In an interesting essay, Dr. Marvin Moser writes that “as late as the 1950s, elevated blood pressure was considered by many experts to be necessary for adequate perfusion of vital organs.”[1] The eminent American cardiologist Paul Dudley White suggested in 1937 that “hypertension may be an important compensatory mechanism that we should not tamper with even if we were certain we could control it.”

In 1937, 54 year old Franklin Roosevelt’s blood pressure was 162/98. But in accordance with medical opinion of the time, his personal physician did not prescribe medication to lower it. By 1941, a reading of 188/105 was recorded and finally a barbiturate and massages were prescribed. In 1944, a cardiologist examined Roosevelt and was appalled at what he found. Many of the now well-understood results of untreated high blood pressure were present. A chest x-ray showed fluid in his lungs and an enlarged heart from congestive heart failure. His urine showed protein due to kidney damage. The cardiologist recommended digitalis (a medication to treat heart failure) and a low salt diet. By the time Roosevelt attended the Yalta conference his blood pressure was recorded at 260/150. Seeing Roosevelt at the conference, Winston Churchill’s physician Lord Moran noted that “Roosevelt looked straight ahead with his mouth open as if he were not taking things in.” In 1945, while sitting for a portrait, Roosevelt complained of a headache and suddenly lost consciousness. His blood pressure was measured at over 300/190 and he was later found to have a cerebral hemorrhage.

In the late 1950s, thiazide diuretics were identified as the first well tolerated and effective medication for treating high blood pressure (hypertension). In the 1960s and 1970s, new blood pressure medications became available and a consensus on the importance of treating hypertension solidified.

It is now clear that treating hypertension early can prevent heart attacks and strokes, as well as heart and kidney failure. But until recently, there has been debate about how low we should aim to get the pressure. In November of this year, a landmark study called SPRINT (Systolic Pressure Intervention Trial) offered tremendous insight into this issue. The study took people 50 years and older with hypertension and randomized them to aim for a systolic blood pressure of either a) less than 140 or b) less than 120. The study was stopped earlier after 3.3 years when it became clear that the people with tighter blood pressure control were experiencing clear benefits. There were significantly less bad outcomes such as heart attacks, congestive heart failure, strokes, and death in the group with the lower blood pressure.

My takeaway from this study is to aim for a systolic blood pressure closer to 120 in patients I treat for hypertension. The trial provides firm evidence that doing so lowers the risk of having a heart attack, stroke, and congestive heart failure. Nonetheless, a person’s individual situation must be taken into account. As people age, the ability to compensate when standing up can be compromised, making them prone to fall if blood pressure is lowered too aggressively. In addition, decreasing blood pressure below a certain level in some people can cause fatigue and a poor quality of life. It takes more medications to achieve a lower blood pressure and these can sometimes have side effects. So patients and their doctors should work together to find a combination of medications and behaviors (such as exercise and diet) that fits their unique situations.

[1] Historical Perspectives on the Management of Hypertension