Health Blog

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Nurse  Senior Woman

Dr. Victor Sierpina - Dangerous guidelines

Dec 8, 2015, 02:11 AM by Michael Cooper

One of my patients is a delightful, beautifully coiffed, cognitively sharp 92 year old. Her occasional spikes of blood pressure in the 170-200 range caused us anxiety despite the lack of neurological or cardiac symptoms. Tinkering with her medications caused side effects without improving the problem. Finally, she stopped checking it so much and continues to do just fine on lower medication dosages.

Frankly, I shuddered at a recent study in the New England Journal of Medicine recommending lowering blood pressure to below 120 systolic in those older than 75. The conclusion of the article based on about 9,400 patients admitted that, “rates of serious adverse events of hypotension, syncope, electrolyte abnormalities and acute kidney injury or failure, but not of injurious falls, were higher in the intensive-treatment group than in the standard-treatment group.” The standard treatment groups were those with blood pressure under 140.

As a physician who takes care of a lot of people 75 and older, dizziness, weakness, fatigue and falls are major risks of over treating blood pressure. So-called orthostatic hypotension is a drop in blood pressure when they stand from a sitting or lying position and is a common condition of the elderly. It often results in dizziness or even fainting. A potential consequence is a fall along with hip fractures, concussions, bleeding into the brain and other trauma. So I worry that this new guideline will cause more harm than good.

In fact, for those 60 and older, normal blood pressure has recently been redefined to anything up to 150/90. So the recent New England Journal of Medicine study on lowering blood pressure, through only one report, throws confusion into the clinical decision making process. The study also did not deal with diabetic patients whose optimal blood pressure has been revised upwards for some time from 120/80 to 140/90.

About 10 years ago, the New England Journal of Medicine published an article warning against the blind adoption of clinical guidelines in patients with multiple medical problems. Clinical guidelines are established by consensus among experts based on various trials of treatments and tend to be focused on one condition or disease treatment.

In cases where people have multiple conditions, for example, diabetes, heart disease and high blood pressure, studies are more complicated and thus harder to do and to draw real-world conclusions and recommendations.

I recall an excellent lecture several years ago by Dr. James Goodwin, then head of Geriatrics at UTMB, that showed a graph on managing blood pressure in those older than 80. What his data showed was that the tighter the control of blood pressures in this age group, the higher their mortality. Thus, standard guidelines may not be appropriate for this group whose stiffer arteries may give artificially elevated readings.

Any clinical guideline needs to be interpreted with caution and in the context of the specific patient, other health conditions, medications, functional status and likely longevity. Over-zealous treatment to meet certain guidelines that are now benchmarks for quality of care may actually be harmful.

So, whatever your age, be sure to ask your doctor what the known risks and benefits of following the latest clinical guidelines are for someone like you.