Hypertension guidelines in adults older than 60

In January 2017, ACP and AAFP published the following guidelines on treatment of hypertension in patients older than age 60.

Recommendations are listed with slightly modified wording for easier and succinct reading:

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relevant articles:

Annals of Internal Medicine

Systematic Review

January 2017

Recommendation 1:

Initiate treatment in adults ≥ 60 with systolic blood pressure persistently ≥ 150 mmHg to achieve a target sBP  < 150 mmHg to reduce the risk for mortality, stroke, and cardiac events. (Grade: strong recommendation, high-quality evidence).

Recommendation 2:

Consider initiating or intensifying pharmacologic treatment in adults ≥ 60 with a history of stroke or transient ischemic attack to achieve a target sBP < 140 mmHg to reduce the risk for recurrent stroke.

Recommendation 3:

Consider initiating or intensifying pharmacologic treatment in adults ≥ 60 at high cardiovascular risk, based on individualized assessment, to achieve a target sBP < 140 mmHg to reduce the risk for stroke or cardiac events.

ACP and AAFP recommend that clinicians select the treatment goals for adults ≥ 60 based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

More from the publication:

Hypertension, an elevation of systemic arterial blood pressure, is a very common chronic disease in the United States. The overall prevalence of hypertension among U.S. adults is 29%, and it increases to 65% in adults ≥60. Hypertension was associated with a total of $46 billion in health care services, medications, and missed days of work in the United States in 2011.

Appropriate management of hypertension reduces the risk for cardiovascular disease, renal disease, cerebrovascular disease, and death. However, determining the most appropriate BP targets, particularly for adults aged 60 years or older, has been controversial. Debate about the goal for sBP among adults treated for hypertension has intensified, especially in light of recent recommendations (JNC8). In addition, when selecting BP targets for adults aged 60 years or older, clinicians need to consider comorbid conditions that could affect treatment choice. Treatments for hypertension include lifestyle modifications, such as weight loss, dietary modification, and increased physical activity, and antihypertensive medications, which commonly include thiazide-type diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin-receptor blockers (ARBs), calcium-channel blockers, and β-blockers.

Evidence was insufficient to determine the benefit of treating diastolic hypertension in the absence of systolic hypertension. Most trials assessed treatment outcomes based on sBP, and no trials included patients with a mean dBP > 90 mmHg and a mean sBP < 140 mmHg.

Individual assessment of benefits and harms is particularly important in adults ≥60 with multiple chronic conditions, several medications, or frailty. These patients might theoretically benefit from more aggressive BP treatment because of higher cardiovascular risks. However, they are more likely to be susceptible to serious harm from higher rates of syncope and hypotension, which were seen in some trials. Moreover, the absolute benefits of more aggressive BP treatment in elderly persons, those with multimorbidity, or those who are frail are not well-known, given limitations of the trials. These patients often receive multiple medications and are on drug regimens that are difficult to manage and increase the cost and risk for drug interactions. Indeed, most trials had exclusion criteria that implicitly or explicitly excluded patients who had dementia or diminished functional status. Few trials were available to compare patients with and without diabetes, which made drawing conclusions about relative treatment effects in these populations difficult. Whether the difference in results between SPRINT and ACCORD was because of diabetes status is unclear, but it is reasonable to rationalize that the benefits observed with the lower targets achieved in SPRINT most closely apply to patient populations without diabetes.