Normal Blood Pressure for Elderly Patients
For elderly patients aged 65-79 years, target blood pressure should be 130-139/70-79 mmHg, and for those aged 80 years and older, target 140-150 mmHg systolic, recognizing that more aggressive targets may not be tolerated and could cause harm in the very elderly. 1
Age-Specific Blood Pressure Targets
Patients 65-79 Years Old
- The European Society of Cardiology/European Society of Hypertension recommends 130-139/70-79 mmHg as the target range 2, 1
- The American College of Cardiology/American Heart Association guidelines suggest a more aggressive target of <130/80 mmHg, though this has been criticized for elderly populations who may not tolerate such low pressures 2
- If the lower target cannot be achieved without adverse effects, systolic blood pressure of 130-139 mmHg is acceptable 1
Patients ≥80 Years Old
- Target systolic blood pressure of 140-150 mmHg is recommended 1
- This higher target recognizes that many very elderly patients cannot tolerate systolic blood pressure <140 mmHg, as demonstrated in trials where patients with poor vascular compliance and high pulse pressures were unable to achieve lower targets 2
- The HYVET trial, which studied patients >80 years old, achieved cardiovascular risk reduction with on-treatment systolic pressures that were not <140 mmHg 2
Critical Diastolic Blood Pressure Considerations
- Maintain diastolic blood pressure between 70-90 mmHg in very elderly patients 1
- Avoid reducing diastolic blood pressure below 60 mmHg, as this may compromise coronary perfusion and increase cardiovascular risk 1
- If diastolic blood pressure falls <60 mmHg, consider reducing antihypertensive therapy regardless of systolic blood pressure 1
When to Consider More Lenient Targets (Up to 140-150/90 mmHg)
The following clinical scenarios warrant higher blood pressure targets 1:
- Age ≥85 years
- Pre-treatment symptomatic orthostatic hypotension
- Clinically significant moderate-to-severe frailty at any age
- Limited predicted lifespan (<3 years)
Key Differences Between Major Guidelines
There is significant controversy between American and European guidelines 2:
- ACC/AHA recommends <130/80 mmHg for all adults including elderly, based largely on the SPRINT trial 2
- ESC/ESH recommends 130-139/70-79 mmHg for ages 65-79 and 140-150 mmHg for ≥80 years, emphasizing that SPRINT excluded patients with orthostatic hypotension and those with poor vascular compliance 2
- The ESC/ESH approach provides detailed management of isolated systolic hypertension, which is common in patients >70 years, while ACC/AHA guidelines lack substantive discussion of this critical issue 2
Important Clinical Pitfalls to Avoid
- Do not apply the same blood pressure target to a 30-year-old and an 80-year-old, despite ACC/AHA recommendations suggesting this approach 2
- Monitor closely for orthostatic hypotension, which increases fall risk in the very elderly and was an exclusion criterion in SPRINT 2, 1
- Recognize that isolated systolic hypertension requires different management than combined systolic-diastolic hypertension, with trials demonstrating cardiovascular event reduction even at systolic blood pressures between 140-150 mmHg compared to placebo 2
- Many elderly subjects in systolic hypertension trials were unable to tolerate systolic blood pressure <140 mmHg, yet still achieved clear cardiovascular benefit 2
Treatment Approach
- Start with low doses of antihypertensive medications and titrate slowly 1
- First-line options include thiazide-type diuretics, calcium channel blockers, and ACE inhibitors or ARBs 1
- Allow at least 4 weeks to observe full response to medication adjustments 1
- Aim to achieve target blood pressure control within 3 months, but proceed cautiously in the very elderly 1
Defining Normal vs. Hypertensive Blood Pressure
While treatment targets differ by age, the definition of hypertension remains consistent: