The 120/80 Blood Pressure Target Is Wrong

[00:00:00]The gold standard blood pressure of 120 on 80 is probably completely wrong for you. In fact, I'd almost guarantee it.

[00:00:06]So, picture these two people in your mind. One is a mid-40-year-old man. His blood pressure is 118 on 76 and he's worried about heart disease that runs in his family. Then the second person is a late 80-year-old woman. She needs to use a walking stick to get around and her blood pressure is 124 on 68 and she's on two blood pressure medications. Now based on that information alone, what is the crucial difference between those two people in terms of the blood pressure that they should be targeting? Now most people think that it's their age but it's not. It's frailty. Frailty and past medical history. So let me explain and this is crucial for you to understand so that you can significantly lower your heart attack and stroke risk while minimizing any adverse reactions. Now why do we chase or why is there that mythical 120 on 80 blood pressure? So the general mechanism is that the higher your blood pressure the more strain there is on your blood vessels and over time that can lead to heart attacks and strokes and it's known as the silent killer because you don't t you don't tend to feel high blood pressure until something goes pop as in that heart attack or stroke. Now a quick note before we go on. I'm Brad Stanfield. I'm a family medicine doctor and I make these videos to explain the science of living a long healthy life. But even though I'm a physician, I'm not your physician. So please discuss with your doctor before making any changes to your health plan. Now over the years blood pressure targets have generally gone down. Now this is not a conspiracy by big farmer just to sell more drugs. The blood pressure targets have lowered because of trials such as this one in 2015 and it's called the sprint study.

[00:01:36]So it involved 9,361 people all over the age of 50 years old.

[00:01:42]Now what they wanted to check was a blood pressure which was standard at the time of 140 compared to an intensive lowering uh of blood pressure to 120.

[00:01:52]Now this study was meant to last about 6 years but it was stopped early after just 3 years because what they noticed is a 25% lower risk of a combination of heart attacks, strokes and deaths. Now a quick note on relative verse absolute risk because that 25% number sounds huge. Whereas in the intensive group they had 1.65 65% of patients per year that had the major cardiovascular events. So that was the heart attacks, strokes or death versus 2.19% per year in the standard treatment group. So that was the 140 number. So that doesn't sound like a huge difference because in plain terms that's only about half a percentage point fewer events per year.

[00:02:30]But when you average that out or when you extrapolate that out you know 10 20 30 years that absolute risk reduction is huge. And that is why we care about lowering blood pressure because again we can most of the time lower blood pressure without causing any side effects. But more on that later. Now if this sounds settled, why isn't the answer that just everyone should be aiming for a blood pressure of lower than 120? Well, let's have a look at who was actually in that sprint trial because what we don't want to do is extrapolate a different population. So there was a particular population of people in the sprint trial. And if you're not part of that population, then we don't want to extrapolate those results from this sprint trial onto you.

[00:03:08]Now, in the sprint study, there were no diabetics. These people had no history of strokes and they were not frail. So, that's the first problem. Again, thinking back to that woman that we mentioned at the start of the video, that mid 80year-old. So, this uh study wouldn't apply to that person. The second is that the sprint study, they measured blood pressure with an automated device when the patient sat alone. Now, a read that reading typically runs about five or 10 units lower than if you just went to your doctor to get your blood pressure checked. And we'll talk about how to measure your blood pressure correctly later in the video. So, there are a lot of confounding factors here. And again, we don't want to extrapolate this data.

[00:03:44]So, how so does this mean that lower is better if we include uh patients with diabetes or with strokes or who are a bit frail? And a 2024 trial answers that exactly. So it was called the E sprit study and this study again it was huge.

[00:04:00]It was over 10,000 people and it added in diabetics and stroke patients. Now there we saw a 12% lower risk of a combination of heart attacks, strokes and deaths uh in the 120 group in the blood pressure of 120 compared to 140.

[00:04:15]So it wasn't quite as big a difference uh compared to the sprint study, but it's still significant. So if aiming for a lower blood pressure keeps winning even in the fit people, even in the frailish people, even in diabetics and stroke survivors, then why on earth would anyone need to aim for a higher blood pressure? Well, you have to imagine that it's a tight rope that we're trying to uh that we're trying to balance here because yes, if we lower blood pressure, we do lower the risks of heart attacks and strokes, but if we lower it too much, if we cause problems, then when you stand up, you can start to feel dizzy. Uh and worst case scenario, you can actually fall over. uh and you can cause other serious adverse events.

