A new clinical practice guideline for the pharmacologic treatment of hypertension in adults aged 60 years and older has been published by the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP).
The agencies conducted a systematic review of randomized, controlled trials for primary outcomes and observational studies through January 2015. Evaluated outcomes included all-cause mortality, morbidity and mortality related to stroke, major cardiac events, and harms. The agencies used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) method to evaluate the evidence.
“Appropriate management of hypertension reduces the risk for cardiovascular disease, renal disease, cerebrovascular disease, and death,” the authors of the guidelines wrote in the Annals of Internal Medicine. “However, determining the most appropriate BP [blood pressure] targets, particularly for adults aged 60 years or older, has been controversial.”
The ACP and AAFP recommend that clinicians should start treatment in adults who are 60 years of age and older with systolic blood pressure persistently greater than 150 mm Hg to reduce the risk of mortality, stroke, and cardiac events (Grade: strong recommendation, high-quality evidence).
“Although this guideline did not specifically address pharmacologic versus nonpharmacologic treatments for hypertension, several nonpharmacologic treatment strategies are available for consideration,” the authors noted. Effective nonpharmacologic treatments include lifestyle modifications such as weight loss, changes in diet, and an increase in physical activity. Pharmacologic treatments include antihypertensive medications such as thiazide-type diuretics, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, calcium-channel blockers, and beta-blockers.
The ACP and AAFP also recommend that clinicians initiate pharmacologic treatment in adults 60 years of age and older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk of recurrent stroke (Grade: weak recommendation, moderate-quality evidence).
The agencies also state that clinicians should consider initiating or intensifying pharmacologic treatment in adults 60 years of age and older who have a high cardiovascular risk to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk of stroke or cardiac events (Grade: weak recommendation, low-quality evidence).
Cardiovascular risk should be based on individual assessment, but the agencies state that increased cardiovascular risk generally includes individuals with known vascular disease, most patients with diabetes, older persons with chronic kidney disease with an estimated glomerular filtration rate less than 45 mL/min/per 1.73 m2, those with metabolic syndrome, and older individuals.
For each recommendation, the ACP and AAFP note that treatment goals should be based on discussions with the patient about the benefits and harms of specific blood pressure targets.
The guidelines also state that individual assessment of benefits and harms is particularly important among older individuals with multiple chronic conditions, several medications, or frailty. Although these patients may theoretically benefit from aggressive blood pressure treatment, they are also more susceptible to serious harm from higher rates of syncope and hypotension. This patient population also usually receives multiple medications that are difficult to manage and increase the risk for drug interactions.
“The balance of benefits and harms identified in our evidence report is based in part on rigorous and accurate assessment of BP [blood pressure],” the authors noted. “Some patients may have falsely elevated readings in clinical settings (known as “white-coat hypertension”). Therefore, it is important to ensure accurate BP measurement before initiating or changing treatment of hypertension. The most accurate measurements come from multiple BP measurements made over time.”
- Qaseem A, Wilt TJ, Rich R, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017. doi:10.7326/M16-1785