High blood pressure
is a recognized risk factor for stroke and other circulatory diseases. This makes blood pressure lowering with
medications one of the top priorities of physicians. Unfortunately, there are also risks
associated with the use of anti-hypertensive drugs. An article showing an increased risk of
serious injuries related to falls in people aged 70 or greater on blood
pressure medications was published this week. (Antihypertensive Medications and Serious Fall Injuries in a Nationally
Representative Sample of Older Adults JAMA
Intern Med. Published online February 24, 2014.)

Based upon what I
observe in people consulting me high blood pressure is being grossly over treated
today. There are two facts about blood
pressure that are being ignored by most physicians. The first is that blood pressure tends to
increase as people grow older. The
second is that while the risk of having a stroke, heart attack, or dying increases
as blood pressure rises, the risk of those outcomes also increases as blood
pressure falls.

The medical term for
high blood pressure is essential hypertension.
Essential means "needed” or "necessary.”
Prior to the introduction of anti-hypertensive medications in the 1960s
it was commonly accepted that a higher blood pressure was needed to keep blood
circulating properly as arteries stiffened with age. While this phenomenon is no longer considered
by U.S. physicians studies have confirmed its existence. People who are a risk for a poor outcome due
to high blood pressure are those who are at the highest level among their age
group, not those who have a specific blood pressure number. A twenty-five year old with a blood pressure
of 130/80 is actually at higher risk of a blood pressure related problem later
in life than a seventy-five year old with a blood pressure of 150/90. Nevertheless, I see people in their seventies
and beyond who have been placed on medication to bring their pressure down to
that of an average twenty year old.

Risk of a poor
outcome increases as blood pressure rises, but it also rises as blood pressure
falls. This is referred to as the "J”
curve of blood pressure. Every study
that has looked at outcome has found that the most favorable blood pressure
when taking medication is a diastolic (lower number) pressure in the 80 – 85 mm/Hg
range.

When Dr. Franz
Messerli analyzed 22,000 people treated for hypertension he found that the
fewest deaths and non-fatal heart attacks occurred with a diastolic blood
pressure of 84. The risk of death or non-fatal heart attack increased 20 % when
diastolic blood pressure was lowered to 70 and 80% if it was brought down to
65. Those who had their diastolic pressure lowered to 60 or less had a fourfold
increased risk of heart attack or death!

The J-Curve was
confirmed in a recent study called the "Treatment to New Target” (TNT) trial,
which showed that the number of strokes and heart attacks increased as
medication was used to lower the blood pressure below 140 systolic or 80
diastolic. Even more shocking was the finding that the number of deaths from
all causes steadily increased as blood pressure was lowered from a high of
170/100 to a low of 110/60.

When I see someone
taking high blood pressure medication with a blood pressure lower than 130/80 I
work with them to decrease the dose and bring their pressure into a safer
range. This week's article is in line
with what is already known about blood pressure management. I hope that one day the weight of the
evidence will convince other physicians to do the same.