Higher Systolic BP Target Recommended for Older Patients

New guidelines suggest aiming for a systolic pressure less than 150 mm Hg in hypertensive individuals aged 60 or older.
New guidelines suggest aiming for a systolic pressure less than 150 mm Hg in hypertensive individuals aged 60 or older.

The American College of Physicians and the American Academy of Family Physicians have issued new clinical guidelines on hypertension recommending that adults aged 60 years and older be treated to a target systolic blood pressure of less than 150 mm Hg to reduce the risks of early death, stroke, and cardiovascular events.

"The evidence showed that any additional benefit from aggressive blood pressure control is small, with a lower magnitude of benefit and inconsistent results across outcomes," Nitin S. Damle, MD, MS, president of the American College of Physicians, stated in a release. "Most benefits of targeting of less than 150 mm Hg apply to individuals regardless of whether or not they have diabetes."

The new target is higher than some previous recommendations. The American Heart Association, for example, still defines hypertension as 140 mm Hg and above. The SPRINT trial, included in the supporting systematic review, indicated a systolic blood pressure target of less than 120 mm Hg for people without diabetes, but evidence for the lower target has been inconsistent. Lower targets have been linked to hypotension, syncope, and higher medication usage, although not falls, cognitive decline, or renal outcomes such as end-stage renal disease.

Older patients at increased cardiovascular risk – including those with diabetes, chronic kidney disease (estimated glomerular filtration rate below 45 mL/min/per 1.73 m2, metabolic syndrome, and advanced age – should be treated to less than 140 mm Hg to reduce the risk of stroke or cardiovascular events, including fatal and nonfatal myocardial infarction and sudden cardiac death. The guidelines also recommend a target of less than 140 mm Hg for seniors with a history of stroke or transient ischemic attack to prevent future strokes.

The guidelines emphasize accurate measurement of ambulatory blood pressure for diagnosis and monitoring. In most of the included studies, blood pressure was measured after 5 minutes of rest with multiple readings. Many patients have elevated readings in the presence of a health care professional, known as "white coat hypertension."

“Individual assessment of benefits and harms is particularly important in adults aged 60 years or older with multiple chronic conditions, several medications, or frailty,” the authors highlighted in the Annals of Internal Medicine. “These patients might theoretically benefit from more aggressive BP treatment because of higher cardiovascular risks. However, they are more likely to be susceptible to serious harm from higher rates of syncope and hypotension, which were seen in some trials.”

For the guidelines, a committee reviewed data from randomized control trials and observational studies published up to September 2016. The guidelines did not offer diastolic blood pressure recommendations due to weak evidence.

George Bakris, MD, professor of medicine and director of the ASH Comprehensive Hypertension Center at the University of Chicago, disagrees with the guideline recommendations. “The current guidelines do nothing more than rehash what was published by the expert panel a few years ago and do nothing to extend this information. Thus, I find them myopic in scope and nature,” Dr Bakris told Renal & Urology News.

Given the recent data from SPRINT, especially data showing that patients with a mean age of 79.9 years benefited from BP values well into the lower range of 120 mm Hg systolic pressure, Dr Bakris questioned why 2 Japanese studies that were much smaller and 3 other studies formed the basis of the expert panel opinion. In addition, most data are from patients over age 65 years, “so this arbitrary cutoff of age 60 just because the data set evaluated fits this shows no clinical judgment.”

New guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) coming out this year should be more helpful, he said. The 2017 American Diabetes Association guidelines currently recommend systolic blood pressure of less than 140/90 and, if the patient and physician agree, lowered to the range of 125 to 130 mm Hg using conventional blood pressure measurements in the office.

"Given the multiple well-done meta-analyses published over the last 2 years, it is clear that while CKD progression isn't further slowed by very low blood pressure, cardiovascular risk is reduced," Dr Bakris said.

References

  1. 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. doi: 10.7326/M16-1785.
  2. ACP & AAFP release guideline for treatment of hypertension in older adults. American College of Physicians. January 17, 2017. [press release]

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