130/80 mm Hg: Do we really need a new definition of hypertension?

The new US guideline already defines a blood pressure of 130/80 mm Hg measured during the day as hypertension. Literally, overnight, every second US American suddenly became a high-pressure patient. Does hypertension now also have to be redefined in Europe?

An exciting but unnecessary debate

The new US guideline already defines a blood pressure of 130/80 mm Hg measured during the day as hypertension. Literally, overnight, every second US American suddenly became a high-pressure patient. Does hypertension now also have to be redefined in Europe?

Already today - without redefinition - hypertension is the number one engine for cardiovascular mortality worldwide. As the most widespread non-infectious disease, high blood pressure causes enormous costs for health care systems.

On the other hand, hypertension is considered to be very easy to diagnose - a blood pressure monitor is all that is needed to determine it. Furthermore, the disease is comparatively easy to treat in many cases. There is now a wide range of effective blood pressure medications.

A definition is important, but does it need to be redefined?

Defining a threshold value for the blood pressure above which a patient is considered to require treatment is both meaningful and important. Patients can be divided into risk groups on the basis of their blood pressure, measures such as prevention or treatment can be better planned and the treatment objective - namely a blood pressure within the normal range - can be formulated in the first place.

It is already known that above a blood pressure of 120/80 mm Hg, the risk of cardiovascular disease also increases. However, this value does not represent the limit above which hypertension is defined. In its current guideline, the EU speaks of hypertension from a blood pressure of 140/90 mm Hg. Deviating from this, the US guidelines recently set a value of 130/80 mm Hg. Is such an "aggressive" definition of high blood pressure really necessary and effective?

The argument in favor: Arguments for a redefinition of hypertension

Hypertension is primarily a blood pressure level that can be influenced by treatment and treated with medication. The former pre-hypertension from the guideline is therefore now divided into elevated blood pressure (120-129/< 80 mm Hg) and grade 1 hypertension (130-139/80-89 mm Hg).

Studies have shown that even with systolic blood pressure above 130 mm Hg, the risk of stroke is up to 20% higher than with values below 130 mm Hg. In general, the higher the blood pressure, the higher the risk of cardiovascular events. In addition, it is known that blood pressure in patients with 130/80 mm Hg reacts to treatments and medications.

For example, a non-pharmaceutical intervention (e.g. change of diet, higher activity,...) already causes a drop in blood pressure of about 2-4 units. The drug therapy of blood pressure of 130/80 mm Hg is also intended to reduce the risk of strokes and dementia.

Conclusion: Patients with a blood pressure of 130/80 mm Hg or higher benefit from interventions, which is why this blood pressure value is to be classified as hypertension.

The argument against a redefinition of hypertension

The EU guideline assesses hypertension more conservatively than the US guideline. EU-wide, a blood pressure of 130-139/85-89 mm Hg is considered rather normal, while hypertension is present from 140/90 mm Hg. A redefinition of hypertension would have a major impact on patients and also on costs and the insurance industry. So what evidence is there that justifies such a course of action?

In short: none. Patients with high normal blood pressure do not benefit in terms of morbidity and mortality from treatment measures such as antihypertensive drugs. On the contrary, such an approach could even be harmful, especially in older patients. The only exception is patients with high normal blood pressure and high risk (> 10 %) of cardiovascular disease.

In addition, the TROPHY study showed that lifestyle changes can slow the onset of hypertension very little.

Conclusion: There is currently no convincing evidence that people with high normal blood pressure need to be called hypertensive in order to treat them with hypotension. So should every patient with a blood pressure of 130/80 mm Hg or more be classified as a hypertensive? No!

What would a redefinition mean in practice?

The new definition would also declare the majority of the population in the EU to be hypertensive and worthy of treatment. However, this is currently neither medically indicated nor sensible. Finally, please imagine the following scene:

Doctor: Your blood pressure is 130/80 mm Hg. You have high blood pressure, just like every other European.
Patient: Well, if almost everyone has that, it's not bad, is it? Is there any good medicine for that?
Doctor: Before we start with medication... What do you think about a healthier diet and more exercise?
Patient: I'd rather take the pill. Thank you, Doctor.

Unfortunately, this scenario is not completely absurd, because surveys in the USA have shown that more than 96% of people would prefer to take one tablet if it could prolong their lives by another five years rather than doing more sports.

Must hypertension be redefined? Great debate. 27.08.2018. ESC Munich

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