Some medical professionals having trouble taking new criteria to heart

Like about 76 million other Americans, Carl Reiber has hypertension.

For Reiber, vice provost for academic affairs at the University of Nevada, Las Vegas, the diagnosis came about five years ago. Since then, Reiber, now 53, has worked successfully to keep his high blood pressure in check through exercise, diet and medication.

For most adults, a diagnosis of hypertension comes in pretty much the same way as Reiber’s, and the treatment for it falls pretty much along the same straightforward path.

However, treating hypertension in people ages 60 and older can be a bit trickier because of the cumulative effects of aging, a patient universe that tends to be managing more than one medical condition and taking multiple medications in doing so, and the potentially hazardous side effects some hypertension medications can bring to older patients.

Late last year, a national panel released proposed new guidelines for treating hypertension in people ages 60 and older, setting a new — some would argue looser or less aggressive — blood pressure target point for seniors.

Some physicians, nurses and clinicians disagree with the proposal, citing the potentially deadly health risks hypertension can pose.

Blood pressure is a measurement of the pressure circulating blood places on the walls of the body’s blood vessels. It’s expressed in the form of two numbers, systolic pressure and diastolic pressure. The unit of measurement for both is millimeters of mercury, and it’s often referred to in terms of “something-over-something.”

The systolic pressure, the top number, denotes the pressure in the arteries when the heart beats or contracts, says Pat Alpert, an advanced practice registered nurse and associate professor and chair of the physiological department at the UNLV School of Nursing.

Then, the bottom number, or diastolic pressure, denotes the pressure in the blood vessels when the heart is relaxing between beats, Alpert says.

Normal blood pressure is considered to be 120 over 80 or lower. Blood pressures higher than that are described in stages of hypertension. According to the American Heart Association, the stages are: prehypertension (systolic of 120 to 139 or diastolic of 80 to 89), stage 1 hypertension (systolic of 140 to 159 or diastolic of 90 to 99), stage 2 hypertension (systolic of 160 or higher or diastolic of 100 or higher), and “hypertensive crisis,” when emergency assistance is necessary (systolic higher than 180 or diastolic higher than 110).

Hypertension often is called “the silent killer.” It usually presents no visible symptoms and is discovered only through a blood-pressure check during a health screening. However, left untreated, the immediate or cumulative effects of high blood pressure are associated with a frightening roster of serious conditions that include stroke, heart problems and kidney disease.

Blood pressure can rise with age as the body’s blood vessels lose elasticity and a lifetime’s accumulation of arterial plaque takes its toll. Dr. Matthew Martin, assistant director of the family medicine residency program at Valley Hospital and assistant professor at Touro University Nevada College of Osteopathic Medicine, says, in the past, the general target for geriatric patients has been to maintain blood pressure below 140 over 90.

With the proposed new guidelines, he says, “what we’re suggesting now is perhaps, in this geriatric population, that we want to loosen our control a bit.”

So, for otherwise healthy people 60 and older who don’t have diabetes, kidney disease or other medical issues, the proposed guidelines move slightly upward — from the current 140 over 90 to 150 over 90 — the point at which medications would be prescribed to treat hypertension.

The new guidelines are based on a review of hypertension treatment outcomes in seniors and reflect a balancing of the potential risks, the potential benefits and the effectiveness of aggressively treating hypertension in older patients. Among the issues the committee considered is that some of the medications prescribed for hypertension can cause dizziness or lightheadedness, and that can lead to falls in a particularly vulnerable group of patients.

“One of the biggest contributors for death in that (senior) population is falls,” Martin says. “If one gets lightheaded and falls, the risk of fracture and pneumonia when lying on the back while recuperating, those go up.”

Another potential issue: Older people already might be taking other prescription medications that can interact with blood-pressure medications, and adding another medication into the pharmacological mix can cause unwanted side effects and interactions.