[00:04:50]So for example, this came into sharp focus in 2015 when a trial from the uh internal medicine journal was published.

[00:04:58]So in frail nursing home residents over the age of 80, those with a systolic blood pressure, so that's the top one under 130 who were on two or more blood pressure drugs had a and get this 78% higher risk of dying over the 2-year period compared to those that had a blood pressure of higher than 130. Now, one of the reasons for this is that when you stand up and you're a bit frail, if your blood pressure is too low, then uh your body isn't going to pump that blood to your brain and so your brain is starved of oxygen and then you can feel faint and fall over. So, for example, a meta analysis of 50,000 people found that orthostatic hypotension, so again, this is where you stand up and your blood pressure isn't quite high enough to push that blood to your brain, uh that carried a 73% higher risk of falling. Now that's that's significant because in these older people if they fall and they break a hip they have a 20 to 30% uh chance of dying within one year. So again we've got this tight rope that we need to that we need to balance and this is the part that again almost everyone gets wrong and this is why I led with this at the start of start of the video and many doctors actually get this wrong as well. This is not about age. When the trials looked at their own fittest patients who were over the age of 75, the ones who were sent uh for that under 120 target, those people still got benefit and they did not fall more than anyone else. So the falls story was never really about an age story. It's about a frailty story. It's not about birthdays, it's whether the body has become too frail. So again, picture that older woman at the start of the video who needed to use a walking stick to get around that person. If we're aiming for a blood pressure of lower than 120, we're probably going to cause them to fall because when they stand up, their blood pressure is going to be too low. This also extends to frail 50 and 60 year olds. So, in the clinic, I'll often see patients unfortunately who haven't had the chance to look after themselves. And even though they're only about mid-50, they've lost significant amounts of muscle mass. Uh, and so when they're trying to get around, they move slow.

[00:07:00]When they get up, you can see that they're starting to wobble. They're losing their balance. and that person has become frail even though they're 50 years old, which is why we should not be focusing just on the age number. I see plenty of people uh in the clinic who are very fit and they're 90 years old.

[00:07:16]And so for those people, yes, we could be aiming for a blood pressure of lower than 120. And on the flip side, really fit people, they might want to go for a blood pressure of even lower than 120.

[00:07:24]They might want to go for a target of maybe below 115. And the reason for that is that there's no magic safe threshold when it comes to blood pressure. So in 2002 across a million adults, cardiovascular death roughly doubled for every 20 points of systolic blood pressure all the way down to 115 over 75. So again, there's no magic safe threshold. So for some people who are super fit, they might want to have a blood pressure of of lower than 115. So how do you get this balance right?

[00:07:52]Because it is such a tight rope. Well, before you argue about what your target should be, whether it should be 120 or 130 or even all the way down to 115, here's the uncomfortable truth. Because most people are they're going for a measurement that is simply wrong. So, when you'll go into your uh doctor and you get your blood pressure checked, that is often a really incorrect measurement because uh generally when you go into the clinic, your blood pressure goes up anyway. Often times, uh there needs to be a bit of rush. So, there's bad cuff technique and all of that just wrecks the reading. So, a way bit of reading rather than relying on just one uh measurement at the doctor's office is to measure it at home. So, you don't want to exercise or have caffeine within the past 30 minutes. You want to be nicely seated with your back supported, your feet flat, so you don't want to be crossing your legs. And you want your arm to be at about heart height. So, you don't want it up here.

[00:08:42]You don't want it to be hanging down like this. And you want to make sure that the uh cuff size is correct. We don't want to be talking. And you want to have an empty bladder and ideally you want to be sitting down for at least about 5 minutes just to really try and relax. And you do not want to be trusting one number. So what I recommend to my patients in the clinic is to take two readings. So ideally one in the morning and then one in the evening. Do that for a week. Now throw out the first day's readings because they're generally inaccurate and then you want to average the rest. And that will give you a far better, more accurate reading compared to just one reading in the doctor's office. And only then once you've got that accurate reading, that's when you can start to figure out which target you should be aiming for. And a quick screen that I do with my patients is do they have any dizziness when they stand up?

[00:09:27]Can they stand up unaded? Can they easily jump and then balance themselves?

