Controlling high blood pressure (hypertension) is an important factor in reducing the risks associated with heart disease. But it’s becoming increasingly clear that there’s no one right way to treat high blood pressure. Rather, the best approach depends on the person being treated, says Johns Hopkins cardiologist John William (Bill) McEvoy, M.B.B.Ch., M.H.S.  

“There are a number of factors to consider before deciding on a blood pressure goal for a particular patient,” McEvoy says. “One size does not fit all.”

Measuring Risk of Hypertension

Hypertension, or high blood pressure, is only one of many factors that can affect heart disease risk. Other factors can vary widely from person to person. As medicine moves toward personalization, doctors often take those differences into account to design custom blood pressure treatment plans, McEvoy says.

That customized approach often starts with tests to understand a person’s overall risk of cardiovascular events such as heart attack or heart failure. Such tests include:

• Cardiovascular risk assessments: General practitioners and cardiologists can calculate your cardiovascular risk, which predicts your likelihood of having a cardiovascular event in the next 10 years. This concept has been used for some time to determine whether to prescribe medications to lower cholesterol, says McEvoy. It’s increasingly being used to guide blood pressure therapy as well.
• Coronary calcium scan: This test uses an ultrafast CT scan of the heart to measure the amount of calcium in your coronary arteries. Patients with more calcium in their arteries are at greater risk of heart disease.

Normal Blood Pressure: Aim Low

Traditionally, patients have been treated for high blood pressure if the top (systolic) number of their blood pressure reading was above 140 mmHg. However, recent studies suggest that patients at high risk of cardiovascular events should consider aiming lower, says McEvoy. For high-risk patients, a systolic blood pressure of 130 or even 120 might be a better target.T

o achieve that low goal, many patients will have to consider more intensive drug therapy. Patients at low or intermediate risk of heart events, on the other hand, might not need to be so aggressive in treating their high blood pressure with medications. They may be able to try lowering their blood pressure through lifestyle changes such as diet, exercise and salt reduction.

Risk level is only one piece of the picture. Does the patient have other health conditions? What other medications does the patient take? How does he or she experience side effects from the medications? “A shared decision should consider the patient’s concerns, fears and desires for their medical care, along with the provider’s understanding of the patient and his or her interpretation of the published data,” McEvoy says.

Aim for Realistic Blood Pressure

A more personalized approach to blood pressure is a good thing, McEvoy says. Yet more aggressive blood pressure targets aren’t realistic for all patients.

 In fact, many people with high blood pressure aren’t even meeting the traditional goal of lowering their reading to below 140 mmHg, he adds. Step 1 should be to aim for that more modest target. Once you reach that point, it may be worth starting a discussion about whether to move the goalpost. 

“Gone are the days where the physician says ‘Your blood pressure goal is x,’ and that’s the end of the story,” he says. “At the end of the day, it comes back to shared patient-physician decision-making.”