Dr Paul Mason - blood pressure, longevity, and drugs

Summary: optimal systolic BP is 129, BP drugs don’t promote longevity.

(I am not endorsing this post, I am posting it for comment.)

https://x.com/DrPaulMason/status/1883855381392506924

Here is a summary on ‘Blood Pressure, longevity and drugs’ I have composed for my patients. My conclusions might surprise you.

‘Blood Pressure, Longevity and Drugs’
High blood pressure (hypertension) is a well-known risk factor for early death. The belief that lowering blood pressure can lead to an increase in life expectancy has driven Australians to spend over $1.2 billion annually on blood pressure medications. However, while these drugs lower blood pressure, they don’t address the most common root cause of hypertension, which is insulin resistance. As a result, the expected longevity associated with a particular blood pressure may well be different in unmedicated and medicated individuals.

What’s the Ideal Blood Pressure for longevity?
Studies assessing the association between blood pressure and mortality often has significant limitations. These studies are often conducted in developed countries on high-risk populations. This means that many study subjects are likely to be taking blood pressure medications, limiting the generalisability of findings to unmedicated populations. Additionally, the number of very elderly participants in these studies is typically limited, restricting the ability of these studies to inform us about blood pressure and optimal longevity.

One study, published in BMJ in 2018, addresses these limitations and is the most methodologically sound study I have found on this topic. This was a prospective longitudinal study of 4,658 elderly Chinese individuals with an average age of 92 years (including 825 centenarians). Given the impressive age of the subjects, this study has the potential to inform us of optimal blood pressure for longevity.

There are two numbers in a standard blood pressure reading. The top number refers to systolic blood pressure (SBP) and indicates pressure when the heart pumps. The bottom number refers to diastolic blood pressure (DBP), which is the pressure when the heart relaxes between beats.

Systolic blood pressure (the top number reflecting peak pressure when the heart pumps) was shown by this study to predict longevity, with an optimal reading being 129 mmHg. Systolic blood pressures both below and above this level were found to represent an increased mortality risk, though this was not significant between about 120 mmHg and 140 mmHg. Importantly, the risk of premature mortality was greater for lower blood pressures than for higher blood pressures.

Diastolic blood pressure (bottom number, reflection pressure when the heart is relaxed), was shown to be all but worthless when it comes to predicting longevity. All-cause mortality was basically identical across a wide range of diastolic blood pressure (40 mmHg to 130 mmHg).# In essence, it is reasonable to only consider systolic blood pressure (the top number) when predicting longevity based on blood pressure**.

These findings have been replicated in other populations too. A UK-based study of females over the age of 80 had broadly similar findings, identifying the lowest risk of mortality when systolic blood pressure was between 120 to 139 mmHg. Another study of 68,901 Korean adults over the age of 65 found that the optimal systolic blood pressure in terms of mortality was 130-139 mmHg. In summary, the optimal systolic blood pressure for longevity in an unmedicated population is likely to be around 130 mmHg, with diastolic blood pressure being all but irrelevant.

Does Treating High Blood Pressure with Drugs Increase Life Expectancy?
Perhaps the most influential clinical guidelines on the management of blood pressure in Australia were published by the Australian Heart Foundation in 2016. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers, and thiazide-type diuretics are all recommended as first-line management for hypertension. Despite the strong recommendation to use these drugs for hypertension, on balance, there is no compelling evidence that taking blood pressure medications for hypertension increases life expectancy. This was demonstrated by a 2017 meta-analysis of 74 individual trials involving over 300,000 patients, which found no evidence that treating hypertension, even when systolic pressures were over 160 mmHg, offered any mortality benefit. Of course, it may be argued that some classes of medication may be superior to others, offering benefits through mechanisms independent of their blood-lowering effect. There is little compelling evidence, however, that any of the four classes of medication commonly initiated for hypertension offer mortality benefit.

