5 Questions: Randall Stafford on new blood pressure guidelines

A panel of the nation’s leading heart experts issued new blood pressure guidelines Nov. 13 that redefine for the first time in 14 years what constitutes high blood pressure.

Tens of millions more Americans now meet the criteria for having high blood pressure and must consider changing their lifestyles or taking medications — or both — to reach the lower levels considered safe. High blood pressure has been redefined as reading of 130 over 80, down from 140 over 90, said Randall Stafford, MD, PhD, professor of medicine and director of the Program on Prevention Outcomes and Practices at Stanford. He was one of the 21 experts who worked on developing the new guidelines. The project was jointly sponsored by the American Heart Association and the American College of Cardiology.

The new guidelines seek to reduce hypertension levels nationwide to improve public health. The condition can lead to heart attack, stroke, kidney failure and death if not detected early and treated appropriately, he said. Stafford, who underwent two kidney transplants and is an avid cyclist, is an advocate for physical activity as a means of helping to control blood pressure. He has lived with high blood pressure since his early 20s. As both a physician and a patient, he knows firsthand how complicated it can be to determine the best strategy for each person with high blood pressure.

Stafford spoke with writer Tracie White about why the new guidelines are important and how they can be implemented. He also wrote several posts about high blood pressure for the Scope blog.

Q:  How are the new guidelines different from the previous ones, and why were they needed?

Stafford: The changes were motivated largely by data from a federal study published in 2015 called SPRINT [the Systolic Blood Pressure Intervention Trial], which showed that lowering blood pressure well below 140 over 90 had substantial benefits, including for older people.

There are two main messages: First, people at a higher risk of a future heart attack or stroke should be treated more intensively to achieve a blood pressure below 130 over 80.  In particular, older people should be treated just as intensively as younger people. Second, the new guidelines define normal blood pressure as less than 120 over 80 or less. While medication should not necessarily be used to achieve this blood pressure, other nondrug strategies should be employed to lower blood pressure toward this level.

Q: How many people have high blood pressure, and what do these changes mean for them?

Stafford: It is estimated that under these new guidelines, 103 million Americans have high blood pressure, up from 72 million under the previous standard.

Nearly half of all American adults, and nearly 80 percent of those aged 65 and older, will find that they qualify for blood pressure medication and will need to take steps to reduce their blood pressure.

High blood pressure increases the risk of having a heart attack or stroke, as well as several other diseases affecting the arteries in the body. The impact of blood pressure is strongest at very high levels of blood pressure (greater than 180 over 110) but is still significant at any level above 120 over 80. For someone in their 50s, a blood pressure of 160 over 100 increases the risk of having a heart attack or stroke by 50 percent compared with a blood pressure of 120 over 80.

Q: Can you discuss the various treatments for lowering high blood pressure and how these will change under the new guidelines?

Stafford: While medications that lower blood pressure are a key tool, many nondrug strategies are also useful, but often neglected. Lifestyle changes are not easy, but should be central to how we approach high blood pressure. Changes in physical activity, diet, sleep and weight not only lower blood pressure with few side effects, but also favorably impact the risk of other important outcomes such as cancer and cognitive decline. Many drugs work more effectively when combined with lifestyle changes. The new guidelines hinge on people at higher risk for future bad events — like heart attacks and strokes — being treated more intensively.  This requires being more aggressive about lifestyle changes, as well as being more willing to prescribe multiple medications for blood pressure. A good first step for many people is to begin a routine of walking each day with a gradual increase in the distance covered.

Q: Despite scientific evidence that shows the tremendous health benefits of lifestyle changes such as diet and exercise, why does it remain so difficult for health care professionals to motivate patients to make these changes?

Stafford: Increasing physical activity is a potent strategy for reducing the risk of multiple chronic diseases, yet in the United States, most of the population is sedentary or near-sedentary.

In many ways, this is a failure of our health care system. This system is really a “sick care” system that is organized around dealing with acute, short-term problems rather than issues that need continued attention over time.

Physicians similarly want quick solutions and often don’t have the training needed to provide persuasive advice about lifestyle change. We live in environments that promote obesity and that make healthy choices difficult. Surrounded by advertising promises and hype, consumers themselves want an easy fix to their problems, rather than the hard work required to live a healthier lifestyle. In the end, however, the substantial benefits can make the hard work worth it.

Q: You’re an advocate of a “risk-based care” approach for treating high blood pressure. Is this model of disease treatment useful in other clinical situations?

Stafford: The new blood pressure guidelines stress that people at higher risk of future harmful events should be treated more aggressively. More widespread use of this concept would lead to more effective and less costly care for many conditions. In fact, we already use this risk-based care approach in other clinical situations. 

For example, treatment recommendations for high cholesterol, asthma and reduced bone mineral density are based on future risk. We could easily broaden this approach to how we treat other conditions, such as diabetes and bronchitis. The downside, of course, is that we need to give up the simplicity of a one-size-fits-all approach. 

In addition, if we understand that our true goal is to reduce future risk, this implies that we need to treat all of the factors that contribute to high risk. For example, if we are really “treating” the future risk of stroke and heart attack, we should emphasize lifestyle changes and simultaneously consider blood pressure medicines, statins and aspirin.