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High blood pressure

New guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC) indicate that high blood pressure should be treated earlier. The first new guidelines since 2003 for the detection, prevention, management and treatment of high blood pressure recommend a healthy level is less than 120/80 mm Hg. Intervention for hypertension is now recommended at 130/80 mm Hg rather than 140/90 mm Hg.

Due to these new guidelines, the prevalence of reported high blood pressure will change. Now 46% of people evaluated—nearly half of the U.S. adult population—will be defined as having high blood pressure.1This is up from one third of American adults and two thirds of people with diabetes who previously reported having high blood pressure or taking prescription medications to lower their blood pressure.2 The new guidelines will particularly impact younger people. Rates for those under age 45 are expected to triple for men and double for women.1

The new guidelines account for the possibility that complications can occur at lower levels and facilitate earlier intervention.1 This is a call to action that people need to think earlier about monitoring, and if needed, lowering blood pressure, initially with lifestyle approaches, rather than waiting until the medication is necessary.1 If you have type 2 diabetes, controlling high blood pressure can help reduce the risk for cardiovascular disease, and a range of other negative health outcomes.3

The American Diabetes Association (ADA) and the American Heart Association (AHA) have set standards for care which recommend maintaining good control of blood pressure, especially for people with diabetes who also have hypertension.

What does blood pressure measure?

Blood pressure is the force of blood flow exerted against the walls of blood vessels as it is pumped by the heart throughout the body. To measure blood pressure two readings are taken. Systolic blood pressure (SBP) is the measurement taken while the heart muscle is contracting. Diastolic blood pressure (DBP) is the reading taken when the heart is at rest, between beats or contractions. SBP is the first (upper) number, and DBP is the bottom (lower) number. The reading is presented in millimeters (mm) of mercury (Hg). The standard pressure in healthy people is 120/80 mmHg. 2

Hypertension is associated with a range of health problems

The heart has to work harder if you have high blood pressure thereby increasing the risk for heart disease and diabetes. High blood pressure raises your risk for heart attack, stroke, eye problems and kidney disease. It is a medical problem that doesn’t go away by itself. It requires treatment and changes to diet and lifestyle. 5,7

Hypertension may be accompanied by atherosclerosis, the hardening of the arteries, in which fatty deposits called plaques form on the interior walls of the arteries. This can cause them to become thickened, narrowed, and less resilient.5,7

Blood pressure categories in the new guidelines are: 1

  • Normal: Less than 120/80 mm Hg
  • Elevated: Systolic between 120-129 and diastolic less than 80
  • Stage 1 hypertension: Systolic between 130-139 or diastolic between 80-89
  • Stage 2 hypertension: Systolic at least 140 or diastolic at least 90 mm Hg
  • Hypertensive crisis: Systolic over 180 and/or diastolic over 120. Patients may require prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

Some physicians will prescribe medication for Stage I hypertension if a patient has already had a heart attack or stroke, or is at high risk of heart attack or stroke based on age, diabetes mellitus condition, chronic kidney disease, or high cholesterol.

What causes hypertension?

There is no clear understanding of the precise cause for developing hypertension unless it is a side effect from a medication or other health condition. Multiple factors are known to contribute to hypertension.5

In people with diabetes, specific factors that contribute to the development of hypertension include:7

  • Kidney disease
  • Being overweight or obese
  • Taking too much insulin
  • Expansion of fluid in the body and retention of sodium, which may be caused by high blood sugar and insulin
  • Stiffness of arteries

Certain factors increase your risk for hypertension. These include:

  • Having a family history of hypertension
  • Ethnic background: African Americans have higher rates and greater severity of hypertension than Caucasians.
  • High sodium (salt) consumption
  • Excess alcohol consumption
  • Obesity and weight gain
  • Vitamin D deficiency
  • Lack of exercise or inactivity
  • High Cholesterol, elevated low-density lipoproteins [LDL], elevated triglycerides, and low levels of the protective high-density lipoproteins [HDL].
  • Personality types: those who are irritable, impatient and have depression are at higher risk for hypertension.

What are the symptoms of hypertension?

Uncontrolled high blood pressure is dangerous because it is often a “silent” condition. That is, it often occurs without recognition of any outward symptoms. Since it is not something you can detect on your own, have it checked at each regular medical appointment. 11

What are the treatment options to help lower my BP?

Effective treatment options to help lower blood pressure, and maintain a healthy blood pressure target, include lifestyle and medication. 1,2

Lifestyle changes

There are steps you can take to combat the factors that contribute to high blood pressure. These include:3,8

  • Decrease the amount of salt in your diet
  • Maintain a healthy diet
  • Lose weight as directed, especially if you are overweight or obese
  • Don’t smoke
  • Exercise regularly
  • Don’t drink alcohol to excess

Medication

Lifestyle changes alone may not achieve your target blood pressure. Medications, antihypertensives, are also effective at reducing blood pressure. There are 4 different classes of antihypertensive that are commonly used to lower blood pressure:

  • Diuretics
  • Angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs)
  • Calcium channel blockers
  • Beta blockers

A doctor will help determine which of these medications, alone or in combination, are most appropriate for your condition.

The Future

The ADA will update and revise the online version of the Standards of Care on an ongoing basis with necessary annotations as new technology, research, and treatments emerge. Regulatory changes will be incorporated to provide physicians with the most up-to-date clinical advice.2

Written by: Linda S. Minton and Jonathan Simmons | Last reviewed: April 2019
  1. New ACC/AHA High Blood Pressure Guidelines Lower Definition of Hypertension. Available at: https://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017. 4.10.19.
  2. High Blood Pressure. Available at: http://www.diabetes.org/are-you-at-risk/lower-your-risk/bloodpressure.html. Accessed 4.11.19.
  3. Centers for Disease Control and Prevention. Diabetes Report Card 2012. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2012.
  4. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the eighth joint national committee (JNC 8). JAMA 2014;311:507-20.
  5. Wilson PWF. Overview of the risk equivalents and established risk factors for cardiovascular disease.Cannon CP, Downey BC, eds. UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013.
  6. Kaplan NM, Domino FJ. Overview of hypertension in adults. Bakris GL, Forman JP, eds. UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013.
  7. American Diabetes Association. Standards of Medical Care in Diabetes—2014. Diabetes Care 2014;37:S14-S80.
  8. Bakris GL. Treatment of hypertension in patients with diabetes mellitus. Kaplan NM, Nathan DM, Forman JP, eds. UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013.
  9. Mann FE. Patient information: High blood pressure in adults (Beyond the Basics). Bakris GL, Forman JP, eds. UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013.
  10. Patient information: Medicines for high blood pressure (The Basics). UptoDate. Wolters Kluwer Health. Accessed at: www.uptodate.com. 2013
  11. American Diabetes Association Releases 2018 Standards of Medical Care in Diabetes, with Notable New Recommendations for People with Cardiovascular Disease and Diabetes. Available at: http://www.diabetes.org/newsroom/press-releases/2017/american-diabetes-association-2018-release-standards-of-medical-care-in-diabetes.html. Accessed 4.10.19