Hypertension Journal

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Hypertension in the Elderly: A Perspective
Hypertension in the Elderly: A Perspective
Prerna Kapoor1, Aditya Kapoor2
1Department of Medicine, General Hospital, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India
2Department of Cardiology, Sanjay Gandhi PGIMS, LucknowUttar Pradesh, India
Address for correspondence: Aditya Kapoor, Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, Uttar Pradesh, India
E-mail: akapoor65@gmail.com
Received: 13-11-2017; Accepted: 21-12-2017
The elderly is the most rapidly growing demographic subset of world population. Not only does the prevalence of hypertension(HT) increase with age but elderly patients also have existent comorbidities such as coronary artery disease (CAD), congestiveheart failure, chronic renal impairment, stroke, and cognitive decline. Although it may be difficult to provide an exact definition ofelderly, ACCF/AHA guidelines have defined age-specific subgroups as "young old" (65-74 years), "older old" (75-84 years), andthe "oldest old" (>85 years). Due to age-related reduction in vessel distensibility and enhanced vascular stiffness, systolic bloodpressure rises, while diastolic blood pressure plateaus in late middle age, with a slight decline thereafter. Consequently, most elderlyindividuals have isolated systolic HT. Managing HT in elderly patients represents a therapeutic challenge for physicians, and tillrecently, the overall benefits of treating these patients remained unclear. The following review focuses on salient features of HT inthe elderly population along with reappraisal of blood pressure management principles in them.
Keywords: Hypertension, elderly, diagnosis and management
How to cite this article: Tewari S. Hypertension: Where westand and the road ahead. Hypertens 2018;4(1): 1-4.
Source of support: Nil
Conflict of interest: None


Hypertension (HT) as defined by a blood pressure over 140/90mmHg is frequently encountered in elderly individuals andis an important risk factor for cardiovascular morbidity andmortality. Due to an overall longer life expectancy, elderlypatients, especially those older than 80 years, currently representthe fastest growing stratum of society. It is estimated that by2050, approximately 1-5th of the world population will be olderthan 80 years.[1] Due to the age-associated increased prevalenceof HT, most of the elderly are hypertensive. Data from theFramingham Heart Study demonstrated that 90% of thosewho were normotensive at age 55 developed HT and nearlytwo-thirds of males and three-fourths of females develop HTby 70 years of age.[2,3] Management of HT in elderly patients iscomplex and challenging because of existent comorbidities andconcerns related to drug dosages and resultant adverse effects,often leading to poor blood pressure control. Moreover, tillrecently, evidence-based data on management of HT (especiallyin those older than 80 years) were lacking since most trials hadnot exclusively studied patients in this age group.

What is Elderly

Since there is heterogeneity among different individualswith regard to aging, giving an exact definition of elderly isdifficult. Although, in general, individuals with age >65 yearsare considered as elderly, the ACCF/AHA guidelines for the1st time subclassified these into age-specific subgroups, namelythe "young old" (65-74 years), "older old" (75-84 years), andthe "oldest old" (>85 years).[4]

The basic pathophysiology of HT in elderly involves agerelatedchanges in arterial structure and function due to increasedcollagen deposition, calcification with accompanying crosslinking,and degradation of elastin fibers. The resultant reductionin vessel distensibility leads to heightened pulse wave velocity,higher peripheral vascular resistance, and late systolic bloodpressure (SBP) augmentation.[5] The late SBP augmentationis primarily due to the early returning reflected waves from theperiphery which summate with the anterograde waves. Thislate systolic peak imposes an additional load on the heart whichfurther increases the myocardial wall tension. Compared toyounger patients, these patients often have wider pulse pressure,lower intravascular volume, and greater degree of endothelialdysfunction. There is reduction of forward flow due to fall incardiac output (secondary to decreased stroke volume and highperipheral resistance), limiting organ perfusion. Orthostaticdysregulation is common with aging, leading to orthostatichypotension because of associated impaired baroreflexfunction, reduction in venous capacitance, and increasedvenous insufficiency. Orthostatic HT, where BP increases withpostural change, can also occur. Impaired neurohormonalmechanisms are also common in elderly including age-relateddecline in plasma renin activity and increase in peripheralplasma norepinephrine concentration possibly secondary to thereduction in responsiveness to ß-adrenergic receptors.[6] Existentcomorbidities such as CAD, heart failure, atrial fibrillation, renaldysfunction, cerebrovascular disease, cognitive impairment, andperipheral vascular disease further confound the underlyingphysiology.

