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New Blood Pressure Guidelines: Q&A With Exercise Physiologist

February 07, 2018

Editor’s note: Amanda Zaleski, an exercise physiologist with the Hartford HealthCare Heart & Vascular Institute’s Department of Preventive Cardiology,  led an early morning “Walk and Talk” at Westfarms mall Feb. 2 to celebrate National Heart Month. Walkers learned about the new blood pressure guidelines, watched a CPR demonstration and received free blood pressure and body fat screenings. The event took place on Go Red Day, a nationally recognized initiative to raise awareness surrounding heart disease in women, which is the leading cause of death in women across America. We’ve summarized below the Q & A with the audience.

By Amanda Zaleski
Exercise Physiologist

Q: I heard that there are new blood pressure guidelines. What does this mean for me?
A: This is correct and very important to learn and know as there are some individuals who were not considered to have hypertension a few months ago who may now meet the criteria for hypertension today. In November 2017, The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines released new guidelines, which now define high blood pressure or “hypertension’ as having a resting systolic blood pressure of 130 mmHg or greater, a resting diastolic blood pressure of 80 mmHg or greater, taking antihypertensive medication, being told by a physician or health professional on at least two occasions that one has high blood pressure, or any combination of these criteria. The report also defines an additional class of patients with systolic blood pressure ranging from 120 to 139 mmHg and diastolic blood pressure 80 mmHg or less as having elevated blood pressure and a heightened risk of developing hypertension in the future.

These new thresholds and classifications for hypertension represent a significant shift in common knowledge that many of us have come to be familiar with. For the past 14 years, we previously defined hypertension as having a resting systolic blood pressure of 140 mmHg or greater, a resting diastolic blood pressure of 90 mmHg or greater. We also previously defined systolic blood pressure ranging from 120 to 139 mmHg and/or diastolic blood pressure ranging from 80 to 89 mmHg as prehypertension, which is a term we will no longer use.

Normal   blood pressure: less than 120 and 80 mmHg.

Elevated blood pressure: 120-129 and <less than 80 mmHg.

Hypertension stage 1: 130-139 or 80-89 mmHg.

Hypertension stage 2: 140 or higher or or 90 mmHg or higher.

Q: Can you explain what the two numbers mean?
A: Blood pressure is reported as two numbers. The top number, or “systolic blood pressure,” is the pressure in the artery being measured (usually the brachial or upper arm) when the heart contracts or beats. The bottom number, or “diastolic blood pressure,” is the pressure in the artery when the heart is refilling with blood or resting between beats.

Q: I just received a new blood pressure monitor and it prompts me to take my blood pressure three times in each arm. Why would I need to take it three times?
A: Proper patient positioning and preparation are critical for ensuring blood pressure accuracy. For example, prior to the first reading, one should be seated quietly for at least 5 min, with the legs uncrossed, bladder empty, and the back and arm supported, such that the middle of the cuff on the upper arm is at heart level and with an appropriate sized cuff. The AHA standards state that blood pressure should be measured three times in each arm (left and right), separated by at least 1 min, with the higher of the arms averaged. It is great to hear that newer models of home blood pressure monitors are beginning to incorporate these standards into their technology as a default. This will undoubtedly improve the accuracy of home self-monitoring of blood pressure, which is such an important aspect for the diagnosis, treatment, and control of hypertension.

Q: My daughter is on a blood pressure-lowering med and her blood pressure is now in the normal ranges. She says that she does not have hypertension anymore. Is that true? Who is right?
A: Mom is correct on this one! Hypertension is technically defined as having a resting systolic blood pressure of 130 mmHg or greater, a resting diastolic blood pressure of 80 mmHg or greater, taking antihypertensive medication, being told by a physician or health professional on at least two occasions that one has high blood pressure, or any combination of these criteria. Even for people with blood pressure in the normal ranges, if they are taking an antihypertensive medication they are indeed considered to have hypertension.

