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Hypertension in older adults: What is the target blood pressure?

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We should aim for a standard office systolic pressure lower than 130 mm Hg in most adults age 65 and older if the patient can take multiple antihypertensive medications and be followed closely for adverse effects.

This recommendation is part of the 2017 hypertension guideline from the American College of Cardiology and American Heart Association. 1 This new guideline advocates drug treatment of hypertension to a target less than 130/80 mm Hg for patients of all ages for secondary prevention of cardiovascular disease, and for primary prevention in those at high risk (ie, an estimated 10-year risk of atherosclerotic cardiovascular disease of 10% or higher). The target blood pressure for those at lower risk is less than 140/90 mm Hg.

There are multiple tools to estimate the 10-year risk. All tools incorporate major predictors such as age, blood pressure, cholesterol profile, and other markers, depending on the tool. Although risk increases with age, the tools are inaccurate once the patient is approximately 80 years of age.

The recommendation for older adults omits a target diastolic pressure, since treating elevated systolic pressure has more data supporting it than treating elevated diastolic blood pressure in older people. These recommendations apply only to older adults who can walk and are living in the community, not in an institution, and includes the subset of older adults who have mild cognitive impairment and frailty. The goals of treatment should be patient-centered.

DATA BEHIND THE GUIDELINE: THE SPRINT TRIAL

The Systolic Blood Pressure Intervention Trial (SPRINT) 2 enrolled 9,361 patients who, to enter, had to be at least 50 years old (the mean age was 67.9), have a systolic blood pressure of 130 to 180 mm Hg (the mean was 139.7 mm Hg), and be at risk of cardiovascular disease due to chronic kidney disease, clinical or subclinical cardiovascular disease, a 10-year Framingham risk score of at least 15%, or age 75 or older. They had few comorbidities, and patients with diabetes mellitus or prior stroke were excluded. The objective was to see if intensive blood pressure treatment reduced the incidence of adverse cardiovascular outcomes compared with standard control.

The participants were randomized to either an intensive treatment goal of systolic pressure less than 120 mm Hg or a standard treatment goal of less than 140 mm Hg. Investigators chose drugs and doses according to their clinical judgment. The study protocol called for blood pressure measurement using an untended automated cuff, which probably resulted in systolic pressure readings 5 to 10 mm Hg lower than with typical methods used in the office. 3

The intensive treatment group achieved a mean systolic pressure of 121.5 mm Hg, which required an average of 3 drugs. In contrast, the standard treatment group achieved a systolic pressure of 136.2 mm Hg, which required an average of 1.9 drugs.

Due to an absolute risk reduction in cardiovascular events and mortality, SPRINT was discontinued early after a median follow-up of 3.3 years. In the entire cohort, 61 patients needed to be treated intensively to prevent 1 cardiovascular event, and 90 needed to be treated intensively to prevent 1 death. 2

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Preventing cardiovascular disease in older adults: One size does not fit all

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