A Closer Look at Specific Drug Classes:
ACE Inhibitors A 2014 meta-analysis published in JAMA examined these drug classes in patients with diabetes. Nine out of 11 studies on ACE inhibitors (e.g., Ramipril, Perindopril) found no benefit. The two outliers were industry-funded, with significant methodological limitations. One of these outliers was not in fact a new study, but rather a ‘re-analysis’ of existing trial data from a previous study which just so happened to come to a different conclusion. The other outlier was the ADVANCE trial which also had major methodological limitations. One of these was the use of a run in period (commonly seen in statin trials). Before the study officially started, every eligible subject received the active medications for 6 weeks. If they had any side effects to the drugs, they were removed from eligibility before the study even started (~14% of subjects who registered for the trial ultimately did not take part in the study). Of course, subjects removed during the run-in period were not included in adverse event data.

Consequently, practices such as this load the deck in favour of the drug intervention, leading to an overestimation of the net benefits. Further, these studies were on diabetics, and thus not applicable to the general population. Without these two industry funded outlier studies, the marginal benefit found by this meta-analysis for ACE inhibitors in terms of all cause mortality all but evaporates.

ARBs A 2014 meta-analysis published in JAMA examined these drug classes in patients with diabetes. Seven individual studies assessed Angiotensin II Receptor Blockers (e.g., Candesartan, Irbesartan, Losartan, Olmesartan, Telmisartan, Valsartan), with none finding a mortality benefit.

Calcium Channel Blockers
Calcium channel blockers are another class of medication often used for the management of hypertension. One of the earliest drugs in this class was nifedipine, which was introduced into the Australian market in the 1980’s. The immediate-release formulation of nifedipine was discontinued in Australia in October 2020 after it was found to significantly increase the risk of death in patients with heart disease by 2-3 times. Slow release nifedipine remains available, and is often prescribed to lower blood pressure. Despite this, I could not locate any research finding nifedipine to offer benefit when compared to ‘no treatment at all’ in terms of mortality. Most randomised controlled trials compared nifedipine against other blood pressure drugs rather than placebo, meaning can’t tell us whether nifedipine is superior to ‘no treatment at all’. The only randomised controlled trial that I could find comparing nifedipine against a placebo in the treatment of hypertension, the ‘Systolic Hypertension in Europe trial’ found there to be no mortality benefit. & Similarly, there is no evidence of mortality benefit compared to placebo for other calcium channel blockers, including amlodipine, felodipine and lercanidpine.

Thiazide diuretics
As with other blood pressure lowering medications, there is little if any evidence that thiazide type diuretics (eg. hydro-chlorothiazide) and thiazide ‘like’ diuretics (eg. indapamide) improve longevity when used to treat hypertension. This was demonstrated by a 2015 meta-analysis and systematic review of 21 studies which failed to find any mortality benefit of either thiazide-type or thiazide-like diuretics when compared to placebo.

Conclusion
In summary, the use of blood pressure medications appears to offer no compelling mortality benefit. Most studies compare drugs against each other rather than placebo, creating an illusion of benefit. Additionally, non-inferiority trials—where a new drug is compared against an older drug—often perpetuate the recommendation of multiple drugs without clear evidence of efficacy. Medications are simply no substitute for addressing the underlying causes of hypertension. Focusing on improving diet, exercise, and overall metabolic health offers a more effective and sustainable path to longevity and well-being.


It’s worth noting that the systolic blood pressure found to be optimal for longevity, 129 mmHg, is a level the American Heart Association considers to represent elevated blood pressure. Indeed, it is just shy of the 130 mmHg threshold which is considered stage 1 hypertension. That the optimal blood pressure for longevity as identified by this study is considered to represent elevated blood pressure ought to have us rethinking our blood pressure goals.

Importantly, this study also looked at whether or not study participants were taking medications for blood pressure and found these findings to be independent of medication status. There is another measure called ‘pulse pressure,’ which is the difference between SBP and DBP (SBP - DBP = pulse pressure). Being derived from both systolic blood pressure and diastolic blood pressure, the predictive value of pulse pressure was found to be midway between the two (inferior to the simpler systolic blood pressure). This study also found that blood pressures below 120 mmHg were more common in the last three months of life (despite the absence of any medication changes), with blood pressures below 110 mmHg being associated with the highest risk of all.

