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Hypertension is defined as a systolic blood pressure (SBP) > 120 mmHg and/or a diastolic blood pressure (DBP) > 90 mmHg.1 Approximately 80 million adults in the United States have hypertension and it is predicted that this number will continue to rise.2 Hypertension is among the leading modifiable risk factors for myocardial infarction, stroke, heart failure, and renal disease.2 Much debate exists regarding optimal BP goals, especially in older patients, to reduce the risk of these complications. There is also controversy about what age threshold should be used to differentiate BP goals in patients without co-morbid conditions such as renal disease, diabetes, or cardiovascular disease. Recommendations for BP goals vary among national organizations.
Committee members from the Eight National Joint Commission (JNC 8) recommended the following blood pressure goals in 2014:3
- General patient population (without diabetes or chronic kidney disease (CKD)
- Age < 60: SBP < 140 mmHg and DBP < 90 mmHg
- Age > 60: SBP < 150 mmHg and DBP < 90 mmHg
- Patients with diabetes or CKD, regardless of age
- SBP < 140 mmHg and DBP < 90 mmHg
The following Table includes various BP goal recommendations from several national organizations:
|Guideline/Statement||Patient Group||Goal (mmHg)|
|American Diabetes Association4||Diabetes
Those with diabetes who are younger patients, + albuminuria, and/or hypertension AND one or more additional atherosclerotic CV risk factor
|American Heart Association Prevention/American College of Cardiology/American Hypertension Society5||Age > 80
CAD*, ACS^, or HF#
CAD*, post-MI, stroke/TIA, carotid artery disease, PAD or AAA
|American Society of Hypertension/International Society of Hypertension6||Age 18-79
Age ≥ 80
Chronic kidney disease
|Kidney Disease: Improving Global Outcomes7||No proteinuria
|* a lower target BP may be appropriate for some patients with CAD
^ target BP of < 140/90 mmHg in patients with an ACS who are hemodynamically stable; a target BP of < 130/80 mmHg is a reasonable at time of hospital discharge
# may consider target BP of < 130/80 mmHg
AAA = abdominal aortic aneurysm; ACS = acute coronary syndrome; CAD = coronary artery disease; CV = cardiovascular; HF = heart failure; MI = myocardial infarction; PAD = peripheral arterial disease; TIA = transient ischemic attack
Clinicians raised several concerns regarding the BP goal recommendations provided by JNC8. One concern relates to the age threshold (e.g., 60 years) for the higher BP goal (i.e., < 150/90 mmHg) in the general patient population. The American Heart Association/American College of Cardiology recommends that the BP goal of < 150/90 mmHg be reserved for those over 80 years of age. Data suggest that a less aggressive BP goal for those aged > 60 years would put a significant number of patients with an already elevated cardiovascular risk at higher risk for complications from hypertension.8-10
Importantly, a proportion (28 to 33.1 %) of older patients have isolated systolic hypertension (ISH which is defined as SBP > 140 mmHg and a DBP < 90 mmHg), which occurs due to physiological changes leading to arterial stiffness and decreased compliance.12,13 In landmark clinical trials such as the Systolic Hypertension in the Elderly Program (SHEP) trial and the Systolic Hypertension in Europe (Syst-Eur) trial, and data from meta-analyses, treatment of ISH in patients > 60 years has resulted in a reduction in clinical outcomes such as stroke and cardiovascular events.14-16 SBP goals have been utilized as the target in recent hypertension trials. This is because there is a higher prevalence of ISH in the elderly. Additionally, it is well-established that the ideal DBP is < 90 mmHg in most instances.
In the Hypertension in the Very Elderly Trial (HYVET), patients > 80 years with a SBP of 160-199 mmHg were randomized to indapamide (with the option of perindopril as additional therapy) or placebo to achieve a BP goal of < 150/80 mmHg. The primary endpoint was non-fatal or fatal stroke. The trial was terminated early as there was a lower risk of stroke and all-cause death in the treatment group. At enrollment, the mean age of the 3845 participants was 83.6 years, with 22.4% aged 85-89 years and 4.6% aged 90 years or older. The median duration of follow-up was 1.8 years. At 2 years, 48% of patients in the active-treatment group vs. 19.9% in the comparator group achieved target BP. Treatment was associated with a 21% relative risk reduction in all-cause death (p = 0.02), a 30% non-significant relative risk reduction in fatal or non-fatal stroke (p = 0.06) and a 39% relative risk reduction in fatal stroke (p = 0.05). The benefits of therapy were seen within a year of treatment. Serious side effects were less common in the treatment group.11
Two of the most recent landmark hypertension trials have focused on determining the optimal BP goal for patients with elevated cardiovascular risk. In the Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus (ACCORD BP) study, patients were randomized to intensive (SBP < 120 mmHg) or standard therapy (SBP < 140 mmHg). Patients with type 2 diabetes and risk factors for cardiovascular disease were included. The mean age was 62.2 years with 34% of participants aged > 65 years. There was no difference in the primary endpoint (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death) between groups. There was no difference in the primary endpoint when comparing those < 65 to those > 65 years of age.17
In the Systolic Blood Pressure Intervention Trial (SPRINT), 9361 patients > 50 years of age who were at an increased risk of CV events were randomized to an intensive SBP target (< 120 mmHg) or standard SBP target (< 140 mmHg). Notable exclusion criteria were those with diabetes, history of stroke and an estimated glomerular filtration rate of < 20 ml/min/1.73 m2. The mean age of participants was 67.9 years; 28.2% were > 75 years. The mean baseline SBP was approximately 139 mmHg and over 90% of participants were receiving an antihypertensive agent before enrollment. The primary outcome was the composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular causes. The trial was stopped early, at a median of 3.26 years of follow-up, due to the benefits with intensive BP lowering. The rate of the primary outcome was significantly lower in those randomized to the intensive SBP target (0.41%/year vs. 2.19%/year, p < 0.0001). The risk of heart failure (1.3 %/year vs. 0.67%/year, p = 0.002) and death from any cause (1.03%/year vs. 1.4%/year, p = 0.005) was lower in the intensive group. There was no difference in the rate of the other individual components of the primary outcome between groups. Overall, there was no difference in serious adverse events between groups. Hypotension, syncope, acute kidney injury/renal failure, and serious electrolyte abnormalities were rare but significantly higher in the intensive treatment group.18
