What is an appropriate blood pressure goal for the elderly: review of recent studies and practical recommendations

Abstract

Hypertension is common in the elderly, and isolated systolic hypertension is responsible for the majority of hypertension in this population. Hypertension in the elderly can be attributed to numerous structural and functional changes to the vasculature that develop with advancing age. Increased systolic blood pressure is associated with adverse outcomes, including stroke, cardiovascular disease, and death. Some studies demonstrate an inverse relationship between cardiovascular outcomes and diastolic blood pressure whereas other studies show a J-shaped or U-shaped association between blood pressure and outcomes. The complex J-shaped association coupled with the unique characteristics of elderly patients have led to much debate and confusion regarding the treatment of hypertension in this population. Clinical trials indicate a benefit to therapy in older adults, and there appears to be no age threshold above which antihypertensive therapy should be withheld. Treatment of hypertension in elderly patients is further complicated by increased susceptibility to brain hypoperfusion with orthostatic hypotension as well as the risk of drug-drug interactions. We recommend a systolic blood pressure goal of <140 mmHg in patients less than 80 years of age and a systolic blood pressure goal of 140-150 mmHg in patients 80 years of age or older. Reduction of blood pressure is probably more important than the specific agent used and initiation of drug therapy with an angiotensin converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or diuretic are all reasonable options, and the decision should be individualized based on underlying comorbidities.

Keywords: antihypertensive treatment; blood pressure target; elderly; hypertension.

Figure 1

Mean SBP and DBP by age, race/ethnicity, and sex in the US population; data from NHANES III. Notes: Reprinted with permission from Lippincott Williams and Wilkins/Wolters Kluwer Health: Hypertension, BurtVL, Whelton P, Roccella EJ, et al, Prevalence of hypertension in the US adult population, Results from the Third National Health and Nutrition Examination Survey, 1988–1991, 1995;25(3):305–313. Copyright © 1995. Promotional and commerical use of the material in print, digital or mobile device format is prohibited without the permission from the publisher Lippincott Williams and Wilkins. Please contact journalpermissions@lww.com for further information. Abbreviations: DBP, diastolic blood pressure; NHANES, National Health and Nutrition Education Survey; SBP, systolic blood pressure.

Figure 2

Risk of death in control patients of select randomized controlled trials according to baseline SBP and DBP. Notes: Reprinted from The Lancet, 355(9207), Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials, 865–872. Copyright © 2000, with permission from Elsevier. Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure.

Figure 3

Adjusted hazard ratio for major CV event in relation to SBP (A) and DBP (B) from the Treating to New Targets (TNT) trial. Dotted lines denote upper and lower bounds of the 95% confidence interval. Notes: Reprinted from Eur Heart J, 31(23), Bangalore S, Messerli FH, Wun CC, et al; Treating to New Targets Steering Committee and Investigators. J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial, 2897–2908. Copyright © 2010, with permission from Oxford University Press. Abbreviations: CV, cardiovascular; DBP, diastolic blood pressure; SBP, systolic blood pressure.