What is the management approach for a 71-year-old individual with elevated blood pressure (hypertension) of 134/95 mmHg according to National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries (CKS)?

Management of Hypertension in a 71-Year-Old with BP 134/95 mmHg

For a 71-year-old with a blood pressure of 134/95 mmHg, you should initiate both lifestyle modifications and pharmacological treatment to reduce cardiovascular risk, with a target BP of 120-129/70-79 mmHg. 1, 2

Initial Assessment and Classification

• Your blood pressure of 134/95 mmHg is classified as hypertension (≥140/90 mmHg for systolic or ≥90 mmHg for diastolic) 2
• The elevated diastolic pressure (95 mmHg) is particularly concerning and requires prompt intervention 1
• At age 71, you can be assumed to have at least a 10% 10-year cardiovascular disease risk, placing you in a high-risk category 1

Recommended Treatment Approach

Step 1: Immediate Lifestyle Modifications

• Adopt a Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diet pattern 2, 3
• Reduce sodium intake and increase potassium consumption 3
• Engage in regular physical activity including both aerobic and resistance training (aim for at least 150 minutes per week) 2, 4
• Limit alcohol consumption (preferably avoid completely) 2, 3
• Maintain healthy body weight (BMI 20-25 kg/m²) 2
• Stop tobacco use if applicable 2

Step 2: Pharmacological Treatment

• Begin pharmacological treatment immediately alongside lifestyle modifications due to your age and BP level 1, 2

• First-line treatment options include:

  • Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone, indapamide) 1, 5
  • Calcium channel blockers (e.g., amlodipine) 1, 5
  • Angiotensin receptor blockers (ARBs) or ACE inhibitors 1, 5

• Recommended initial approach: Start with a two-drug combination of a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic, preferably as a single-pill combination 2

• Initial doses should be lower and titration more gradual due to your age, with careful monitoring for orthostatic hypotension 1, 5

Blood Pressure Targets and Monitoring

• Target blood pressure: 120-129/70-79 mmHg 1, 2
• Measure BP in both sitting and standing positions to detect orthostatic hypotension 1, 5
• Monitor BP regularly at home and keep a log to bring to follow-up appointments 2
• Schedule follow-up within 2-4 weeks to assess treatment response and adjust medications if needed 5

Treatment Escalation if Needed

• If BP remains uncontrolled after 2-4 weeks on initial therapy, consider:
  • Increasing medication doses gradually 1
  • Adding a third medication if needed (typically a RAS blocker + calcium channel blocker + thiazide diuretic) 2
• Many elderly patients require two or more drugs to achieve target BP 1

Special Considerations for Your Age Group

• Avoid rapid dose escalation which can lead to orthostatic hypotension and falls 5
• Beta-blockers are not recommended as first-line therapy unless you have specific indications (e.g., coronary artery disease) 5
• Be vigilant for drug side effects which are more common in elderly patients 1
• If you experience symptoms of orthostatic hypotension (dizziness when standing), inform your healthcare provider immediately 1, 5

Expected Benefits

• Proper BP control can reduce your risk of cardiovascular events by approximately 20-30% 6
• Three months of exercise-based lifestyle intervention may produce a reduction in BP of approximately 5 mmHg systolic and 3 mmHg diastolic 4
• Pharmacological treatment with standard doses can reduce office BP by approximately 9/5 mmHg with a single agent and up to 20/11 mmHg with combination therapy 1

Remember that consistent adherence to both lifestyle modifications and medication is crucial for successful blood pressure management and cardiovascular risk reduction 2, 7.