In a subsequent paper, the results of those aged > 75 years (n = 2636) enrolled in SPRINT were reported. The primary outcome was again significantly lower with the intensive SBP goal among those 75 years or older (2.59%/year vs. 3.85%/year; hazard ratio 0.66 [95 % confidence interval 0.49 – 0.91)). The effect of intensive therapy on the primary outcome appeared to be more pronounced among those aged > 75 years with a number needed to treat of 27 vs. 61 over a 3 year period in the overall SPRINT results. There was no difference in the rate of serious side effects between groups. There was a lower risk of injurious falls in the intensive treatment group (4.9% vs. 5.5%) and a higher risk of orthostatic hypotension with dizziness in the intensive treatment group (1.9% vs. 1.3%), although neither finding was statistically significant.19
Concerns have also been raised regarding the risk of cognitive impairment with anti-hypertensive use. It is well-established that hypertension during mid-life increases the risk of dementia later in life. It is not clear, at this time, that treating hypertension later in life delays or slows the progression of cognitive decline.20-21 However, there is the risk that too aggressively or abruptly changing blood pressure in older patients can impact cognition. Given the known benefits of treating hypertension, clinicians should follow a common phrase in managing hypertension in older patients – start low, and go slow! If acute cognitive decline occurs with initiation or titration of anti-hypertensive therapy, then therapy should be modified to determine if less aggressive treatment can restore previous cognitive function.
There is no need to sprint to a target BP in older patients. Doing so can increase the risk of side effects, such hypotension, acute kidney injury, and cognitive decline. The effects of anti-hypertensive therapy are not immediate and therefore it is prudent to gradually lower BP to a safe target for patients. BP goals should not be one-size-fits-all. The goal should be tailored based on the presence of co-morbid conditions, fall risk, tolerability of therapy, life-expectancy, and other patient-specific factors.
Given the results of HVYET, SPRINT and other trials, recommendations for BP goals include:
- BP goal < 150/90 mmHg for those > 80 years old without diabetes, chronic kidney or cardiovascular conditions
- BP goal < 140/90 mmHg for those with diabetes and chronic kidney disease regardless of age
- Lower goal may be considered for select patients with elevated cardiovascular risk and/or chronic kidney disease
Kristin Watson, PharmD, BCPS-AQ Cardiology
- Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: the JNC 7 report [published correction appears in JAMA 2003;290(2):197]. JAMA 2003; 28:2560.
- Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics–2015 update: a report from the American Heart Association. [published correction appears in Circulation 2015;131:e53] Circulation 2015;131:e29–e322.
- James PA, Oparil S, Carter BL, et a 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014;311:507-20.
- American Diabetes Association. Cardiovascular disease and risk management. Diabetes Care 2016;39(Suppl.1):S60–S71.
- Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association,American College of Cardiology, and American Society of Hypertension. Circulation 2015;131:e435-70.
- Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens 2014;16:14-26.
- Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Inter., Suppl. 2012; 2: 337–414.
- Borden, WB, Maddox TM, Tang F, et al. Impact of the 2014 expert panel recommendations for management of high blood pressure on contemporary cardiovascular practice: insights from the NCDR PINNACLE registry. J Am Coll Cardiol 2014;64(21):2196-2203.
- Navar-Boggan AM, Pencina MJ, Ken Williams, Sniderman AD, Peterson ED. Proportion of US Adults Potentially Affected by the 2014 Hypertension Guideline. JA2014;311(14):1424-29.
- Miedema MD, Lopez FL, Blaha MJ et al. Implications of the Eighth Joint National Committee Guidelines for the management of high blood pressure for aging adult: Atherosclerosis Risk in Communities Study. Hypertension. 2015;66:474-80.
- Beckett NS, Peters R, Fletcher AE, et al. Treatment of Hypertension in Patients 80 Years of Age or Older N Engl J Med 2008;358:1887-98.
- Liu X, Hoang VM, Liu Y, Brown RL. Untreated Isolated Sytolic Hypertension among Middle-Aged and Old Adults in the United States: Trends in the Prevalence by Demographic Factors During 1999-2010. Int J Chronic Dis 2015;2015:508584.
- Bavishi C, Goel S, Messerli FH. Isolated systolic hypertension: an update after SPRINT. Am J Med 2016;129:1251-58.
- SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991; 265: 3255–64.
- Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet 1997; 350: 757–64.
- Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000;355:865-72.
- The ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362:1575-85.
- The SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015; 373:2103-2116.
- Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years. JAMA 2016;315:2673-82.
- Birns J, Kalra L. Cognitive function and hypertension. J Human Hypertension 2009;23:86-96.
- Iadecola C, Yaffe K, Biller J, et al. Impact of hypertension on cognitive function: a scientific statement from the American Heart Association. Hypertension 2016;68:000-000. DOI: 10.1161/HYP.0000000000000053. Originally published online October 16, 2016.
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