Among seniors, “it’s not uncommon that they have multiple illnesses,” Alpert says. “It’s not uncommon to be on 10, 11, 12 medications, so the more medications you take … you tend to run the risk of having side effects. And. it’s not uncommon to see people on two or three hypertension medications.”

Martin stresses that the proposed guidelines are only that: guidelines that front-line health care providers can take into account when treating individual senior patients. The guidelines “help us make informed clinical decisions,” he adds, but they don’t “override good decision-making.

“So if there were persons with certain conditions where lower blood pressure is indicated, we may shoot for that, and that’s something you may want to discuss with your doctor. On the other hand, if (a patient has) other symptoms — (such as) lightheadedness — then, certainly, we can re-address the blood-pressure goals.”

“We do know that lower blood pressures are generally healthier,” says Dr. Lisa Rosenberg, a geriatrician with Touro University Nevada. “But in older adults, you have to be aware of other issues. Maybe muscles are weakened. Maybe there are balance issues, and that makes the risk of lowering blood pressure much more dangerous because they may fall and sustain injury.”

Under the proposed change, she says, when a patient’s unique medical needs call for it, “we can kind of let that blood pressure be higher than the previous guidelines would have led us to believe.”

The proposed guidelines haven’t been universally embraced. Some physicians — including, even, some members of the panel that worked on the guidelines — have opposed their adoption, citing the significant risks hypertension poses and, Alpert says, “uncertainty” about the validity of the data used to formulate the new guidelines.

“I think people are a little hesitant,” she says. “There isn’t a 100 percent buy-in from all of the experts, so that makes it a little iffy.”

However, the proposed guidelines at least should prompt greater dialogue between physician and patient. For example, Rosenberg says, if a patient “calls back and says, ‘I took the new medication, and I was dizzy,’ then my answer is always, ‘That’s the wrong medication for you.’

“I have had, in my own experience when I was training, (a cardiologist say), ‘The best blood pressure for anybody is the lowest blood pressure they can tolerate without getting dizzy and falling down.’ But that’s not the way we think about it anymore.”

Martin says the proposed guidelines reflect a reality front-line physicians commonly see. He recalls that, while presenting a review of the guidelines to a group of physicians, “as I looked around the room, I saw many heads nodding. It’s something physicians have known for a while.”

The important thing, Martin adds, is to not “make this a blanket statement for every patient.”

And for patients, he says, the key takeaway is to “never make a medication change without consulting your doctor.”

That, Alpert notes, is one of the fears expressed by opponents of the new guidelines: That “when people read this, they’ll say, ‘I no longer have to take my meds because my blood pressure is 148 over 90.’ ”

That can bring serious consequences.

“I can’t tell you how many patients who have come in with congestive heart failure tell me they were told 10 years ago that their blood pressure is a little high and they should see a provider, and they didn’t really feel so bad, so they didn’t see someone,” Alpert says.

The proposed guidelines also may help to direct a sharper focus on lifestyle changes that can help to manage hypertension. Reiber — who’s also a UNLV biology professor and researcher in cardiovascular physiology — says he “became concerned” about his blood pressure when a routine exam placed it at nearly 180 over 100.

“That’s really bad,” he says, and while stress was a factor, “I also had put on weight. I was up to around 220 and I shouldn’t run more than 175.”

“They put me on meds, but I also decided that exercise and diet had to be a more aggressive part of my life,” Reiber says. He started exercising daily and altered his diet, in part by substituting chicken, fish and vegetables for beef. The last time his blood pressure was taken, it was about 130 over 75.

Reiber’s is a lesson anybody who is concerned about his or her blood pressure should take to heart.

“With obesity, blood pressure goes up,” Rosenberg explains, and losing just five or 10 pounds “can take a lot of pressure off of the blood vessels, and the heart has to do much less work to circulate the blood.”

Contact reporter John Przybys at jprzybys@reviewjournal.com or 702-383-0280.