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Isolated Systolic HT

Due to reduction in vessel distensibility and enhanced vascularstiffness, SBP rises gradually with aging, while DBP plateausin late middle age, with a slight decline thereafter. Expectedly,the prevalence of ISH increases with age and >90% of patientsover the age of 70 years have ISH.[7,8] Previously, the elevationof SBP was thought to be an age-dependent physiologicaladaptive response considered a prerequisite for normal organperfusion. However, now, elevated SBP is rightly perceived to bean independent risk factor for CV events and evidence supportstreating ISH in older patients.[9,10]

Diastolic BP and Pulse Pressure

The decline in DBP with aging is related to the blunted ability ofthe stiff capacitance vessels to adequately expand and contract insystole and diastole, respectively. Due to the age-related plateauand subsequent fall in DBP, only 10-15% of elderly individualshave diastolic HT. In older individuals, the CV risk associatedwith DBP is bimodal; values >90 mmHg and < 65-70 mmHgboth have a similar increased risk. Moreover, the age-relatedfall in DBP implies that with increasing age there is an increasein pulse pressure (SBP-DBP), which increases the pulsatilestress on the arterial system.[11] Hence, in younger individuals,DBP is the strongest correlate of CV risk, which is in contrastto that in the elderly. With increasing age due to the inversecorrelation of DBP to CV risk, pulse pressure is a stronger riskfactor for predicting CV events than SBP, DBP, or mean arterialpressure.[12]

White coat HT, masked HT, pseudo-HT, and orthostatichypotension are all more commonly observed in the elderly.
  1. White coat HT is characterized by BP readings that areconsistently higher than normal (>140/90 mmHg) only inthe clinical setting, while the readings recorded outside, eitherby ambulatory monitoring or self-measurement at home, arenormal. Age-specific trends indicate a 30-50% prevalence ofWCH in 2-4th decades of life, which reaches up to nearly 75%in the eighth decade of life.
  2. Masked HT, on the other hand, is the term used for normaloffice BP readings with high home BP recordings. It is alsoknown as reverse white coat HT, white coat normotension,or isolated ambulatory HT.
  3. Pseudo-HT is common in elderly patients and a commoncause of falsely high SBP reading. It is due to failure ofthe non-distensible, sclerotic arteries to collapse duringsphygmomanometer cuff inflation. This can lead tospuriously high BP readings resulting in overtreatment andoften over escalation of therapy, leading to adverse effects.The possibility of pseudo-HT should be considered whenpersistently high BP readings are documented withoutobvious target organ damage or if the BP is difficult to controlwith usual medications, especially when associated withpostural hypotension. The presence of radial artery pulsethat is still palpable after the cuff has been inflated above theSBP (Osler maneuver) should be performed in such cases,although its usefulness is doubtful. Often, direct intra-arterialmeasurement of BP may be required to confirm pseudo-HT.

  1. Orthostatic hypotension: May be seen in about 15-30% ofthe elderly hypertensives. Normally, on standing, there isa small increase in DBP accompanied by a small decreasein SBP. Orthostatic hypotension is diagnosed when thereis a drop of >20 mmHg (SBP) or >10 mmHg (DBP) inchanging from supine to standing position with or withoutsymptoms which may include dizziness, lightheadedness,giddiness, or even syncope. Postulated causes include agerelatedbaroreflex dysfunction, autonomic insufficiency,hypovolemia, or drug-related adverse effects (especially withthe vasodilator group of anti-HT drugs). Therefore, standingBP measurements are recommended in all elderly patients asa routine, before institution of therapy.

Diagnosis of HT

As per previous recommendations, an SBP >140 mmHg and/or a DBP >90 mmHg (at least three different BP measurementstaken on ≥2 separate occasions) is sufficient to diagnose HT,using an appropriately sized cuff.[13,14] The 2017 ACC/AHAcategorizes BP levels into four levels.[15]
  • Normal: < 120/80 mmHg
  • Elevated: SBP 120-129 mmHg, DBP < 80 mmHg
  • Stage 1 HT: SBP, 130-139 and DBP 80-89 mmHg
  • Stage 2 HT: SBP >140 and DBP >90 mmHg.

No separate diagnostic criteria are listed for the elderly inthese latest guidelines.

Evaluation for postural hypotension or HT is mandatory forall elderly patients. At the time of initial evaluation, it is essentialto measure BP in each arm, and the arm with the highest BPshould be used for future BP measurements.

As for all patients with HT, evaluation of elderly patients withHT essentially involves identification of treatable or secondarycauses, if any; assessing for target organ damage and payingspecial attention to assessment of overall CV risk and othercomorbid associations. Most guidelines recommend estimatingglobal CV risk before initiating therapy. Commonly used globalrisk assessment scoring systems emphasize the importance ofage and most individuals older than 70 years would be classifiedas having high CV risk (>10% risk of CAD in next 10 years).[16,17]According to the ACCF/AHA consensus document, routineextensive laboratory testing in elderly patients with HT is notadvisable.[4] Recommended tests include urinalysis for albuminuriaor microalbuminuria, blood chemistry (fasting blood sugar or A1c ifdiabetes mellitus is suspected, serum potassium, creatinine, eGFR,and lipids including total cholesterol, low-density lipoprotein, highdensitylipoprotein, and triglycerides), and an electrocardiography.

