120 or bust? Blood pressure care could get more aggressive for millions

Here's a new number to remember: 120.

Millions of Americans with high blood pressure may soon find their doctors urging them to take additional medications, come in for more check-ups and make more lifestyle changes in an aggressive effort to drive their top blood pressure readings that low – largely because of a study that got its first full airing on Monday.

The study, published in the New England Journal of Medicine and presented at a meeting of the American Heart Association, shows that deaths and cardiovascular illnesses were cut by a quarter when patients aimed for 120 millimeters of mercury or less of systolic pressure. That's the top number of the two in a blood pressure reading.

A comparison group aimed for 140 or less, the goal widely recommended today.

The benefits of aggressive treatment were striking, even though they came with some increased side effects and would exact a still-uncalculated cost on the health care system, medical experts said.

"This could have a large impact on the prevention of cardiovascular disease. It's an extraordinarily important study," said Daniel Jones, a past president of the heart association and director of obesity research at the University of Mississippi. He also is a member of an expert panel that will update blood pressure treatment guidelines over the next year.

About one third of U.S. adults have high blood pressure and it is a leading reason people visit doctors.

The study came out two months after preliminary results were released with fanfare, but few details, by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health. The institutes, which funded the trial, stopped it early after finding clear results.

Here are some important details:

• The three-year study included 9,300 people over age 50 with high blood pressure and other heart disease risks, but it did not include people with diabetes. A previous smaller trial failed to find similar benefits for them, for reasons still not explained.

• Participants who aimed to stay below 140 needed an average of two drugs; those who aimed for 120 or lower needed three – and reached average readings of 121.

• Cardiovascular problems including heart failure, stroke, heart attacks, and death from heart disease occurred in 243 people (5.2%) in the intense treatment group, vs. 319 people (6.8%) in the standard treatment group.

• Deaths from any cause occurred in 155 people (3.3%) in the intense treatment group vs. 210 (4.5%) in the standard treatment group.

• Serious side effects, including fainting, abnormally low blood pressure and acute kidney damage, occurred in 220 people (4.7%) in the intense treatment group vs. 118 (2.5%) in the standard treatment group. Despite the fainting risk, there was no increase in injuries from falls in the intense treatment group. And people over age 75 seemed to tolerate extra medications "at least as well" as younger people, said study co-author Jackson Wright Jr., a professor of medicine at Case Western Reserve University. "That was unexpected."

The study is "a game-changer," but "this is not an edict from Moses – '120 for everyone,' " said George Bakris, director of a hypertension center at the University of Chicago. Bakris, who was not involved in the new study beyond some early trial-design talks, was among several doctors who wrote reactions in the New England Journal of Medicine and other journals

In real life, he said, many patients do not want to take more medications and others have individual circumstances that make it unwise.

If widely adopted, the lower target could be urged for at least 17 million U.S. adults, according to a separate study published in the Journal of the American College of Cardiology.

Study co-author Lawrence Fine, prevention chief at the heart, lung and blood institute, said in a statement that many patients and providers may want to wait for updated guidelines, but that they can start talking now about "whether this lower goal is best for their individual care."

A variety of drugs that work in several ways are used to treat high blood pressure. While the financial costs of aggressive treatment are a concern, Jones said, "the good news is that these are not whiz bang drugs that cost a lot of money… most of them are generic." Drug companies donated two drugs used in the study.

Jones and other experts also urged patients and doctors not to lose sight of the power of lifestyle changes to lower blood pressure. Losing weight, eating less salt, not smoking and exercising can all help, they said.

"Lose those 20 pounds you've been talking about losing and we might not have to use another medication to get you there," Jones said.