Q: How much of an influence does weight have on your blood pressure?
A: Weight has a very big influence on blood pressure. Individuals who are overweight or obese are 2 to 2.5 times more likely to have hypertension than individuals who are normal weight. However, weight loss of as little as ~2.5lb results in reductions of systolic blood pressure of 1.2 mmHg and diastolic blood pressure of 1.0 mmHg; with greater blood pressure reductions experienced with greater weight loss.

Q: How much of an influence does salt have on your blood pressure and how much is too much?

A: High dietary salt causes hypertension in about 30 percent of those with hypertension. Dietary modifications such as the Dietary Approaches to Stop Hypertension (DASH) diet (i.e., a plant-focused diet rich in fruits, vegetables, nuts, whole grains, low-fat and non-fat dairy, lean meats, fish, poultry and heart-healthy fats) and sodium restriction can reduce blood pressure by 2 to 14 mmHg. The new blood pressure guidelines recommend daily sodium intake of less than 1500mg/d as an optimal goal, but suggest aiming for at least 1000mg/d if that is not achievable.

Q: How many more people will be on blood pressure-lowering drugs now that the guidelines have changed?
A: This is a great question as there has been a lot of criticism and speculation that these guidelines were devised to increase the use of antihypertensive medications at the benefit of major pharmaceutical companies, however, this is simply not true. In fact, these new guidelines emphasize the importance of lifestyle changes instead of medications, with a significant focus on the antihypertensive benefits of good diet and exercise. For example, physical activity was rated among the best nonpharmacologic interventions for the prevention and treatment of hypertension as it lowers blood pressure 5 to 8 mmHg among adults with hypertension. Furthermore, the change in terminology from “prehypertension” to “elevated blood pressure” will hopefully serve as a catalyst for earlier adoption of lifestyle and pharmacological intervention strategies for individuals who were already at a heightened risk before. So, if you look at the numbers, the change in the threshold for which we now diagnose hypertension means 46 percent of adults in the United States now have qualify as having hypertension, compared with 32 percent under the old guidelines — an increase of 14 percent. However, the percentage of adults recommended antihypertensive medication has only increased by about 2 percent (though this is difficult to predict given the addition of the Atherosclerotic Cardiovascular Disease, or ASCVD, risk calculator to the hypertension treatment algorithm).

Q: How much of an influence does age play in deciding whether one might be put on a blood pressure-lowering medication?
A: The answer is, it depends. When lifestyle interventions are not effective in achieving blood pressure goals, the decision to initiate antihypertensive therapy is guided by the individual’s blood pressure values, the presence of disease (such as cardiovascular disease, diabetes mellitus or chronic kidney disease) and 10-year risk for heart disease and stroke as assessed by the ASCVD risk calculator found here. 

Following the treatment algorithm, individuals are recommended to begin antihypertensive therapy if one has blood pressure values greater than or equal to 140mmHg and/or greater than or equal to 90mmHg or if one has blood pressure values 130-139mmHg and/or 80-89mmHg with ASCVD risk  greater than 10 or known clinical disease (listed above).

Age is a big component of the ASCVD risk calculator, but the calculator doesn’t work so well in individuals less than 40 years old or greater than 80 years old. Therefore, it is important to remember that these are guidelines, however, clinicians are encouraged to continue to treat patients on an individual level and weigh other lifestyle factors that influence overall cardiovascular health such as nutrition, stress, healthy weight, smoking, alcohol, salt intake, and physical activity.

Q: I heard that we should no longer do mouth-to-mouth when performing CPR. Is that true?
A: This is true and this change occurred because researchers were finding that a major reason bystanders were not administering CPR was that many individuals were reluctant to put their mouths on the mouth of a stranger. There is powerful evidence that chest compression alone is far better than doing nothing at all, especially if done correctly. Thus, “hand only CPR” was designed to give greater confidence to bystanders because we know that immediate high-quality CPR can double or even triple a person’s chance of survival. The simplified procedure involves just two steps:

Step 1) Call 911.

Step 2) Hands Only CPR: Push hard and fast in the center of the chest to the beat of any tune that is 100 to 120 beats per minute, such as “Staying Alive” by the Bee Gees. To find more songs that are 100 to 120 beats per minute, click here.

For information on your heart and your health, visit the Hartford HealthCare Heart & Vascular Institute here.