What are the recommended blood pressure (BP) targets and treatment strategies for older adults with hypertension?

Blood Pressure Recommendations for Older Adults

For adults aged 60 years and older with hypertension, initiate treatment when systolic blood pressure (SBP) is persistently ≥150 mmHg to achieve a target SBP of <150 mmHg to reduce mortality, stroke, and cardiac events. 1

Age-Specific BP Targets

Adults 60-79 years old:

• Primary target: <150/90 mmHg (strong recommendation, high-quality evidence) 1
• Consider more aggressive target of <140/90 mmHg for specific populations:
  • Patients with history of stroke or TIA (to reduce recurrent stroke risk) 1
  • Patients with high cardiovascular risk 1, 2

Adults ≥80 years old:

• Target: <150/90 mmHg 2, 3
• Consider a mean arterial pressure (MAP) of 65-70 mmHg 2
• European Society of Cardiology recommends 130 to <140/70-79 mmHg for patients ≥65 years if tolerated 2

Treatment Algorithm

1. Start with accurate BP measurement:

   • Measure BP in both arms at first visit 2
   • Position patient properly (back supported, legs uncrossed, arm at heart level) 2
   • Consider ambulatory BP monitoring for suspected white coat hypertension 1

2. Begin with non-pharmacological interventions:

   • Mediterranean or DASH diet 2
   • Sodium restriction (<1500 mg/day) 2
   • Regular physical activity (90-150 minutes/week) 2
   • Weight loss if overweight/obese 1, 2
   • Limit alcohol consumption 2

3. Pharmacological treatment:

   • First-line options (consider as combination therapy):

     • RAS blocker (ACE inhibitor or ARB) plus either:
       • Dihydropyridine calcium channel blocker, or
       • Thiazide/thiazide-like diuretic 2
     • Consider fixed-dose single-pill combinations for better adherence 2

   • For morning BP spikes:

     • Administer at least one antihypertensive at bedtime 2
     • Use long-acting medications for 24-hour coverage 2

   • For resistant hypertension (BP ≥140/90 mmHg despite three drugs including a diuretic):

     • Add mineralocorticoid receptor antagonist 2

Special Considerations

High-Risk Populations:

• History of stroke or TIA: Target SBP <140 mmHg 1
• High cardiovascular risk: Consider target SBP <140 mmHg 1

Monitoring and Safety:

• Monitor serum creatinine and potassium after initiation or dose changes of ACE inhibitors, ARBs, or diuretics 2
• Avoid combining two RAS blockers (ACE inhibitor with ARB) due to increased risk of hyperkalemia, syncope, and acute kidney injury 2
• Regularly assess for adverse effects including:
  • Electrolyte disturbances with thiazides
  • Cough and hyperkalemia with ACEIs
  • Dizziness with calcium channel blockers
  • Fatigue with β-blockers 1

Evidence Quality and Controversies

The evidence supporting a target of <150 mmHg for adults aged 60+ is high-quality 1, but there are some controversies in the field:

• Recent Cochrane review (2024) found that lower BP targets (<140/90 mmHg) reduce stroke (high-certainty evidence) and likely reduce serious cardiovascular events (moderate-certainty evidence) compared to higher targets, with unclear effects on all-cause mortality 4

• Some experts advocate for more aggressive targets (<140/90 mmHg) for all older adults 5, while others emphasize caution in the very elderly and frail 3

• The European Society of Cardiology suggests applying the "as low as reasonably achievable" (ALARA) principle if target cannot be reached due to side effects 2

Common Pitfalls to Avoid

1. Treating by numbers alone without considering overall cardiovascular risk and comorbidities
2. Aggressive BP lowering in frail elderly which may increase risk of falls and adverse events 3
3. Ignoring between-arm BP differences >10 mmHg, which may indicate increased cardiovascular risk 2
4. Inadequate attention to medication burden and drug interactions in older adults who may be taking multiple medications 1
5. Failing to address morning BP spikes which correlate with increased cardiovascular events 2

Remember that treatment goals should be periodically discussed with the patient, weighing benefits and harms of specific blood pressure targets 1.