Blood pressure: How low do you really need to go?

The surprising reasons you might be able to delay using meds to lower your pressure—or not take them at all

Published : April 12, 2015 06:00 AM

Been told that your blood pressure is too high? Or maybe you're already on meds to lower yours. Well, you might not have to lower it as much as you once thought. Many experts, including our own at Consumer Reports Best Buy Drugs, say that millions of Americans don't have to aim quite as low when trying to manage their blood pressure.

That means you might be able to delay or even avoid taking a blood pressure medication, which reduces the risk of side effects and lowers your cost.

The not-so-great news is that it has been more than a year since the advice, from experts convened by the National Heart, Lung, and Blood Institute, came out, but many doctors have not yet adopted the new blood pressure targets. Here's why we think they should, and what it means for you:

Have high blood pressure? How do you manage it?

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How low should you go?

High blood pressure continues to be a serious health problem; it's still a leading cause of heart attacks and strokes. The ideal blood pressure levels remain the same: a systolic blood pressure of 120 millimeters of mercury or less (the top number) and a diastolic blood pressure (the bottom number) of 80 mmHg or less.

Until recently, most experts agreed that medication was needed if a person's systolic level (which reflects the pressure in arteries when the heart contracts) hit 140 or if the diastolic level (the pressure between heartbeats) reached 90. The goal was even lower for people with diabetes or chronic kidney disease because they're vulnerable to heart attacks and strokes: a systolic of 130 and a diastolic of 80.

But the independent group of experts suggested changing those cutoffs based on a review of the medical research. Contrary to long-held assumptions, they concluded that most people age 60 or older don't need drugs until their levels hit 150/90 and that drugs aren't necessary for most people with diabetes or chronic kidney disease until their systolic pressure reaches 140/90.

Several groups, notably the American Heart Association, haven't endorsed the new targets. But other research, including a 2014 analysis in the British Medical Journal, actually suggests that drug treatment isn't proved to help most people until systolic pressure hits 160.

Our medical experts think that the goal of 150/90 for most people age 60 or older and 140/90 for most people with diabetes or chronic kidney disease is reasonable. They point out that getting levels below 140/90 can require high doses of blood pressure drugs or multiple medications. That increases the risk of side effects, which can include persistent coughing, erectile dysfunction, and frequent urination, depending on the medication. The drugs can also cause dizziness, which can lead to falls.

Blood pressure medications usually aren't expensive (often less than $30 per month), but once people start taking them they often continue for the rest of their lives. Over time, that can be costly.

"Getting blood pressure under control is important," says Marvin M. Lip­man, M.D., Consumer Reports' chief medical adviser. "But it's important to do it in as safe a way as possible."

Read our Best Buy Drugs advice on how to lower blood pressure. And see our reviews of the best home blood pressure monitors.

Take these two key steps

Even if your blood pressure is moderately elevated, our experts say that you might not need to start taking medications, at least not right away. Instead, do these two things first:

1. Confirm the diagnosis.

Blood pressure levels fluctuate depending on factors such as how you're sitting and whether the monitor's cuff is properly positioned. And many people have "white-coat hypertension," in which blood pressure is normal at home but spikes in a doctor's office, perhaps because of their anxiety.

If your levels are high in your doctor's office, ask him or her to confirm the readings. The gold standard for that is 24- to 48-hour monitoring. But that kind of monitoring isn't widely available, and insurance might not cover the cost. In that case, schedule several follow-up visits. It's also wise to invest in a home monitor so that you can check levels on your own.

2. Try lifestyle changes first.

There are a number of measures—including losing weight, exercising more, cutting back on sodium, and drinking less alcohol—that can sometimes reduce or even eliminate your need for drugs. If your systolic level is moderately elevated (150 to 160 for people 60 and older; 140 to 150 for others), consider drugs only if after six months of serious attempts at diet and lifestyle changes your blood pressure hasn't dropped enough.

If you're 60 or older or you have diabetes or kidney disease and already take blood pressure medications that aren't causing side effects, there's no need to change your prescription. But if the effects are bothersome and your levels are under control, ask your doctor about switching your prescription, lowering your dose, or cutting back to one drug.

Be medication-wise

If you do need a drug, choose carefully. Until recently, the standard advice for most people was to start with a "water pill," or a thiazide diuretic such as hydro­chlorothiazide, either alone or with another drug. Diuretics are still a good choice for many people. But several other classes of drugs usually work just as well. And like diu­retics, they're available as low-cost generics, most of them costing less than $1 per day.

In some cases, other drugs are actually better choices than diuretics. For example, people with kidney disease may fare better on ACE inhibitors such as enalapril or lisinopril because those drugs can also help reduce complications of kidney disease.

Having a choice of blood pressure drugs can also help you minimize side effects. The medications are relatively safe, but some trigger side effects that can be severe enough to warrant switching to another drug.

If your doctor says that you need drugs, ask what numbers he or she is hoping to reach. Whether it's with lifestyle changes alone or combined with drugs, the aim for most people is to keep blood pressure below 140/90 if they're younger than age 60 or have diabetes or kidney disease, and below 150/90 if they're older. The ideal remains below 120/80, but you don't have to get your levels that low to substantially cut your risk of heart attack and stroke.  

Which drug is right for you?

The answer depends on your ethnic background and whether you have other health
problems, such as diabetes. Most generic drugs cost less than $30 per month. (For additional details, see our Best Buy Drugs report on blood pressure drugs.)



Things to know

Thiazide diuretics such as chlorthalidone, hydrochlorothiazide

Good candidates: Most people with high blood pressure.
Side effects: Frequent urination, erectile dysfunction.
Tips: Can lower potassium levels, so consume plenty of the mineral and note cramping or an increased heart rate.

ACE inhibitors such as benazepril, enalapril, and lisinopril

Good candidates: People with diabetes, heart failure, kidney disease, or a history of heart attack or stroke.
Side effects: Persistent dry cough and, in rare cases, potentially deadly allergic reactions, especially in African-Americans.
Tips: If coughing is bad, consider an ARB (see below).

ARBs such as losartan

Good candidates: People who would be good candidates for an ACE inhibitor but can't take one because of coughing.
Side effects: Similar to ACE inhibitors but less likely to cause coughing.
Tips: Don't take with ACE inhibitors.

Calcium channel blockers such as amlodipine


Good candidates: African-Americans.
Side effects: Dizziness, fast or slow heartbeat, flushing, headaches, swollen gums, and, in rare cases, breathing problems.

Editor's Note:

This article also appeared in the May 2015 issue of Consumer Reports on Health.  

These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is financed by the multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

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