What are the recommended blood pressure parameters for adults with hypertension or at high risk of cardiovascular events, considering factors such as age, comorbid conditions like diabetes, kidney disease, or heart failure, and potential risks of overly aggressive blood pressure lowering?

Blood Pressure Parameters for Holding Antihypertensive Medications

For most adults on antihypertensive therapy, consider holding medications when systolic blood pressure falls below 100-110 mmHg or diastolic blood pressure falls below 60 mmHg, particularly if accompanied by symptoms of hypotension such as dizziness, lightheadedness, or orthostatic symptoms. 1

Risk-Stratified Approach to Medication Holding

General Adult Population (Age <60 years)

• Hold medications if systolic BP <100 mmHg or diastolic BP <60 mmHg, especially with symptomatic hypotension 1, 2
• Target BP for treatment is <130/80 mmHg, so holding parameters should account for excessive lowering beyond this goal 1, 2
• Consider holding if patient experiences orthostatic hypotension (drop >20 mmHg systolic or >10 mmHg diastolic upon standing) 1

Elderly Patients (Age 60-79 years)

• Hold medications if systolic BP <110 mmHg or diastolic BP <60 mmHg 1
• Treatment target is <140/90 mmHg in this population per ACP/AAFP guidelines, with more conservative holding parameters appropriate 1
• Monitor closely for adverse effects including syncope, falls, and acute kidney injury which occur more frequently with intensive BP lowering 1

Very Elderly Patients (Age ≥80 years)

• Hold medications if systolic BP <120 mmHg or diastolic BP <65 mmHg 1, 3
• This population has higher risk of adverse events from overly aggressive BP lowering 1, 3
• Frail elderly patients require even more cautious approach with holding threshold of systolic BP <130 mmHg 3, 4

Special Populations Requiring Modified Holding Parameters

Heart Failure Patients (HFrEF or HFpEF)

• Hold medications if systolic BP <100 mmHg with symptoms 1
• Target BP is <130/80 mmHg for HF patients, but guideline-directed medical therapy (GDMT) should be maintained when possible 1
• ACE inhibitors, ARBs, and beta-blockers are essential for mortality benefit and should only be held for significant hypotension 1

Post-Stroke or TIA Patients

• Hold medications if systolic BP <110 mmHg 1
• Target systolic BP is <140 mmHg for stroke prevention, with moderate-quality evidence supporting this target 1
• More conservative holding parameters needed due to cerebral perfusion concerns 1

Diabetes Mellitus

• Hold medications if systolic BP <110 mmHg or diastolic BP <60 mmHg 1
• The ACCORD trial showed increased serious adverse events with intensive BP lowering (target <120 mmHg) in diabetic patients 1
• Monitor for orthostatic hypotension which is more common in diabetic patients with autonomic neuropathy 1

Chronic Kidney Disease

• Hold medications if systolic BP <110 mmHg with symptoms or acute kidney injury 1
• Target BP is <130/80 mmHg for CKD patients 1
• Monitor serum creatinine and potassium closely, holding medications if creatinine rises >30% from baseline 1

Clinical Assessment Before Holding Medications

Symptomatic Indicators for Holding

• Dizziness, lightheadedness, or presyncope - hold medications regardless of absolute BP value 1, 5
• Orthostatic hypotension - drop >20/10 mmHg upon standing warrants medication adjustment 1
• Fatigue or weakness disproportionate to clinical condition 1
• Acute kidney injury - creatinine elevation >30% from baseline 1

Measurement Technique Considerations

• Office BP measurements are typically 5-10 mmHg higher than research protocol measurements 1
• Ensure proper measurement: 5 minutes seated rest, empty bladder, correct cuff size, arm supported at heart level 1, 2
• Multiple readings separated by 1 minute should be obtained before making holding decisions 1
• Home BP monitoring provides more accurate assessment, with holding threshold approximately 5 mmHg lower than office values 2, 6

Common Pitfalls and Caveats

Avoid Premature Medication Holding

• Single low BP reading without symptoms does not mandate holding medications 1, 2
• Confirm with repeat measurement and assess for symptoms before withholding therapy 1
• Consider time of day and recent medication timing - trough levels may show higher BP 5

High-Risk Situations Requiring Caution

• Patients with high comorbidity burden are more susceptible to adverse effects from both high and low BP 1
• Multiple chronic conditions increase risk of medication-related harm, requiring individualized holding parameters 1
• Frail patients with limited functional status need more conservative approach 1, 3

Medication-Specific Considerations

• Beta-blockers should not be abruptly discontinued due to rebound hypertension and tachycardia risk 1
• ACE inhibitors and ARBs in heart failure patients provide mortality benefit independent of BP lowering 1
• Diuretics may need holding before other agents if volume depletion suspected 1

Practical Algorithm for Medication Holding Decisions

Step 1: Measure BP properly with patient seated, rested 5 minutes, correct technique 1, 2

Step 2: Assess for symptoms (dizziness, lightheadedness, orthostatic changes) 1, 5

Step 3: Apply age-specific thresholds:

• Age <60: Hold if systolic <100 mmHg or diastolic <60 mmHg with symptoms 1, 2
• Age 60-79: Hold if systolic <110 mmHg or diastolic <60 mmHg 1
• Age ≥80: Hold if systolic <120 mmHg or diastolic <65 mmHg 1, 3

Step 4: Consider comorbidities requiring modified thresholds (HF, CKD, diabetes, stroke history) 1

Step 5: If holding indicated, withhold one medication (typically most recent addition or diuretic first) and reassess in 24-48 hours 1, 5