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Here is a long thread discussing potential benefits of lower blood pressure levels: Optimal Blood Pressure we Should Target? Systolic Under 110 or 100?

I’m skeptical 129 systolic is ideal for healthspan. Here’s a summary of my discussion about this post with Claude.ai:

The doctor’s advice regarding an optimal systolic blood pressure of 129 mmHg and dismissing diastolic pressure requires significant correction based on current evidence.

Evidence Against Doctor’s Claims

Recent large-scale studies demonstrate that lower blood pressure targets provide superior outcomes for both longevity and healthspan. The Women’s Health Initiative study of 16,570 participants showed that systolic BP around 120 mmHg was associated with the highest probability of survival to age 90, regardless of age[1].

Medicine 3.0 Perspective

Peter Attia’s Medicine 3.0 approach emphasizes optimization for healthspan, not just lifespan. Current evidence aligns with this framework, showing:

Optimal Targets

  • Systolic: 110-130 mmHg, with strongest benefits around 120 mmHg[1]
  • Diastolic: Important especially for those under 50[2]

Benefits of Lower BP

  • 27% reduction in all-cause mortality with intensive control
  • 5.4 years later onset of cardiovascular disease[3]
  • Compression of morbidity (longer healthy life, shorter period of illness)

Age Considerations

  • Under 50: Both systolic and diastolic readings are crucial predictors[2]
  • Over 50: Systolic becomes more significant, but diastolic remains relevant[2]

Impact on Healthspan

Lower blood pressure is associated with:

  • Extended cardiovascular disease-free survival
  • Better physical functioning in old age
  • Reduced risk of cognitive decline[14]
  • 30-40% reduction in heart attack, heart failure, and stroke risk[14]

The evidence strongly suggests that optimal blood pressure management should target both systolic and diastolic readings, with goals generally lower than the doctor suggested. Medicine 3.0’s focus on maximizing healthspan supports more aggressive BP control than traditionally recommended, while considering individual factors and using both lifestyle interventions and appropriate medications when needed.

Sources
[1] Systolic Blood Pressure and Survival to Very Old Age. Results from … Systolic Blood Pressure and Survival to Very Old Age. Results from the Women’s Health Initiative - PMC
[2] Which blood pressure number matters most? The answer might … Which blood pressure number matters most? The answer might depend on your age | American Heart Association
[3] Association of cumulative systolic blood pressure with long-term risk … Association of cumulative systolic blood pressure with long-term risk of cardiovascular disease and healthy longevity: findings from the Lifetime Risk Pooling Project cohorts - PMC
[4] Blood Pressure in Adulthood and Life Expectancy With … https://www.ahajournals.org/doi/10.1161/01.hyp.0000173433.67426.9b
[5] an individual participant-level data meta-analysis - The Lancet https://www.thelancet.com/article/S0140-6736(21)01921-8/fulltext
[6] Low midlife blood pressure, survival, comorbidity, and health-related … Low midlife blood pressure, survival, comorbidity, and health-related quality of life in old age: the Helsinki Businessmen Study - PubMed
[7] The total and direct effects of systolic and diastolic blood pressure … The total and direct effects of systolic and diastolic blood pressure on cardiovascular disease and longevity using Mendelian randomisation | Scientific Reports
[8] Stage 1 Hypertension and the 10‐Year and Lifetime Risk of … Stage 1 Hypertension and the 10‐Year and Lifetime Risk of Cardiovascular Disease: A Prospective Real‐World Study - PMC
[9] Impact of diastolic and systolic blood pressure on mortality - PubMed Impact of diastolic and systolic blood pressure on mortality: implications for the definition of "normal" - PubMed
[10] Relationship of Blood Pressure to 25-Year Mortality Due to Coronary … https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/648465
[11] Blood pressure and ageing - PMC - PubMed Central Blood pressure and ageing - PMC
[12] Optimal Blood Pressure Control for Optimal Longevity - AHA Journals https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.124.011135
[13] AMA #41: Medicine 3.0, developments in the field of aging, healthy … #231 - AMA #41: Medicine 3.0, developments in the field of aging, healthy habits in times of stress, and more - Peter Attia
[14] Regular Blood Pressure Checks Can Save Your Life Regular Blood Pressure Checks Can Save Your Life | Wake Forest University School of Medicine
[15] What is healthspan, and how can you maximize yours? What is healthspan, and how can you maximize yours? | American Heart Association
[16] 10 ways to control high blood pressure without medication 10 ways to control high blood pressure without medication - Mayo Clinic
[17] Optimal blood pressure: how low should we go? - Oxford Academic https://academic.oup.com/ajh/article-abstract/12/S7/113S/191259?redirectedFrom=fulltext

