, a professor in the division of cardiovascular medicine and the director of Preventive Cardiology and Women’s Cardiovascular Health at the Ohio State University Wexner Medical Center in Columbus.
“The best way to know your blood pressure is to have it checked at your doctor’s office,” she says.
“There are risk factors that can contribute to high blood pressure, including a poor diet with high sodium intake, alcohol and tobacco consumption, being overweight or obese, physical inactivity, sleep apnea or poor sleep and high stress levels,” says Dr. Mehta. There are uncontrollable risk factors too, including age and family history, she says.
Expert Advice to Keep Your Blood Pressure in Check
If you have high blood pressure, the American Heart Association recommends home monitoring with an automatic cuff-style biceps device — wrist and finger monitors are not recommended because they are less reliable. But remember — home monitoring is not a substitute for regular visits to your doctor.
Mehta recommends keeping a log and working on the factors that you can control.
In addition to taking any prescribed medications, eat a healthy diet, limit alcohol consumption, reduce stress when possible, don't smoke, exercise regularly, and get adequate sleep, she says.