Hypertension Heresy: Are We Overtreating High Blood Pressure?

Prepare for whiplash. What I am about to share with you will confuse you and make your doctor quite anxious. But I feel obligated to share data on high blood pressure that are seemingly contradictory. Pretending that there aren’t inconsistencies would be dishonest. Here are some of the questions we will be asking: 1) What is “normal” blood pressure? 2) Should everyone have the lowest blood pressure possible? 3) Does lowering BP reduce the risk of dementia? 4) Is there such a thing as overtreating high blood pressure?

Doctors Are Placed in a BP Double Bind:

Do you know the definition of “double bind?” One explanation we like comes from Collins:

” a situation in which a person is faced with contradictory demands or expectations, so that any action taken will appear to be wrong”

That about sums up the situation when it comes to aggressive treatment of hypertension, especially in older people.

On the one hand, physicians are encouraged to treat high blood pressure aggressively. In recent years guidelines from the American College of Cardiology and the American Heart Association pressure health care professionals to keep most patients below 120 systolic and below 80 diastolic. More about that shortly.

On the other hand, research reveals that aggressive treatment to achieve those goals in older people may lead to some worrisome outcomes.

Can Overtreating High Blood Pressure Lead to Fractures in Older People?

We are going to start with question #4 first: Is there such a thing as overtreating high blood pressure?

A study published in JAMA Internal Medicine (April 22, 2024) asks this specific question:

“Is initiating antihypertensive medication associated with increased fracture risk among older long-term Veterans Health Administration nursing home residents?”

The investigators studied more than 29,000 elderly people living in Veterans Administration nursing homes. People who were prescribed antihypertensive drugs were matched with others of similar age who did not get blood pressure pills.

Those who began their blood pressure treatment were more than twice as likely to fall and break a bone in the first month. The risk was 5.4 per 100 person-years compared to 2.2 per 100 person-years for those not taking blood pressure medications.

Patients with dementia and those with higher initial blood pressure were at the greatest risk.

The researchers concluded:

“Findings indicated that initiation of antihypertensive medication was associated with elevated risks of fractures and falls.”

“Caution and additional monitoring are advised when initiating antihypertensive medication in this vulnerable population.”

A commentary in the same issue of the JAMA Internal Medicine (April 22, 2024) notes that dropping blood pressure too quickly among elderly individuals could make them dizzy or unsteady and that could lead to falls.

When an older person falls, the consequences can be disastrous:

“…fractures, closed head injuries, internal bleeding or death.”

The authors of the commentary point out that older people may not feel good when they take a bunch of BP meds.

These physicians conclude:

“The hope is that, as health care practitioners, we can embrace a nuanced approach to taking care of patients without feeling pressure to simply treat a number.”

Amen to that!

Are We Overtreating High Blood Pressure in Older People?

A few years ago, a study published in JAMA Internal Medicine (Dec. 13, 2021) suggested that older people might live longer and have less dementia if their blood pressure were higher. How much higher? You may be shocked!

This reader points out contradictions between an “old-time” doc and a “modern” physician:

Q. Some years ago, I worked for an old-time doctor, now retired. He told me that keeping my blood pressure around 140/90 would be just fine as I grow older.

I have learned that the old gent was right. Now I’d just like to convince my current family doctor! She says I’ll be much healthier if I can get it down to 130/80 or lower.

A. In general, doctors believe that lower blood pressure is better. However, trying to get blood pressure down to a target range below 130/80 may not be suitable for everyone (American Journal of Medicine, Oct. 2022). The title of this article is:

“Controversies in Hypertension II: The Optimal Target Blood Pressure”

The authors point out that:

• “The optimal target blood pressure in the treatment of hypertension is uncertain and is not the same for all patients.
• “Factors potentially modifying the intensity of therapy include age, frailty, and polypharmacy [lots of medications].
• “More intensive antihypertensive therapy does not appear to slow the progression of chronic kidney disease.
• “The diastolic J-curve remains controversial but may bear consideration if obstructive coronary artery disease and a very low diastolic pressure coexist.”

