When to Stop Blood Pressure Maintenance Therapy
Blood pressure-lowering medication should be maintained lifelong, even beyond age 85 years, if well tolerated—discontinuation is not recommended for patients with confirmed hypertension. 1
Lifelong Treatment Recommendation
The 2024 ESC guidelines explicitly state that BP-lowering drug treatment should be maintained lifelong, even beyond the age of 85 years, provided the treatment is well tolerated. 1
The 2020 International Society of Hypertension guidelines do not provide any criteria for stopping antihypertensive therapy once initiated for confirmed hypertension (BP ≥140/90 mmHg). 1
The 2017 ACC/AHA guidelines similarly do not recommend discontinuation of BP medications in patients with established hypertension, emphasizing instead the importance of achieving and maintaining target BP levels. 1
Rare Exceptions Where Temporary Discontinuation May Be Considered
In patients with symptomatic orthostatic hypotension, moderate-to-severe frailty, or limited life expectancy with high burden of comorbidity, a team-based approach using clinical judgment and patient preference may guide decisions about treatment intensity—but this represents dose reduction or simplification, not complete cessation. 1
One older study from the ISH guidelines noted that in a protocol-driven trial, 25.6% of self-measured BP participants permanently stopped treatment when diastolic BP fell below 80 mmHg, suggesting possible white coat hypertension—however, only 64.7% of these patients maintained adequate BP control off medication, indicating most required resumption of therapy. 1
The "As Low As Reasonably Achievable" (ALARA) Principle
When BP-lowering treatment is poorly tolerated and achieving target systolic BP of 120-129 mmHg is not possible, the ESC recommends targeting a systolic BP level that is "as low as reasonably achievable" rather than stopping treatment entirely. 1
This approach prioritizes dose reduction, medication simplification, or switching to better-tolerated agents rather than complete discontinuation. 1
Critical Monitoring Parameters That Do NOT Justify Stopping Treatment
Achievement of target BP (<140/90 mmHg or <130/80 mmHg depending on guidelines) requires continued medication to maintain control—this is not an endpoint for stopping therapy. 1
Age alone, including patients over 80 or 85 years, is not a reason to discontinue BP medications if they are well tolerated. 1
The presence of multiple medications (polypharmacy) should prompt simplification through single-pill combinations rather than discontinuation. 1
Common Pitfall to Avoid
Do not interpret "well-controlled BP" as an indication to stop medications—the control is achieved BECAUSE of the medications, and discontinuation will result in BP elevation and increased cardiovascular risk. 1
Intermittent compliance or discontinuation introduces potential for adverse events, including rebound hypertension with certain drug classes (beta-blockers, clonidine), and loss of cardiovascular protection. 2
Even in apparent treatment-resistant hypertension where BP control provides less cardiovascular protection than in non-resistant hypertension, the strategy should be treatment optimization rather than discontinuation. 3