Pharmacologic Treatment of Hypertension in Older Adults

March 2, 2017

Pharmacologic Treatment of Hypertension in Older Adults

  1. Jamaluddin Moloo, MD, MPH

For older patients (age, ≥60), a new guideline recommends starting treatment when systolic blood pressure is ≥150 mm Hg.

  1. Jamaluddin Moloo, MD, MPH

Sponsoring Organizations: American College of Physicians (ACP); American Academy of Family Physicians (AAFP)

Target Audience: All clinicians

Background

This joint guideline presents evidence on benefits and harms of treating to higher versus lower systolic blood pressure (SBP) targets in older adults (age, ≥60) with hypertension. Recommendations are based on a systematic review of randomized controlled trials (for primary outcomes) and observational studies (for harms).

Key Findings

  • All studies showed benefit for hypertension treatment in older adults, most of whom had baseline SBPs >160 mm Hg.

  • With absolute risk reductions (ARRs) expressed as percentage points and adjusted to 5-year time frames, high-quality evidence showed lower all-cause mortality (ARR, 1.64), stroke incidence (ARR, 1.13), and adverse cardiac events (ARR, 1.25) in patients with baseline SBPs ≥160 mm Hg who were treated to achieve SBPs <150 mm Hg.

  • In studies with lower SBP targets (<140 mm Hg) compared with higher targets, low-quality evidence showed no significant relative reductions in all-cause mortality or adverse cardiac events, whereas moderate-quality evidence showed lower risk for stroke (ARR, 0.49). However, many of these studies did not achieve target BPs and failed to show significant BP differences between the intensive treatment and control arms, so they might have been unable to show a difference in clinical outcomes.

  • In patients with histories of stroke or transient ischemic attack (TIA), moderate-quality evidence suggested that treating to SBP of 130 mm Hg to 140 mm Hg lowered risk for stroke recurrence (ARR, 3.02) but not for adverse cardiac events or all-cause death.

  • Evidence was insufficient to evaluate benefit of treating patients who have isolated diastolic hypertension.

  • With regard to harms, low-quality evidence suggested that treating to lower BP targets (achieved SBP range, 121.5−143 mm Hg) heightened risk for syncope.

Recommendations

  • Initiate treatment in older adults with SBP persistently ≥150 mm Hg to achieve a target SBP of <150 mm Hg (strong recommendation, high-quality evidence).

  • In older adults with previous stroke or TIAs, consider treating to <140 mm Hg to lower risk for recurrence (weak recommendation, moderate-quality evidence).

  • In older adults at high cardiovascular (CV) risk, consider treating to <140 mm Hg to lower risk for stroke or adverse cardiac events (weak recommendation, low-quality evidence). Patients at high CV risk include those with known vascular disease, most patients with diabetes, patients with chronic kidney disease (CKD), patients with metabolic syndrome or 10-year CVD risk ≥15%, and older patients (age, ≥75).

Comment

The Joint National Committee (JNC) 8 guideline caused controversy by recommending a higher systolic treatment threshold for older patients than for younger patients and those with diabetes or CKD (<150 vs. <140 mm Hg; NEJM JW Gen Med Jan 15 2014 and JAMA 2014; 311:507). This guideline takes a similar approach and advises a target SBP of <150 mm Hg for older patients (age, ≥60) and suggests that we consider additional lowering of SBP for patients with previous stroke or TIA, or for those at high CV risk. The authors acknowledge the influence of the SPRINT trial in making the latter recommendation for patients at high CV risk. However, note that, in SPRINT, researchers compared SBP targets of 120 mm Hg and 140 mm Hg (although measured BPs probably were lower than typical office BPs, given the SPRINT protocol), and it excluded patients with previous stroke or diabetes (NEJM JW Gen Med Dec 15 2015 and N Engl J Med 2015; 373:2103). A recurring theme within the guideline was the need to individualize treatment goals for each patient.

Editor Disclosures at Time of Publication

  • Disclosures for Jamaluddin Moloo, MD, MPH at time of publication Grant / Research support Colorado Health Foundation

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