More about the “J-curve” shortly. We liken it to the story of Goldilocks and the Three Bears. The porridge should never be too hot or too cold. Somewhere in the middle is “just right.” Blood pressure that is too high or too low may pose problems.

Is Overtreating High Blood Pressure Possible?

Age and hypertension:

While chronological age is not a good measure for health, people tend to become less resilient as they grow older. A frail older person, particularly one on multiple medications, may not benefit as expected from very low blood pressure. Dizziness, a common adverse reaction, could lead to falls, among other problems.

In addition, the more pills one must take, the more likely there could be a dangerous drug interaction. That’s just one of the problems with “polypharmacy.” Polypharmacy with hypertension is just another way of saying overtreating high blood pressure.

A Historical Perspective on High Blood Pressure:

I will reveal the data on hypertension, dementia, age and mortality shortly. First, though, we need to review a little history. Until August 15, 2012, almost any American physician would have rushed to prescribe medicine for a patient with a blood pressure reading of 145/95.

In medical school, students learn that hypertension increases the risk of heart attacks, strokes and early death. Consequently, physicians have come to believe that treating hypertensive patients aggressively will lead to better outcomes.

The mantra “lower is better” got a bit more confusing on August 15, 2012, when the Cochrane Collaboration published its analysis:

“Benefits of antihypertensive drugs for mild hypertension are unclear.”

The Cochrane Collaboration represents the highest level of scientific scrutiny of available studies. The experts who analyze the data are independent and objective and have come to be regarded as the ultimate authority on the medical interventions they evaluate. As far as we can tell, there is no better organization for assessing the pros and cons of pharmaceutical and alternative therapies than Cochrane.

There is no doubt that this review created extraordinary controversy and push-back from the medical community. A bedrock belief was being challenged. That’s because the Cochrane experts were suggesting that many Americans diagnosed with high blood pressure were probably being treated unnecessarily.

The researchers reviewed data from nearly 9,000 patients enrolled in four randomized controlled trials. These were people who had been diagnosed with what is called stage 1 hypertension. That means their systolic blood pressure was between 140-159 and their diastolic blood pressure was between 90 and 99.

Here is what the Cochrane Collaboration found:

“Individuals with mildly elevated blood pressures, but no previous cardiovascular events, make up the majority of those considered for and receiving antihypertensive therapy. The decision to treat this population has important consequences for both the patients (e.g. adverse drug effects, lifetime of drug therapy, cost of treatment, etc.) and any third party payer (e.g. high cost of drugs, physician services, laboratory tests, etc.). In this review, existing evidence comparing the health outcomes between treated and untreated individuals are summarized. Available data from the limited number of available trials and participants showed no difference between treated and untreated individuals in heart attack, stroke, and death.”

The abstract concluded:

“Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs [randomized controlled trials]. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.”

In other words, the authors were suggesting that physicians might be overtreating high blood pressure in some cases.

Fast Forward to 2015:

In September 2015, a study of blood pressure treatment was stopped abruptly. The SPRINT (Systolic Blood Pressure Intervention Trial) study was terminated early because the results were so good. Patients with hypertension who got their systolic BP below 120 were less likely to have heart attacks or other cardiovascular events (New England Journal of Medicine, Nov. 26, 2015). You can read more details of the SPRINT study at this link.

This clinical trial led many health professionals to rethink “normal” blood pressure. The label “hypertensive” used to be reserved for people with systolic blood pressure (the upper number) over 150 and diastolic blood pressure (the lower number) above 99. After SPRINT, anyone with blood pressure readings greater than 120/80 is likely to be labeled hypertensive.

Most physicians feel it is their duty to treat high blood pressure aggressively to get the numbers below 120/80. That is what the guidelines require.

Do You Have High Blood Pressure?

The American College of Cardiology (ACC) and the American Heart Association have created guidelines for blood pressure:

Normal blood pressure is considered anything less than 120/80.

