Introduction: When Does Blood Pressure Need Treatment?
Peace be upon you and God's mercy, dear audience. In this segment, we try to answer the question: "At what blood pressure does one need treatment?" This topic has undergone many changes in recent years and there is disagreement among health organizations, affecting the lives of no fewer than one and a half billion people.
Why do we say that? Because the disputed blood pressure range - for example, if the pressure is 138 over 88 - is it considered that the person has high blood pressure and needs treatment? This disputed range is between (130-139) for the upper pressure and (80-89) for the lower pressure, and it is estimated to be present in no fewer than 20% of humans.
The Highest Measurement Rule
In treating blood pressure, if one of the pressures is high and the other is normal, we consider the person to have high blood pressure and place them in the higher category always. For example, if a person's blood pressure is 138 over 78, the upper pressure qualifies them for the elevated category, so we always take the higher one.
Balancing Benefit and Harm in Treatment
We must always balance two issues before starting drug treatment:
- Preventing complications: such as retinal damage, heart muscle damage, arteriosclerosis, foot ischemia, and heart failure.
- Avoiding side effects and costs: medications have side effects and drug interactions, and we do not want to burden the patient with unnecessary costs or expose them to inconvenience if they do not need treatment.
Unfortunately, in our Arab and Islamic world, we do not have guidelines specifically designed for us based on studies conducted on the peoples of the region, so we are forced to rely on American, European, and British guidelines.
Development of Health Guidelines (2014 - 2017)
2014 Guidelines (JNC 8)
According to these guidelines, blood pressure for adults was classified as follows:
- Normal: upper less than 120 and lower less than 80.
- Prehypertension: upper (120-139) or lower (80-89). These do not need medication, but recommendations to improve diet and exercise.
- Stage 1: upper (140-159) or lower (90-99). Here, the need for treatment begins after confirming the lifestyle pattern.
- Stage 2: upper 160 or above or lower 100 or above. There is no disagreement on the necessity of treating this category.
2017 Guidelines (ACC/AHA)
Eleven American organizations, including the American Heart Association, issued new standards that caused a shock and contradiction to what preceded:
- They considered that blood pressure from (130-139) upper or (80-89) lower is Stage 1 hypertension and not "prehypertension."
- This means that millions of people who were classified as healthy have become "hypertensive patients" according to this new definition.
Global Disagreement Over 2017 Standards
European organizations, the World Health Organization, and China did not agree with these strict American guidelines, and the vast majority of countries in the world continued to rely on the number 140 over 90 as the beginning of high blood pressure.
How to Deal with the Category (130-139 / 80-89)?
According to American recommendations, not everyone in this category is treated with drugs immediately, but the following is followed:
- Artery Patients: If the person is suffering from a disease resulting from arteriosclerosis or angina, treatment begins immediately.
- Risk Calculation (10-Year ASCVD Risk): The percentage of the likelihood of heart disease within 10 years is calculated (using special applications that enter age, cholesterol, smoking, and diabetes).
- If the percentage is 10% or more: drug treatment is given.
- If the percentage is less than 10%: lifestyle changes (exercise, salt reduction, weight loss) are sufficient with follow-up.
European and British Guidelines (2018 - 2021)
In 2018, the European Society of Cardiology (ESC) published its guidelines in the "European Heart Journal," and remained committed to the number 140 over 90 as the threshold for starting drug treatment, regardless of the presence of diabetes or the percentage of arteriosclerosis risk, contradicting the American approach of 2017.
Considering Ethnic and Geographic Origins
The European paper included a striking table indicating the need to adjust risk calculation based on the patient's origin:
- South Asians (e.g., India): The risk number is multiplied by (1.4) as they are more susceptible to heart disease.
- West Asians (our Arab region): The number is multiplied by (1.2) to increase the accuracy of predicting risks.
- East Asians (e.g., Indonesia): The number is multiplied by (0.7) as they are relatively less susceptible.
Similarly, in 2019 and 2020, the British organization "NICE" and the International Society of Hypertension (ISH) issued their guidelines, confirming the standard 140 over 90, reinforcing the broad global consensus against American strictness in numbers.
The Importance of the Place and Method of Measuring Blood Pressure
A crucial point to note: all the numbers mentioned earlier (such as 140/90) refer to measurement in the clinic or health center (Office Blood Pressure Monitoring).
Home Measurement vs. Clinic Measurement
There are significant differences between the two measurements, and home measurement or ambulatory device measurement for 24 hours should be resorted to for resolving confusing cases:
- White Coat Hypertension Phenomenon: The patient's blood pressure rises only in the clinic due to anxiety, while it is normal at home. This patient does not need drug treatment.
- Masked Hypertension: Blood pressure is normal in the clinic but very high in the patient's daily and home life. This patient needs treatment despite the normal clinic readings.
General Rule: Blood pressure measured at home is usually 5 degrees lower than clinic measurement. If your blood pressure at home is 135 over 85, this equals 140 over 90 in the clinic, and here you are considered a hypertensive patient and need treatment.
Recent Updates (2021) and Expanding the Scope of Treatment
In April 2021, the American Heart Association (AHA) issued a new update that tends to give drug treatment to the category (130-139 / 80-89) even if their risk percentage is less than 10%, in certain cases:
- Family History: If one of the parents died of a stroke or angina at a young age (such as age 45).
- Pregnancy History: Women who suffered from high blood pressure during pregnancy.
- Long-term View: Proponents of this approach believe that waiting until the risk percentage increases over 10 years is a narrow view, as blood pressure in this range leads to cumulative damage over 20 or 30 years, and giving the drug early prevents the worsening of the condition (Progression).
Summary and Practical Outcomes
To summarize this complex issue and clarify the key points:
- Global Consensus: Most international health organizations (European, British, Chinese, and the World Health Organization) agree that a person is considered hypertensive and in need of treatment if their blood pressure is 140/90 mmHg or higher (in a clinical setting).
- Controversial Category (130-139 / 80-89): Organizations that recommend drug treatment for this category are limited (often American). The decision here depends on the presence of other diseases (diabetes, kidney failure), a strong family history, or a high risk percentage.
- Home Measurement is Key: Treatment should not be initiated based on the first or second measurement in the clinic. Ask the patient to perform a proper and regular home examination. If readings of 135/85 mmHg are consistently observed at home, this indicates a real need for treatment.
May God grant us all good health. Peace be upon you, and the mercy of God and His blessings.