Is hypertension treatment the same for all age groups?

Hypertension Treatment Varies by Age Group

No, hypertension treatment is not the same for all age groups—blood pressure targets and treatment intensity differ significantly based on age, with older adults (≥60 years) generally requiring higher systolic targets than younger patients.

Age-Specific Blood Pressure Targets

Adults Under 60 Years

• Target blood pressure should be <140/90 mm Hg for the general hypertensive population 1, 2
• For adults under 65 years, the American College of Cardiology recommends a more intensive target of <130/80 mm Hg 3, 4
• Diastolic blood pressure is the major predictor of cardiovascular risk below age 50 years 1

Adults 60 Years and Older

• The American College of Physicians and American Academy of Family Physicians recommend initiating treatment at systolic blood pressure ≥150 mm Hg with a target of <150/90 mm Hg 1
• However, for ambulatory, community-dwelling elderly patients, the American College of Cardiology supports a more intensive target of <130 mm Hg 3
• Systolic blood pressure becomes the dominant predictor of cardiovascular risk above age 60 years 1

Adults 75-80 Years and Older

• Evidence from SPRINT subgroup analysis showed that patients aged ≥75 years had lower all-cause mortality with treatment to SBP targets <120 mm Hg compared with <140 mm Hg 1
• For frail patients or those with multiple comorbidities, a more conservative target of 140-145 mm Hg is acceptable 3

Key Physiologic Differences by Age

Blood pressure patterns change fundamentally with aging:

• Until age 50, systolic and diastolic blood pressure rise together 1
• After age 50, systolic blood pressure continues rising while diastolic blood pressure tends to fall 1
• Over 50% of Americans over age 65 have isolated systolic or combined systolic-diastolic hypertension 1
• Fewer than 10% of individuals over age 65 have isolated diastolic hypertension 1

Medication Selection Differences

First-Line Agents for Older Adults

• Thiazide diuretics (particularly chlorthalidone) show the strongest evidence for reducing mortality and cardiovascular events in older adults 3
• Calcium channel blockers (such as amlodipine) are equally effective as diuretics for all cardiovascular events except heart failure 3
• ACE inhibitors and ARBs are well-tolerated but less effective than thiazides and calcium channel blockers for stroke prevention 3

Special Considerations for Older Adults

• Always start at the lowest available dose due to age-related changes in drug metabolism and clearance 3
• Monitor closely for orthostatic hypotension, especially when initiating therapy 3, 5
• For stage 1 hypertension, start with single-agent therapy and titrate sequentially 3
• Exercise extreme caution with two-drug initiation in older patients due to hypotension risk 3

Race-Specific Considerations Across Age Groups

African Americans ≥60 Years

• The Association of Black Cardiologists strongly opposes raising the systolic target to 150 mm Hg in African Americans aged ≥60 years 1
• African Americans have disproportionately higher rates of hypertension-related complications at all ages 6
• Thiazide diuretics or calcium channel blockers are preferred over ACE inhibitors as initial therapy 3, 2
• The black-white life expectancy gap is driven largely by poorly-controlled hypertension 1

Evidence Quality and Controversies

The JNC-8 recommendation to raise the target to <150 mm Hg for those ≥60 years remains controversial:

• This recommendation was based on strict evidence-based criteria but only achieved simple majority support among panel members 1
• The SHEP trial demonstrated significant benefit treating patients ≥60 years to an average systolic blood pressure of 143 mm Hg, with 36% lower stroke rate and 27% lower coronary events 1
• Meta-analyses support treating to <140 mm Hg in older adults 1
• The European guidelines, International Hypertension Society, and American Society of Hypertension all maintained the <140 mm Hg target 1

Treatment Benefits Across Age Groups

Cardiovascular risk reduction is consistent but absolute benefits increase with age:

• Each 10 mm Hg systolic blood pressure reduction decreases cardiovascular events by approximately 20-30% at all ages 4
• For any given systolic blood pressure, the absolute risk of fatal coronary artery disease is 16-fold higher in persons aged 80-89 years compared to those aged 40-49 years 1
• Treatment reduces mortality, stroke, and cardiac events across all age groups, but the absolute benefit is greater in older adults due to higher baseline risk 1

Critical Safety Differences by Age

Older adults face distinct treatment-related risks:

• Low-quality evidence showed increased risk for syncope with lower blood pressure targets (RR 1.52) 1
• Treatment to lower targets increased withdrawals due to adverse events in 4 out of 10 trials, with cough and hypotension most common 1
• No difference in cognitive decline, dementia, fractures, quality of life, or falls between higher versus lower targets 1
• Sodium restriction and weight reduction produce larger blood pressure reductions in older adults compared to younger patients 3

Practical Algorithm for Target Selection

For patients 60-79 years without significant comorbidities:

• Target <140/90 mm Hg, with consideration for <130/80 mm Hg if ambulatory and community-dwelling 3, 2

For patients ≥80 years or frail:

• Target 140-150/90 mm Hg, individualizing based on tolerability 3

For African Americans ≥60 years:

• Maintain target <140/90 mm Hg due to disproportionate risk of end-organ damage 1, 6

For patients with diabetes at any age:

• Target <140/80 mm Hg, with consideration for closer to 130/80 mm Hg for highest cardiovascular risk 7

For patients with history of stroke/TIA:

• Target 130-140 mm Hg systolic to reduce stroke recurrence 1