In elderly hypertensive patients, should we sacrifice optimal BP control in the interest of a simpler medication regimen?
—Larissa S. Buccolo, MD, Jacksonville, Fla.

This is always a judgment call. Obviously, if optimal BP control is associated with side effects, a less stringent target BP would be preferable. In a patient without side effects, there are other considerations. What BP are we aiming at? <140/90 mm Hg? <160/90?

Although there is ample evidence that lowering systolic BP below 160 mm Hg is beneficial, it is not clear that further lowering to <140 is beneficial in elderly patients. Is the BP 5 mm Hg above the target, or is it 30 mm Hg too high? I would not add a truckload of medications to achieve an additional 5 mm Hg of BP lowering. I would also assess home BP and standing BP; if either is normal, aggressive treatment of office BP elevation is less warranted. In the very elderly, it might be best to be less aggressive, since there is no evidence that tight BP control is beneficial, and there is evidence that mental functioning is slowed.

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Another factor is cardiovascular risk. An elderly hypertensive patient who is obese, has elevated lipid levels, and smokes is at higher risk of an event than one who is thin, has a normal cholesterol level, and never smoked. It would be reasonable to settle for slightly less control in the latter patient, who is at lower risk.

And finally, there is cost. I would not burden the patient who truly cannot manage the cost just to achieve a few extra millimeters of BP control.
—Samuel J. Mann, MD (101-5)