Hypertension Targets in adults aged 60 years or older: ACP, AAFP guidelines

Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms.

In 21 March 2017, American College of Physicians and the American Academy of Family Physician released guidelines on Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets. Following are the major recommendations :

Recommendation 1: The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) recommend that clinicians initiate treatment in adults aged 60 years or older with systolic blood pressure (SBP) persistently at or above 150 mm Hg to achieve a target SBP of less than 150 mm Hg to reduce the risk for mortality, stroke, and cardiac events. (Grade: strong recommendation, high-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure (BP) targets with the patient.

High-quality evidence showed that treating hypertension in older adults to moderate targets (<150/90 mm Hg) reduces mortality (absolute risk reduction [ARR], 1.64), stroke (ARR, 1.13), and cardiac events (ARR, 1.25). Most benefits apply to such adults regardless of whether they have diabetes. The most consistent and greatest absolute benefit was shown in trials with a higher mean SBP at baseline (>160 mm Hg). Any additional benefit from aggressive BP control is small, with a lower magnitude of benefit and inconsistent results across outcomes.

Although this guideline did not specifically address pharmacologic versus non-pharmacologic treatments for hypertension, several non-pharmacologic treatment strategies are available for consideration. Effective non-pharmacologic options for reducing BP include such lifestyle modifications as weight loss, such dietary changes as the DASH (Dietary Approaches to Stop Hypertension) diet, and an increase in physical activity.

Non-pharmacologic options are typically associated with fewer side effects than pharmacologic therapies and have other positive effects; ideally, they are included as the first therapy or used concurrently with drug therapy for most patients with hypertension. Effective pharmacologic options include antihypertensive medications, such as thiazide-type diuretics (adverse effects include electrolyte disturbances, gastrointestinal discomfort, rashes and other allergic reactions, sexual dysfunction in men, photosensitivity reactions, and orthostatic hypotension), angiotensin-converting enzyme inhibitors (ACEIs) (adverse effects include cough and hyperkalemia), angiotensin-receptor blockers (ARBs) (adverse effects include dizziness, cough, and hyperkalemia), calcium-channel blockers (adverse effects include dizziness, headache, edema, and constipation), and beta-blockers (adverse effects include fatigue and sexual dysfunction).

Most of the included studies measured seated BP after 5 minutes of rest and used multiple readings. Clinicians should ensure that they are accurately measuring BP before beginning or changing treatment of hypertension. Assessment may include multiple measurements in clinical settings (for example, 2 to 3 readings separated by 1 minute in a seated patient who is resting alone in a room) or ambulatory or home monitoring.

Recommendation 2: ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in adults aged 60 years or older with a history of stroke or transient ischemic attack to achieve a target SBP of less than 140 mm Hg to reduce the risk for recurrent stroke. (Grade: weak recommendation, moderate-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of the benefits and harms of specific BP targets with the patient.

Moderate-quality evidence showed that treating hypertension in older adults with previous transient ischemic attack (TIA) or stroke to an SBP target of 130 to 140 mm Hg reduces stroke recurrence (ARR, 3.02) compared with treatment to higher targets, with no statistically significant effect on cardiac events or all-cause mortality.

Recommendation 3: ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk, based on individualized assessment, to achieve a target SBP of less than 140 mm Hg to reduce the risk for stroke or cardiac events. (Grade: weak recommendation, low-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of the benefits and harms of specific BP targets with the patient.

An SBP target of less than 140 mm Hg is a reasonable goal for some patients with increased cardiovascular risk. The target depends on many factors unique to each patient, including comorbidity, medication burden, risk for adverse events, and cost. Clinicians should individually assess cardiovascular risk for patients. Generally, increased cardiovascular risk includes persons with known vascular disease, most patients with diabetes, older persons with chronic kidney disease with estimated glomerular filtration rate less than 45 mL/ min/1.73 m², those with metabolic syndrome (abdominal obesity, hypertension, diabetes, and dyslipidemia), and older persons. For example, among the included studies, SPRINT (Systolic Blood Pressure Intervention Trial) defined patients with increased cardiovascular risk as those meeting at least 1 of the following criteria: clinical or subclinical cardiovascular disease other than stroke; chronic kidney disease, excluding polycystic kidney disease, with an estimated glomerular filtration rate of 20 to less than 60 mL/min/1.73 m² of body surface area; 10-year risk for cardiovascular disease of 15% or greater based on the Framingham risk score; or age 75 years or older. This trial found that targeting SBP to less than 120 mm Hg compared with less than 140 mm Hg in adults without diabetes or prior stroke, at high-risk for cardiovascular disease, and with a baseline SBP of less than 140 mm Hg significantly reduced fatal and nonfatal cardiovascular events and all-cause mortality. In contrast, ACCORD (Action to Control Cardiovascular Risk in Diabetes) included only adults with type 2 diabetes and found no statistically significant reduction in the primary composite outcome of nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular events (relative risk [RR], 0.94 [confidence interval (CI), 0.80 to 1.11]). This study did find a reduction in stroke events (RR, 0.58 [CI, 0.39 to 0.88]), but there were more serious adverse events associated with an SBP target of less than 120 mm Hg versus less than 140 mm Hg.

You can read the full Guideline by clicking on the link :

Qaseem A, Wilt TJ, Rich R, Humphrey LL, Frost J, Forciea MA. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017 Mar 21;166(6):430-7. [49 references] PubMed