Under new guidelines recently issued by the American Heart Association and the American College of Cardiology, the number of adult Americans diagnosed with high blood pressure, or hypertension, will rise from 72 million to 103 million. The 192-page report, more than a decade in the making, contains 106 recommendations. Two of NYU Langone Health’s leading hypertension experts—Howard Weintraub, MD, clinical director of the Center for the Prevention of Cardiovascular Disease, and Olugbenga G. Ogedegbe, MD, MPH, director of the Center for Healthful Behavior Change—weigh in on the highlights and their related concerns.
Do you consider the new guidelines for hypertension controversial?
Dr. Ogedegbe: I was surprised by some of the recommendations, particularly the one to treat patients with hypertension at a lower threshold. We used to think that hypertension occurs with blood pressure readings above 140/90 on 2 or more office visits. The new guidelines are 130/80. We’re going to have a tsunami of new patients to treat. By lowering the threshold, we’ve made over one-third of our population hypertensive. Yellow is the new green.
Dr. Weintraub: When my colleagues and I reviewed treatment data 2 years ago, we felt that a systolic level between 120 and 130 would be the sweet spot—the level with the fewest side effects and greatest benefits—and this report harmonizes with that thinking. There used to be a “lower is better” mentality.
Risks do fall as blood pressure falls, but if the levels fall too low, the risks rise again because enough blood isn’t flowing to the brain or into the heart. I applaud these guidelines for emphasizing nonpharmacologic therapy for patients who are not at high risk. There’s no medicine like no medicine.
Do you have any concerns about the new threshold?
Dr. Ogedegbe: The moment you label someone with a disease, you change their self-perception—and their quality of life. This, in turn, has been shown to lead to negative consequences, such as missed days at work, because people see themselves as sick. We need to think about how to deliver this new message. We don’t want to add a stressor that will raise the patient’s blood pressure, putting them at even greater risk.
Dr. Weintraub: The findings now extend to people with diabetes, but no study has ever shown that these patients are better off with lower blood pressure. To me, this is a bit of a leap. However, patients with diabetes have always been thought to be at higher risk and hence deserving more aggressive therapy. I’m also concerned that some physicians will aim to get their patients’ blood pressure even lower than the recommended level. That’s when things can backfire.
What are the biggest challenges of implementing these recommendations?
Dr. Ogedegbe: We’ve got to convince patients of their risk without scaring them. Otherwise, it’s going to be difficult for physicians to put all this into practice. Also, people who have treatment-resistant hypertension require additional resources because we have to screen them for concomitant diseases, such as sleep disorders. Few practices have the wherewithal to do that.
Dr. Weintraub: The vast majority of hypertension is treated not by cardiologists but by those in primary care. These providers vary widely in their knowledge base and comfort level, so many are not likely to adopt aggressive, nuanced guidelines. The ramifications of this are huge because the potential benefit is going to be diluted.
Which populations are most at risk under these new guidelines?
Dr. Ogedegbe: About 48 percent of African Americans and 52 percent of African American women will now be diagnosed with hypertension. The reasons are complex—education level, poverty, social determinants, access to care. But actually, everyone is at risk. We used to say that 25 percent of the adult population, regardless of race or ethnicity, had hypertension. Now, it will be about 40 percent of the adult population.
Are plant-based diets effective at keeping hypertension in check?
Dr. Ogedegbe: Studies show that a diet rich in fruits and vegetables can reduce blood pressure. Plants have a lot of potassium, which lowers blood pressure. But it’s important to remember that up to 75 percent of the sodium we consume comes from processed foods. So going vegan won’t help much unless you also control your salt intake.
Dr. Weintraub: I can torture anybody with a diet that brings down their blood pressure, but is it sustainable? I tell patients to stay away from processed foods, lose weight, and take medicine if it’s appropriate.
Beyond high blood pressure, which other factors put people at risk?
Dr. Weintraub: The new guidelines go after everything—blood pressure, weight, lipids, blood sugar, smoking, and stress. This is how we have approached patients for years at the Center for the Prevention of Cardiovascular Disease. It’s more work for healthcare practitioners, but does what’s best for the patient.