What are the guidelines for hypertension management by age range?

Guidelines for Hypertension Management by Age Range

The most current guidelines recommend a systolic blood pressure (SBP) target of 120-129 mmHg for most adults with hypertension, provided the treatment is well tolerated, with a diastolic blood pressure (DBP) target of <80 mmHg. 1

Definition and Diagnosis of Hypertension

• Hypertension is defined as persistent office blood pressure (BP) ≥140/90 mmHg 2
• Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg also confirms hypertension diagnosis 2
• Normal BP is <130/85 mmHg, while high-normal BP is 130-139/85-89 mmHg 2
• For diagnosis, use validated BP measuring devices with appropriate cuff size 2

Age-Specific BP Targets

Adults <65 Years

• Target BP: <130/80 mmHg 1, 3
• This target is recommended for most adults, including those with diabetes or chronic kidney disease 2, 3
• For those with high cardiovascular risk, treatment should be initiated at BP ≥130/80 mmHg 2

Adults 65-80 Years

• Target BP: 120-129 mmHg systolic (if well tolerated) 2, 1
• If lower target cannot be achieved without adverse effects, a systolic BP target range of 130-139 mmHg is recommended 2
• The 2017 ACP/AAFP guidelines suggested a higher target of <150 mmHg systolic for adults ≥60 years, but more recent evidence supports lower targets 2, 4

Adults >80 Years

• Target BP: 130-139 mmHg systolic (individualized based on frailty) 2
• BP-lowering treatment should be maintained lifelong, even beyond age 85, if well tolerated 2
• The HYVET trial demonstrated benefits of treating to <150/90 mmHg in this population 2, 5

Special Populations

Diabetes

• Target BP: <130/80 mmHg 2, 1
• For older patients (≥65 years) with diabetes, target systolic BP range of 130-139 mmHg 2

Chronic Kidney Disease

• Target BP: 120-129/70-79 mmHg if eGFR >30 mL/min/1.73 m² 2
• For moderate-to-severe CKD, individualized targets are recommended 2
• RAS blockers are preferred for patients with albuminuria 2

Pregnancy

• For gestational or chronic hypertension in pregnancy, treatment is recommended when BP ≥140/90 mmHg 2
• Target BP: <140/90 mmHg but not below 80 mmHg for diastolic BP 2
• Systolic BP ≥170 mmHg or diastolic BP ≥110 mmHg in pregnancy is an emergency requiring hospitalization 2

Treatment Approach

Initial Assessment

• Grade 1 Hypertension (140-159/90-99 mmHg): Start lifestyle interventions for all; start drug treatment immediately for high-risk patients or after 3-6 months of lifestyle intervention for others 2
• Grade 2 Hypertension (≥160/100 mmHg): Start drug treatment immediately along with lifestyle interventions 2

Pharmacological Treatment

• First-line medications: ACE inhibitors/ARBs, calcium channel blockers, and thiazide/thiazide-like diuretics 2, 3
• For most patients, combination therapy is often needed to achieve target BP 1
• For non-Black patients: Start with low-dose ACE inhibitor/ARB, then add calcium channel blocker and/or thiazide-like diuretic 2
• For Black patients: Start with calcium channel blocker and/or thiazide-like diuretic 2, 6
• Consider monotherapy in low-risk grade 1 hypertension and in patients aged >80 years or frail 2

Monitoring and Follow-up

• After initiating treatment, follow-up within 2 months 1
• Aim to achieve target BP within 3 months 2, 1
• Once target BP is achieved, monitor every 3-6 months 1
• Check for orthostatic hypotension before starting or intensifying BP-lowering medication, especially in older adults 2

Common Pitfalls to Avoid

• Not checking for orthostatic hypotension in older adults 2
• Using inappropriate cuff size leading to inaccurate BP measurements 2
• Not considering combination therapy early enough to achieve targets 1
• Combining two RAS blockers (ACE inhibitor and ARB), which is not recommended 2
• Stopping medications in older adults without clear indication, as lifelong treatment is recommended if tolerated 2

Recent evidence from multiple clinical trials supports lower BP targets across age groups, with appropriate individualization based on tolerability and comorbidities 1, 4.