What are the guidelines for starting antihypertensive treatment in individuals over 60 with hypertension?

Guidelines for Starting Antihypertensive Treatment in People Over 60

Initiate antihypertensive treatment when systolic blood pressure is persistently at or above 150 mmHg, targeting a systolic blood pressure of less than 150 mmHg to reduce mortality, stroke, and cardiac events. 1

Standard Treatment Threshold and Target

General Population Over 60

• Start treatment at SBP ≥150 mmHg with target <150 mmHg (strong recommendation, high-quality evidence) 1
• This threshold applies to most adults aged 60 years or older without specific high-risk conditions 1
• Treatment at this threshold reduces all-cause mortality (absolute risk reduction 1.64%), stroke (ARR 1.13%), and cardiac events (ARR 1.25%) 1
• The greatest absolute benefit occurs in patients with baseline SBP >160 mmHg 1

Lower Targets for High-Risk Subgroups

History of Stroke or TIA

• Consider initiating or intensifying treatment to achieve SBP <140 mmHg (weak recommendation, moderate-quality evidence) 1, 2
• This lower target reduces risk of recurrent stroke 1

High Cardiovascular Risk

• Consider SBP target <140 mmHg based on individualized assessment (weak recommendation, low-quality evidence) 1
• High cardiovascular risk includes established cardiovascular disease or 10-year ASCVD risk ≥10% 3, 2
• Patients with diabetes should target <140/80 mmHg, with consideration for closer to 130/80 mmHg if at highest cardiovascular risk 3

Chronic Kidney Disease

• Target <130/80 mmHg for patients with CKD, particularly if albuminuria is present 2
• Use ACE inhibitor or ARB as preferred agents when albuminuria is present 2

Pre-Treatment Requirements

Accurate Blood Pressure Measurement

• Confirm persistently elevated blood pressure before initiating treatment 1
• Consider ambulatory blood pressure monitoring for patients with elevated clinic readings to rule out white coat hypertension 1

Baseline Assessment

• Measure both systolic and diastolic blood pressure 1
• Assess for orthostatic hypotension, particularly in patients ≥80 years 2
• Evaluate cardiovascular risk factors and comorbid conditions 1, 3
• Screen for history of stroke, TIA, heart failure, or chronic kidney disease 1

Treatment Approach

Lifestyle Modifications

• Initiate or continue concurrently with pharmacologic treatment 1
• Weight loss, DASH diet, and increased physical activity are effective non-pharmacologic options 1

Pharmacologic Selection

• First-line agents: thiazide-type diuretics, ACE inhibitors, ARBs, calcium-channel blockers 1, 2
• Prescribe generic drugs where available 1
• Consider treatment burden and drug interactions, as many older adults take multiple medications 1
• Two or more antihypertensive medications typically required to achieve BP target <130/80 mmHg 2

Specific Agent Considerations for Elderly

• Hydrochlorothiazide: Start with lowest available dose (12.5 mg) in elderly patients (>65 years), as greater blood pressure reduction and increased side effects may occur; use 12.5 mg increments for titration 4
• Amlodipine: Lower initial dose may be required in elderly patients due to decreased clearance resulting in 40-60% increase in AUC 5

Monitoring Schedule

Initial Phase

• Follow-up within first 2 months after initiating treatment to assess efficacy and tolerability 3, 2

Maintenance Phase

• Once target BP achieved, monitor every 3-6 months 3, 2

Important Caveats and Safety Considerations

Patients Who May Be Harmed by Aggressive Treatment

• Age >80 years without cardiovascular disease 6
• Moderate to severe frailty, cognitive impairment, or functional limitations 6
• Labile blood pressure and/or history of orthostatic hypotension, syncope, or falls 6
• Life expectancy <12 months 6
• For patients ≥85 years with pretreatment symptomatic orthostatic hypotension, consider more lenient target (e.g., <140/90 mmHg) 2

Diastolic Blood Pressure Floor

• Never reduce diastolic BP to <60 mmHg in any older person, regardless of systolic target 6
• Diastolic BP should optimally target 70-79 mmHg 2

Adverse Events to Monitor

• Increased risk of cough, hypotension, and syncope with lower BP targets 1
• Electrolyte disturbances (hypokalemia, hyperkalemia, hyponatremia) 1
• Acute kidney injury 1
• Orthostatic hypotension 1, 4
• No increased risk of falls, fractures, or cognitive decline with treatment 1

Shared Decision-Making

• Select treatment goals based on periodic discussion of benefits and harms with the patient 1
• Balance cardiovascular risk reduction against treatment burden and potential adverse effects 1