From the Guidelines
For individuals 65 years and above, the blood pressure goal should be less than 130/80 mm Hg. This recommendation is based on the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The guideline suggests that the vast majority of older adults have a 10-year ASCVD risk ≥10%, placing them in the high-risk category that requires initiation of antihypertensive drug therapy at BP ≥130/80 mm Hg.
Key Considerations
- Treatment of elevated BP in older persons can be challenging due to comorbidity, polypharmacy, frailty, cognitive impairment, and variable life expectancy 1.
- However, randomized controlled trials (RCTs) have demonstrated that more intensive treatment safely reduces the risk of CVD for persons over the ages of 65, 75, and 80 years 1.
- BP-lowering therapy is one of the few interventions shown to reduce mortality risk in frail older individuals 1.
- Improved BP control does not exacerbate orthostatic hypotension and has no adverse impact on the risk of injurious falls in noninstitutionalized community-dwelling older persons 1.
Management Approach
- Patients with prevalent and frequent falls, advanced cognitive impairment, and multiple comorbidities should be managed cautiously 1.
- The European Society of Cardiology guidelines also support a systolic BP goal of 130-139 mmHg in older people (aged >65 years) 2.
- Optimal BP control reduces the risk of micro- and macrovascular complications, and guidance on lifestyle changes must be provided for patients with hypertension 2.
Treatment Targets
- The diastolic BP target is <80 mmHg, but not <70 mmHg 2.
- BP control often requires multiple drug therapy with a renin-angiotensin-aldosterone system (RAAS) blocker, and a calcium channel blocker or diuretic 2.
From the Research
Blood Pressure Goals for Individuals 65 Years and Above
The recommended blood pressure (BP) goals for individuals 65 years and above vary depending on the individual's health profile and tolerability.
- For hypertensive patients aged 65-80 years, it is recommended to maintain systolic BP below 130 mmHg 3.
- If well-tolerated, a systolic BP target below 120 mmHg can be recommended for patients with chronic kidney disease (CKD) 3.
- The American College of Cardiology (ACC)/American Heart Association (AHA) 2011 expert consensus document recommends that the blood pressure be reduced to less than 140/90 mmHg in adults aged 60-79 years and the systolic blood pressure to 140 to 145 mmHg if tolerated in adults aged 80 years and older 4.
- 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 4.
- The 2017 American College of Cardiology/American Heart Association hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling persons aged 65 years and older with an average systolic blood pressure of 130 mmHg or higher or a diastolic blood pressure of 80 mmHg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 mmHg 5.
Considerations for Frail or Older Adults
- For frail or older adults, the risk and benefit of antihypertensive therapy can be expected to vary across populations, and some observational evidence suggests that older adults who are frail might have better health outcomes with less aggressive BP lowering 6.
- Clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment in elderly adults with hypertension and a high burden of comorbidities and limited life expectancy 5.
- Randomized clinical trials need to be performed in frail elderly patients with hypertension living in nursing homes, and data on patients older than 85 years treated for hypertension are also sparse 5.