What is the recommended treatment for hypertension in a patient over 40?

Treatment of Hypertension in Patients Over 40

Yes, you should administer antihypertensive drugs for patients over 40 with confirmed hypertension, initiating pharmacological treatment promptly when blood pressure is ≥140/90 mmHg regardless of cardiovascular risk, or at ≥130/80 mmHg after 3 months of lifestyle intervention if the patient has high cardiovascular disease risk (≥10% over 10 years). 1

Blood Pressure Thresholds for Drug Initiation

For patients with confirmed BP ≥140/90 mmHg:

• Initiate both lifestyle measures and pharmacological treatment promptly, irrespective of cardiovascular disease risk 1
• This reduces cardiovascular disease risk, stroke, and cardiac events 1

For patients with elevated BP (130-139/80-89 mmHg) and high CVD risk:

• After 3 months of lifestyle intervention, initiate pharmacological treatment if BP remains ≥130/80 mmHg 1
• High CVD risk is defined as ≥10% predicted 10-year risk 1

For patients with elevated BP and low/medium CVD risk (<10% over 10 years):

• BP lowering with lifestyle measures alone is recommended initially 1

Blood Pressure Targets

Target systolic BP of 120-129 mmHg in most adults to reduce CVD risk, provided treatment is well tolerated. 1

• This lower target reduces mortality, stroke incidence, and cardiac events compared to higher targets 1
• If the 120-129 mmHg target is poorly tolerated, apply the ALARA principle (as low as reasonably achievable) 1

First-Line Pharmacological Therapy

Initiate treatment with one of the following drug classes:

• Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide) 1, 2, 3
• ACE inhibitors (e.g., lisinopril, enalapril) 1, 4, 2
• Angiotensin receptor blockers (ARBs) (e.g., candesartan) 1, 2, 3
• Dihydropyridine calcium channel blockers (e.g., amlodipine, extended-release nifedipine) 1, 2, 3

All four classes have demonstrated efficacy in reducing cardiovascular morbidity and mortality 2, 3

Escalation Strategy

If BP is not controlled with a single drug:

• Add a second drug from a different class, preferably in a single-pill combination 1
• Preferred two-drug combinations include: RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB, or RAS blocker + thiazide/thiazide-like diuretic, or CCB + thiazide diuretic 1

If BP is not controlled with a two-drug combination:

• Increase to a three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic, preferably in a single-pill combination 1

Critical pitfall to avoid:

• Never combine two RAS blockers (ACE inhibitor + ARB) together 1

Special Considerations for Age-Related Factors

For patients aged 40-60 years:

• Follow the general recommendations above 1
• Treatment reduces all-cause mortality, stroke, and cardiac events 2, 3

For patients aged 60-85 years:

• Treat according to the same guidelines as younger patients if not moderately to severely frail and treatment is well tolerated 1
• Before initiating or intensifying therapy, test for orthostatic hypotension (measure BP after 5 minutes sitting/lying, then 1 and/or 3 minutes after standing) 1

For patients aged ≥85 years or with moderate-to-severe frailty:

• Maintain BP-lowering treatment lifelong if well tolerated 1
• Consider treatment only from ≥140/90 mmHg in those with pre-treatment symptomatic orthostatic hypotension, clinically significant frailty, or limited predicted lifespan (<3 years) 1
• When initiating treatment, consider long-acting dihydropyridine CCBs or RAS inhibitors first, followed by low-dose diuretics if needed 1

Lifestyle Modifications (Concurrent with Pharmacotherapy)

Implement the following non-pharmacological interventions:

• Weight loss if overweight/obese 2, 3
• Dietary sodium reduction and potassium supplementation 2, 3
• DASH (Dietary Approaches to Stop Hypertension) diet pattern 1, 2
• Increased physical activity 2, 3
• Moderation or elimination of alcohol consumption 2, 3

These lifestyle modifications are partially additive and enhance the efficacy of pharmacological therapy 2

Monitoring and Follow-Up

Once BP is controlled and stable:

• Follow-up at least yearly for BP and other CVD risk factors 1
• Maintain treatment lifelong, even beyond age 85, if well tolerated 1

Important clinical consideration:

• Only 44% of US adults with hypertension have their BP controlled to <140/90 mmHg, highlighting the need for aggressive treatment and monitoring 2