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I can believe there is a sweet spot.

BP that is too low will make life miserable. I have to watch out for tadalafil, NO boosters, potassium, etc. bringing my BP too low. Too low BP feels like very poor health.

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I would think it would not be the same for everyone though?

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What is too low? My systolic BP is usually 100-104 and I feel fine. Spend my time mountain biking and hiking most days. Never get light headed.

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Isn’t he the guy who who was saying that fiber was toxic and sugar causes heart disease?!

Immediate refutations with AI doing the usual mainstream biased “fact checking” based on the kind of studies the author criticizes on good grounds, and another one charging “denialism” about closely related topics that are similarly controversial. So, that is a good sign for there to be an actual issue.
Indeed, he tells that common root causes like insulin resistance are not addressed, and I could well imagine that drugs lowering BP w/o adressing the cause may be harmful, while high BP in healthy people being unnecessarily treated and so on being all mixed up in the statistics makes things more difficult than the average mediocre “The Science defenders” can fathom. Certainly, as with many related issues, addressing the root cause instead is better, but so much less convenient.

@Paul IDK. My “too low BP” is feeling bad. I was pushing back against the linear assumption of “lower is better” as is seem in modern longevity competition in hba1c, apoB/LDL, etc.

If you feel good and you aren’t taking meds to lower BP to abnormally low levels (as in, why do that?), I would guess you’re doing great.

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The conclusion says it all.

Wanted to read his cited studies. But clicking the link takes me to a Twitter (X) log in. I have no account, and do not want to join.

That’s pretty low but if you are asymptomatic rising abruptly to a stand or when you get dehydrated on a hot day etc. it probably means your vascular tone is good. I can guarantee your blood pressure isn’t 100-104 when you are mountain biking or hiking. Probably closer to 180! As you get older your vessels get stiffer and postural hypotension may become more of an issue for you. I just checked your bio and it says you are in your early 70’s! That makes me wonder how you are checking your BP? Getting reliable measurements at home takes some practice.

I use an Omron BP device with a cuff. It is pretty repetitive and more reproducible than DR office. Monday they measured my BP as 94/65! Other times they have gotten as high as 115/70. They do it over clothing (usually my appt is mid morning), I do it on bare skin just upon waking.
My BP has been under 110 my entire life, so it is not something new.
Never felt light headed or dizzy at all.

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That Omron device is probably very accurate especially if the doctors office is getting similar readings.

For the record I can’t stand the automated devices though. I’m always worried they aren’t calibrated correctly or they are calling the sounds incorrectly or imprecisely because they are letting the air bleed too fast. If you have a slow pulse you can miss 8 mm of Hg between a no sound and the next beat. In other words if you are bleeding too fast you can bleed 8-10 mm Hg pressure before the next heart beat and erroneously think your SBP is 10 mm Hg lower than it is.

I have a traditional cuff and a stethoscope at home but it can be awkward holding the stethoscope diaphragm on your arm and pumping the cuff with the same hand while listening. This jumble likely also adds artifacts. So I bought one of these on Amazon and it solved my retentive need to hear it myself. Now I’m pretty convinced my BP is a little on the high side.

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