From the Guidelines
For older individuals with hypertension and diabetes mellitus, the goal blood pressure should be a systolic blood pressure target of 130-139 mmHg, as recommended by the most recent guidelines 1. This target is based on the latest evidence from the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases, which suggests that optimal blood pressure control reduces the risk of micro- and macrovascular complications in patients with diabetes. Key considerations in managing blood pressure in older adults with diabetes include:
- Initiating treatment with lifestyle modifications, such as reduced sodium intake, regular physical activity, weight management, and limited alcohol consumption
- Using first-line medication options, such as ACE inhibitors or ARBs, which are preferred in diabetic patients due to their renoprotective effects
- Adding second-line agents, such as calcium channel blockers or thiazide diuretics, as needed to achieve target blood pressure
- Individualizing blood pressure management based on comorbidities, fall risk, and medication side effects
- Regularly monitoring blood pressure, with home blood pressure measurements providing valuable information The goal is to reduce cardiovascular risk while avoiding hypotension, which can increase fall risk in older adults, as noted in the 2017 American College of Physicians and American Academy of Family Physicians guideline 1. It's also important to consider the findings from the 2018 American College of Cardiology/American Heart Association hypertension guideline, which recommends initiating antihypertensive drug treatment at a blood pressure of 130/80 mmHg or higher in adults with diabetes, and targeting a blood pressure of less than 130/80 mmHg 1.
From the Research
Goal Blood Pressure for Older Individuals with Hypertension and Diabetes Mellitus
- The goal blood pressure for older individuals with hypertension (HTN) and diabetes mellitus (DM) is a topic of ongoing debate, with various studies and guidelines providing different recommendations 2, 3, 4, 5, 6.
- According to a 2018 review article, clinicians should aim for a blood pressure goal of less than 130/80 mmHg in all elderly patients with hypertension and DM, especially in those with high cardiovascular risk 2.
- A 2016 study suggests that the target blood pressure should be individualized based on concomitant diseases, orthostatic blood pressure changes, and the general condition of the patient, with a recommended target of <140-150/90 mmHg in elderly patients with diabetes 3.
- Other studies recommend a systolic blood pressure goal of <140 mmHg in patients less than 80 years of age and a systolic blood pressure goal of 140-150 mmHg in patients 80 years of age or older 4, 5.
- 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 to 145 mmHg if tolerated in adults aged 80 years and older 5.
- In adults aged 80 years and older with diabetes mellitus or chronic kidney disease, a target goal of less than 140/90 mmHg is considered, while a blood pressure below 150/90 mmHg is recommended in those without these conditions 5.
Considerations for Blood Pressure Management
- The treatment of hypertension in elderly patients with diabetes should take into account the increased susceptibility to brain hypoperfusion with orthostatic hypotension and the risk of drug-drug interactions 4.
- A combination of lifestyle measures and medication is often required to achieve optimal blood pressure control, with thiazide diuretics, angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, or calcium channel blockers considered as initial therapy 2, 6.
- The decision to initiate drug therapy should be individualized based on underlying comorbidities, and the goal of treatment should be to reduce blood pressure while minimizing the risk of adverse effects 4, 6.