Elevated blood pressure is 120-129 systolic and over 80 diastolic.

Stage 1 hypertension is 130-139 systolic and/or 80-89 diastolic.

Stage 2 hypertension is over 140 systolic and at least 90 or greater diastolic.

You can read more about the ACC/AHA guidelines at this link.

The SPRINT-MIND Trial:

There was a follow up to the SPRINT trial.

The SPRINT-MIND study asked:

“Does intensive blood pressure control reduce the occurrence of dementia?”

It was published in JAMA (Feb. 12, 2019).

The answer:

“Among ambulatory adults with hypertension, treating to a systolic blood pressure goal of less than 120 mm Hg compared with a goal of less than 140 mm Hg did not result in a significant reduction in the risk of probable dementia. Because of early study termination and fewer than expected cases of dementia, the study may have been underpowered for this end point.”

High Blood Pressure and Dementia:

There is evidence that hypertension in middle age is associated with a greater risk of dementia. How much greater? 60% greater! That was the conclusion of a review published in The Lancet (Aug. 8, 2020).

But the authors of an analysis published in JAMA Internal Medicine (Dec. 13, 2021) point out that in late life:

“…this association disappears, with few studies finding associations with increased risk and most studies reporting neutral or even decreased risks associated with hypertension.”

Are We Overtreating High Blood Pressure?

The researchers analyzed seven cohort studies involving 17,286 participants. Their findings challenge the conventional wisdom that lower is best. They found that elderly people may actually do better when their systolic blood pressure is higher than the guidelines usually recommend.

That’s because the lowest risk point for dementia and mortality combined was 163 mm of mercury for systolic pressure. That is substantially higher than most doctors like to see.

People between 60 and 70 years of age had the lowest risk when their systolic blood pressure was around 135. After age 70, however, the optimal range was 160 to 165. Most cardiologists would cringe at such data.

High Blood Pressure and Dementia?

Hypertension is considered a key risk factor for heart disease, strokes and dementia. The ARIC (Atherosclerosis Risk in Communities) study found that people with high blood pressure in midlife are at greater risk of dementia (JAMA Neurology, Oct. 1, 2017).

The Women’s Health Initiative Memory Study involved 7,207 women between the ages of 65 and 79. They were recruited to participate from 1996 until 1999 (Lancet Healthy Longevity, Jan. 2022). The median follow-up was 9 years. Please pay close attention to the results because they are confusing.

Women with hypertension had a higher risk of “mild cognitive impairment.” Women with systolic blood pressure greater than 120 who were taking BP medicine also had a “higher risk of cognitive loss” compared to women with normal blood pressure. No surprises.

But here is the kicker:

“There were no significant associations between hypertension, SBP [systolic blood pressure], or PP [pulse pressure] and probable dementia.”

The authors state it again:

“Finally, hypertension, elevated SBP, and PP were not associated with an increased risk of probable dementia.”

We told you this would be confusing. We interpret the results as follows. Hypertension does impact thinking in a negative way…but it was not associated with actual dementia. The authors try to explain that away. But they were honest in citing studies that showed no risk reduction for dementia with blood pressure treatment

For example, a study in the Archives of Neurology (Oct. 2001) reported on 635 older people recruited from East Boston.

The conclusion:

“In this large community study, high blood pressure was not associated with an increased risk of AD [Alzheimer’s disease].”

A study published in the American Journal of Epidemiology (Sept. 1, 2002) concluded:

“No statistically significant relation was observed between Alzheimer’s disease risk and high blood pressure…”

Fast Forward to 2023:

Any health professionals reading this article probably noted that those two last studies were old: dated 2001 and 2002. Let’s jump ahead to 2023!

Researchers wanted to know if giving people a “polypill” containing simvastatin to lower LDL cholesterol plus antihypertensive medications (atenolol, HCTZ, ramipril) would reduce “cognitive decline.”

