New Recommendations on High Blood Pressure in Older Adults
The collaborative efforts of nine health organizations have resulted in new recommendations regarding the treatment of high blood pressure in adults age 65 and older. Details of the recommendations are in the form of an expert consensus document, which falls short of full practice guidelines for now.
Hypertension affects more than half of seniors
The authors of the document reported that the target blood pressure should be less than 140/90 mmHg, although a range of 140 to 145 mmHg would be acceptable for individuals who are 80 years old. Among younger people, a normal blood pressure reading is considered to be less than 120/80 mmHg.
The prevalence of high blood pressure among older adults is a concern: about two-thirds of men and three-quarters of women have hypertension, which is a significant risk factor for heart attack and stroke. Despite the large numbers of seniors with the disease, clinical trials often have not included this age group, which has stymied efforts to know how to treat the disease.
After the results of the Hypertension in the Very Elderly (HYVET) trial were reported in 2008, however, experts moved to work on a consensus document on treatment of high blood pressure in older adults. The results of HYVET showed that among people age 80 and older, reducing blood pressure led to a significant reduction in death from stroke, all-cause death, and heart failure.
The new recommendations have not yet been given full practice guideline status because “the evidence base, the experience with technology, and/or clinical practice are not considered sufficiently well developed to be evaluated by the formal ACC/AHA practice guidelines process,” noted the authors of the document.
In the document, the authors recommended the following:
- Clinicians should take at least three blood pressure readings over two or more office visits before they make a diagnosis of high blood pressure
- Certain patient populations, including individuals who have diabetes, chronic kidney disease, and coronary artery disease, should have a goal of 130/80 mmHg rather than the general target of less than 140/90 mmHg.
- Among individuals who have mild hypertension, lifestyle changes, including stopping smoking, limiting salt intake, maintaining a healthy weight, increasing physical exercise, and limiting alcohol consumption to two or fewer drinks per day may be sufficient to lower blood pressure. If such efforts are not adequate, medication can be considered.
- Patients should start with the lowest dose of a single drug, which can be increased gradually if the dose is inadequate. The recommended first line of treatment should be thiazide diuretics, chlorthalidone, and bendroflumethiazide. If a diuretic is not used as the first drug, it is usually recommended as the second drug if the patient needs it.
- In patients whose blood pressure is greater than 20/10 mmHg over their goal, treatment can be initiated with two drugs.
- Among patients who have coronary artery disease and stable angina or a history of myocardial infarction, the first drug to treat high blood pressure should be a beta-blocker (e.g., atenolol, metoprolol). In patients whose pressure remains high or if angina persists, a long-acting dihydropyridine calcium antagonist should be added to the treatment plan.
The document also provides other treatment recommendations.
The new consensus document, entitled “ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly,” was developed by representatives from the American College of Cardiology Foundation and the American Heart Association, along with the American Academy of Neurology, the American Geriatrics Society, the American Society of Hypertension, the American Society of Nephrology, the American Society for Preventive Cardiology, the Association of Black Cardiologists, and the European Society of Hypertension.
As part of the authors’ closing remarks, they noted that “a limiting factor for therapy in older people is uncertainty about appropriate BP [blood pressure] targets,” and that several trials are now underway in elderly patients to compare the effects of reducing systolic pressure to less than 140 mmHg. The authors pointed out that “these trials and others will hopefully cast more light on 1 key treatment objective in older patients: avoidance of cognitive dysfunction,” which may be accomplished by controlling blood pressure.
Aronow W et al. Journal of the American College of Cardiology 2011: doi:10.1016/j.jacc.2011.01.008