What is the optimal blood pressure goal for elderly patients with hypertension?

From the Guidelines

The blood pressure goal for hypertensive elderly patients should typically be below 130/80 mmHg for most individuals, though this may be adjusted to below 140/90 mmHg for very elderly patients (over 80) or those with multiple comorbidities. This recommendation is based on the most recent and highest quality evidence, including the 2017 American College of Cardiology/American Heart Association hypertension guideline 1.

Key Considerations

• Treatment should begin with lifestyle modifications including sodium restriction, regular physical activity, weight management, and limiting alcohol consumption.
• When medications are needed, first-line options include thiazide diuretics, calcium channel blockers, or ACE inhibitors or ARBs.
• Medication should be started at lower doses and titrated gradually to avoid orthostatic hypotension, falls, and electrolyte disturbances.
• Regular monitoring of blood pressure, kidney function, and electrolytes is essential, particularly during dose adjustments.

Individualized Approach

The approach should be individualized based on comorbidities, frailty status, and medication tolerance. The rationale for these targets balances cardiovascular risk reduction with the higher risk of treatment-related adverse effects in elderly patients, recognizing that overly aggressive blood pressure lowering can lead to increased falls, cognitive impairment, and kidney dysfunction in this vulnerable population 1.

Recent Guidelines

Recent guidelines, such as the 2021 guideline-driven management of hypertension, also support a treatment goal of <130/80 mmHg for most older adults, with an individualized approach for those with a high burden of comorbidity and limited life expectancy 1.

Evidence-Based Practice

In clinical practice, evidence-based guidelines should be followed, and treatment goals should be tailored to the individual patient's needs and risk factors. The goal is to reduce morbidity, mortality, and improve quality of life for hypertensive elderly patients.

From the FDA Drug Label

If goal blood pressure (<140/90 mmHg) was not reached, hydrochlorothiazide (12.5 mg) was added first and, if needed, the dose of losartan or atenolol was then increased to 100 mg once daily. The blood pressure goal for hypertensive elderly is less than 140/90 mmHg 2.

From the Research

Blood Pressure Goals for Hypertensive Elderly

• The blood pressure goal for hypertensive elderly patients varies depending on their age, health status, and other factors 3, 4, 5, 6, 7.
• For older patients (60-79 years of age), an initial blood pressure treatment goal is less than 140/90 mmHg 3, while for the nonfrail elderly, the goal is less than 150/80 mmHg 3.
• The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document recommends reducing blood pressure to less than 140/90 mmHg in adults aged 60-79 years and to 140-145 mmHg in adults aged 80 years and older 5.
• Other guidelines, such as the European Society of Hypertension (ESH)/European Society of Cardiology (ESC) 2013 guidelines and the 2013 Canadian Hypertension Education Program guidelines, also recommend reducing blood pressure to less than 140/90 mmHg in adults aged 60-79 years 5.
• For adults aged 80 years and older, a blood pressure below 150/90 mmHg has been recommended, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease 5.
• Recent studies suggest that it is reasonable to target an office systolic blood pressure of less than 130 mmHg in elderly patients with hypertension, with an individualized approach for those who are institutionalized, have high comorbidity burden, or have a short life expectancy 6.
• The method of blood pressure measurement is extremely important to consider when determining the blood pressure goal, and proper procedures for accurate blood pressure measurement must be followed 6.

Considerations for Optimal Blood Pressure Goals

• Comorbidities, frailty, and potential for adverse drug reactions should be considered when determining the blood pressure goal for hypertensive elderly patients 4, 6.
• The patient's life expectancy, functional status, and cognitive function should also be taken into account when making treatment decisions 7.
• Automated blood pressure monitoring in a quiet room can provide accurate blood pressure measurements, and treatment goals can be adjusted accordingly 7.
• High-risk persons aged 75 years and older may require more aggressive blood pressure management, with a goal of less than 120/80 mmHg, but should be carefully monitored for serious adverse events 7.