At what blood pressure reading would you initiate antihypertensive medication in a 69-year-old woman with no cardiovascular (CV) risk factors?

From the Guidelines

For a 69-year-old woman with no cardiovascular risk factors, I would recommend initiating antihypertensive medication when her blood pressure consistently reads 130/80 mmHg or higher across multiple visits. This recommendation is based on the 2017 American College of Cardiology/American Heart Association hypertension guideline, which suggests that adults aged 65 years or older are in the high-risk category for ASCVD 1.

Key Considerations

• The guideline recommends a blood pressure target of less than 130/80 mmHg for all adults with hypertension, regardless of ASCVD risk 1.
• A recent systematic review and network meta-analysis showed continuing reduction in CVD risk at progressively lower levels of achieved SBP 1.
• The choice of antihypertensive drug therapy should be based on the patient's individual characteristics, with thiazide diuretics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers being suitable options for first-line therapy 1.

Treatment Approach

• Treatment should begin with a low dose of a single agent, with follow-up in 2-4 weeks to assess efficacy and tolerability.
• Lifestyle modifications should be implemented alongside medication, including sodium restriction, regular physical activity, weight management, and limiting alcohol consumption.
• The rationale for treating hypertension in older adults is to reduce the risk of cardiovascular events, stroke, heart failure, and kidney disease, as age itself is a significant risk factor for cardiovascular complications even in the absence of other traditional risk factors.

Monitoring and Follow-up

• Before starting medication, it's essential to confirm the elevated readings with proper technique, including having the patient seated quietly for 5 minutes before measurement, using the correct cuff size, and averaging multiple readings.
• Regular follow-up appointments should be scheduled to monitor blood pressure, adjust medication as needed, and reinforce lifestyle modifications.

From the Research

Blood Pressure Threshold for Initiating Antihypertensive Medication

• The current treatment threshold for hypertensive adults without diabetes or cardiovascular or renal disease is blood pressure above 160/100 mmHg or 160/90 mmHg, with some uncertainty over which diastolic threshold should be used 2.
• However, other guidelines recommend initiating antihypertensive drug treatment when systolic blood pressure is at least 140 or diastolic blood pressure at least 90 mmHg in patients with grade 1 hypertension and low or moderate total cardiovascular risk 3.
• For adults aged 60-79 years, the recommended blood pressure goal is less than 140/90 mmHg, while for adults aged 80 years and older, a blood pressure below 150/90 mmHg is recommended, with a target goal of less than 140/90 mmHg considered in those with diabetes mellitus or chronic kidney disease 4.

Considerations for a 69-Year-Old Woman with No Cardiovascular Risk Factors

• Based on the guidelines, for a 69-year-old woman with no cardiovascular risk factors, the blood pressure threshold for initiating antihypertensive medication would be above 160/100 mmHg or 160/90 mmHg 2.
• However, considering other guidelines, initiating antihypertensive drug treatment may be recommended when systolic blood pressure is at least 140 or diastolic blood pressure at least 90 mmHg 3.
• As she is below 80 years old, the recommended blood pressure goal would be less than 140/90 mmHg 4.