Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Pharmacologic Treatment of Hypertension in Older Adults

Ann Intern Med; ePub 2017 Jan 17; Seem, et al

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have jointly developed a clinical practice guideline that provides clinical recommendations on the harms of higher vs lower blood pressure (BP) targets for the treatment of hypertension in adults aged ≥60 years. ACP and AAFP recommend that clinicians select the treatment goals for adults aged ≥60 years based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient. Recommendations include:

  • Recommendation 1: ACP and AAFP recommend that clinicians initiate treatment in adults aged ≥60 years or with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk for mortality, stroke, and cardiac events. (Grade: strong recommendation, high-quality evidence).
  • Recommendation 2: ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in adults aged ≥60 years 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 for recurrent stroke. (Grade: weak recommendation, moderate-quality evidence).
  • Recommendation 3: ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in some adults aged ≥60 years at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for stroke or cardiac events. (Grade: weak recommendation, low-quality evidence).

Citation:

Seem 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. [Published online ahead of print January 17, 2017]. Ann Intern Med. doi:10.7326/M16-1785.

Commentary:

One-third of adults in the U.S. have hypertension and two-thirds of adults aged >60 years have hypertension. The decision of what systolic blood pressure to try to achieve has become quite confusing over the past five years. For about twenty years prior to 2013, the recommended systolic blood pressure target was <140 mm Hg. Then, in December 2013, the Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) was released online and recommended a BP target of <150 mm Hg in persons aged >60 years, with the target for individuals aged <60 years remaining <140 mm Hg.ˡ Moderate- to high-quality evidence suggested that, in persons aged >60 years, a target BP <150/90 mm Hg reduces stroke, heart failure, and coronary heart disease. The panel explicitly stated that a systolic <140 mm Hg provided very little additional benefit. In 2015 the SPRINT trial reported that better outcomes were achieved with a target BP of <120 mm Hg compared to 140 mmHg.² A subsequent sub-group analysis showed this to be true for the patients in the study ≥75 years.³ The SPRINT trial enrolled patients at high CV risk either with existent coronary artery disease or a calculated ten-year risk >15%. The more aggressive target of <120 mmHg lead to the need to use more medications per person, which in turn, led to more adverse effects. The current guideline from ACP/AAFP is a welcome one, reviewing the evidence and essentially concluding that the bulk of the benefit of treatment for patients aged >60 years is obtained with a target BP of <150 mm Hg, and that lower BP targets lead to more side effects. —Neil Skolnik, MD

  1. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.
  2. Wright Jr JT, Williamson JD, Whelton PK, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015;373:2103–2116. doi:10.1056/NEJMoa1511939.
  3. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease out- comes in adults aged ≥75 years: A randomized clinical trial. JAMA. 2016;315(24):2673-2682. doi:10.1001/jama.2016.7050.