Here is what they found (JAMA Neurology, Jan. 30, 2023):

“Results of this randomized clinical trial demonstrated that in participants 65 years or older with vascular risk factors, 5 years of treatment with a polypill containing blood pressure reduction medications and a statin, aspirin, or the combination did not reduce the risk of substantive cognitive decline compared with placebo.”

The Controversy Continues:

What are we to make of this controversial association? The authors acknowledge that a randomized controlled trial found lower mortality and dementia risk among certain people whose systolic blood pressure was reduced below 120. How do we reconcile this contradiction?

To do this, the authors say, we need future studies to:

“…test BP management that is tailored to one’s age, life expectancy, and health context.”

In the meantime, people with hypertension should absolutely consult their health care providers to determine the most appropriate treatment approach to control high blood pressure. Ideally, the selected medication does not cause dangerous side effects like dizziness or fainting.

Not the First Rodeo:

This is not the first time data have challenged the 120/80 goal for everyone, regardless of age. In 2017 we posed a question in this article:

Will Low Blood Pressure Increase the Danger of Dementia in Older People?
Is lower blood pressure always better? Many people think that 120/80 is ideal but older people may be at risk for dementia if diastolic BP goes too low.

We cited an Italian study published in JAMA Internal Medicine, April, 2015.

The authors concluded that we may be overtreating high blood pressure in some older patients:

“Low daytime SBP [systolic blood pressure] was independently associated with a greater progression of cognitive decline in older patients with dementia and MCI [mild cognitive impairment] among those treated with AHDs [antihypertensive drugs]. Excessive SBP lowering may be harmful for older patients with cognitive impairment. Ambulatory blood pressure monitoring can be useful to help avoid high blood pressure overtreatment in this population.”

You can read about the 90+ Study at this link. It too is a man-bites-dog story.

The Finnish Study:

Between 1977 and 1978 public health authorities measured blood pressure in 561 old people in Tampere, Finland (British Medical Journal, March 26, 1988). The vast majority (83%) were 85 years old or older.

The authors concluded:

“The greatest mortality was observed in those in the lowest systolic and lowest diastolic groups. Mortality was least in subjects with systolic pressures of 160 mm Hg or more and diastolic pressures of 90 mm Hg or more. The most essential finding in this series of the very old was an increased mortality in the lowest blood pressure groups.”

They go on to add:

“Raised blood pressure has usually been regarded as increasing the risk of mortality in the elderly. Our results lend support to observations that high blood pressure is not associated with an excess risk of mortality. In fact, our findings suggest that as blood pressure is raised in the very old the risk of death is no longer increased but diminished.”

Final Words

If you want to learn more about the Cochrane Collaboration conclusions, we encourage you to read the reports by Jeanne Lenzer in the BMJ and Slate. She did a good job reviewing the findings and making them understandable.

If you would like to learn more about ways to control high blood pressure with nondrug approaches, we suggest you check out our eGuide to Blood Pressure Treatment.

A Word of Caution:

No one should EVER stop taking a medication without consulting their physician. Those with definite hypertension must be treated aggressively with medication. Hypertension does cause heart attacks, strokes and kidney damage and leads to premature death.

We do encourage those with mild hypertension to make sure their physicians read the review in the BMJ and then take time to review the Cochrane Collaboration report. We also think health professionals should read the research in JAMA Internal Medicine titled:

“Association of Systolic Blood Pressure With Dementia Risk and the Role of Age, U-Shaped Associations, and Mortality“

The article in The American Journal of Medicine (Oct. 2022) offers good advice:

“As a generalization, the lower the pressure, the better. However, a corollary should be not at all costs and not necessarily to the same target in all patients.”

If overtreating high blood pressure leads to dizziness, fainting and falls, it could be counterproductive!

Further Considerations:

We hope there will be more serious consideration of nondrug approaches such as losing weight, deep breathing, exercising and learning how to relax and shed some of the stress that can contribute to higher blood pressure readings. Health coaches can assist in this process. So can family and friends. Older people with high blood pressure require careful oversight by well-informed health care providers.

You can find our eGuide to Blood Pressure Solutions under the Health eGuides tab.