[00:09:31]Do they have any heart conditions? So if they've got favorable answers to those questions, then a target of below 120 on 180 is probably appropriate. Now, of course, make sure to discuss with your doctor first. Now if not as in if you do feel some dizziness when you're standing up uh and you do feel that frailty is is coming on then a higher blood pressure of about 130 or even 140 depending on your frailty might be appropriate. But if you are becoming frail please don't be disheartened because there is so much that you can do to get your strength back and the best way to do that is exercise which also helps to lower your blood pressure safely. Uh and there are a couple of exercises that have been shown to have outsized effects on lowering blood pressure. So in a recent study that pulled 270 randomized control trials together, aerobic exercise, so this is going out for a run for instance, lowered systolic blood pressure by about 4 and a half points while isometric uh so think of walls sits for instance, they came out on top at about eight points of blood pressure lowering. So even if you're struggling for time, you can do a wallsit in your office or at home. And if you are becoming frail, one of the best exercises that I suggest to my patients is to unaded stand up and then slowly sit back down in their chair and do that as many times as they can. Of course, making sure that you do it safely. But that exercise uh it builds up your thigh muscles, your quads, it builds up your glutes, and it can help to lower your blood pressure. The next lever that you can pull is diet. So here I suggest to my patients to increase their potassium intake so long as their kidneys are okay. So I suggest to them to increase their non-starchy vegetable intake. So I'm not talking here about increasing your potato or cuma intake. Ideally what we want is things like broccoli, peas, carrots, corn. And then you can pair that with vegetables uh or foods that have got lots of protein and potassium in them. So chickpeas, lentils, and beans for instance. So eating more potassium uh and this was from a 2013 trial such as fruits and vegetables lowered systolic blood pressure by about 3 and 1/2 points in people with high readings. Next, we want to ideally decrease and stop alcohol. In 2017, in a study that was done in people who were drinking six or more units per day, if they cut back by about half, they lowered their systolic blood pressure by 5 1/2 points. Next is weight loss. So, of course, this comes in with diet and exercise. Across 25 randomized control trials, for every kilogram of weight that's lost, about one point of systolic blood pressure is dropped. So for a 5 kg weight loss that's worth roughly about five points of blood pressure lowering.

[00:11:59]Now here is where we might need a bit of assistance from the doctor because just telling patients to eat less and move more it often doesn't work. For some people it does but for of uh but for many people it doesn't and this is because there are other metabolic issues that are causing problems. So for example one thing that I always screen for in my patients is a thing called Cushings disease. So this is where there's too much cortisol in the blood and what we do is we use a salivory cortisol test at night. Then there are other secondary causes that raise blood pressure things like hypothyroidism.

[00:12:31]Then you've also got primary eldoststeroneism. So uh the way that we check this in the clinic is we check blood eldoststerone renin ratios.

[00:12:39]Another one is fochromosytoma and we check for that using plasma free metinephrines. And another one that's often overlooked is renal artery stenosis. So this is where the arteries that go into the kidneys uh they are narrowed and this can often cause blood pressure to go up. So we think of this in people with high blood pressure who are less than 40 years of age. Now once all of those secondary causes have been excluded then often what I see in the clinic is that the primary reason for why a person's blood pressure is high is their weight. And again telling patients to eat less and move more. Yes, sometimes that can be helpful but often we need a bit more support. And this is what's changed recently. We can use GLP-1 medications now to help patients with their weight loss. Overall, there are four main points I wanted to get across in this video. Don't just adjust the blood pressure target based on age.

[00:13:26]Ideally, we want to adjust it based on frailty. We want to measure blood pressure properly, ideally at home. And then we want to pull the levers that we can actually control. Things like making sure that we're eating well, that we're exercising, we're sleeping. And then we want to treat secondary causes of high blood pressure such as our weight, hypothyroidism, etc. And I've put the full write up uh of this video, including every study that I've cited with all of the numbers, over at drstanfield.com, and it's linked in the pinned comment below. And if you want bonus videos from me each week, including membersonly health reviews, where members they share their health stories, and I walk through what the evidence actually says for someone in their situation, you can join as a channel member or on Patreon. You get the bonus videos, plus early access to these videos, priority replies in the comments, and the Discord community where we discuss the latest health research. And make sure to check out this next video