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When to Initiate Therapy

The threshold for initiation for drugs for HT is largelyindependent of age and previous guidelines recommended thateven in elderly patients, pharmacological treatment should bestarted according to the same criteria as used for younger patients(SBPs >140 mmHg or DBP >90 mmHg).[4,18] However, theserecommendations are not actually evidence based (especiallyfor octogenarians) since none of the initial trials of anti-HTdrug therapy in older patients enrolled patients with Grade 1HT (SBP 140-159 mmHg).[19-27] While the previous ACCrecommendations stated that for those older than 80 years of age,antihypertensive drugs may be initiated if SBP is >150 mmHg,NICE 2011 guidelines also recommended that for those olderthan 80 years, pharmacological treatment for HT be initiatedonly when they have Stage 2 HT.[4,28] For elderly patients, whoare already receiving anti-HT therapy and tolerating it well,therapy should be continued when once they attain the age of80 years. Patients older than 80 years and Stage 1 HT shouldreceive drug treatment only if there is associated target organdamage, diabetes, established cardiovascular or renal disease, oran estimated 10-year CV risk >20%.[28]

Based on previous data from trials of antihypertensive therapyin older subjects which consistently found that even intensivetreatment safely reduced the risk of CV outcomes in persons >65,75, and even 80 years, the 2017 ACC/AHA guidelines state thatBP-lowering goals in elderly need not differ from those in persons<65 years of age.[15] Since ASCVD risk assessment is mandatoryin all adults with HT and most older adults (>65 years) have a 10-year ASCVD risk ≥10%, indicating a high-risk category, initiationof antihypertensive drug therapy at BP ≥130/80 mmHg is nowrecommended. For elderly patients with multiple comorbiditieswho may have higher risk of adverse events, a cautious approachto BP reduction and higher targets may be considered.

Non-pharmacological Treatment

As in younger patients with HT, lifestyle modification is animportant part of management. Surprisingly, elderly patients withHT are less likely to receive advice about lifestyle modification.Measures such as weight reduction, cessation of smoking,restriction of excess sodium and alcohol intake, increase in fruitand vegetable intake, and increased physical activity help notonly in direct reduction of BP but may also help reduce dosesof anti-HT drugs and thus limit adverse effects. Weight lossand reduced sodium intake are particularly beneficial in olderpeople. Interestingly, taste sensitivity is often reduced in elderlyand they paradoxically increase their salt intake, hence, makinga recommendation to reduce salt intake very important. Thetrial of non-pharmacologic interventions in the elderly studyreported that weight loss of ∼3.5 kg was effective in loweringSBP/DBP, respectively, by 4.0/1.1 mmHg in patients with HTin the 60-80-year-old age group.[29,30] Dietary sodium restrictionis particular effective in lowering BP in older individuals,probably reflecting the fact that they are more sodium sensitiveas compared to younger patients.[31] Increased potassiumintake (∼90 mmol/day), achieved by enhanced consumptionof fruits and vegetables, is also effective in lowering BP in olderindividuals, especially those with higher dietary sodium intake.However, one may need to monitor serum potassium levels inelderly patients, especially when potassium supplementation isinstituted in those with impaired renal function.

Trials in Elderly Patients with HT

Most initial trials of elderly hypertensive patients providedevidence of reduction of CV outcomes with pharmacologicalmanagement, irrespective of whether the patients had isolatedsystolic HT or both systolic and diastolic HT.[19-27] Althoughalmost all of these included patients aged 60-70 years or more,the number of patients older than 80 years was limited. Specificlong-term outcome data for octogenarians were made availableonly after the publication of the HT in the Very Elderly Trial(HYVET).[32]

Pre-HYVET Trials
  • The European Working Party on high blood pressure in theelderly recruited patients older than 60 years with SBP of 160-239 mmHg or DBP of 90-119 mmHg. Active treatment withhydrochlorothiazide and triamterene resulted in significantreduction in MI, cerebrovascular events, and cardiovascularmortality.[19] There was a significant interaction betweenage and treatment for CV death with little or no benefitdemonstrable in patients older than 80 years.
  • Among patients older than 60 years with SBP >160 andDBP < 90 mmHg enrolled in the SHEP trial, it was observedthat those treated with chlorthalidone 12.5-25 mg (with orwithout stepped care treatment with atenolol 25-50 mg),there was significant reduction in stroke (36%), heart failure(54%), MI (27%), and overall CVD (32%) over a follow-upof 4.5 years.[21]
  • The Swedish trial in old patients with HT studied hypertensivepatients aged 70-84 years (mean BP 195/102 mmHg)randomized to active therapy (with either of three betablockersor a fixed-ratio combination of hydrochlorothiazideand amiloride). Treatment was associated with significant reduction in fatal and non-fatal stroke, myocardial infarction,and total mortality.[22]
  • The Medical Research Council trial randomized patientsaged 65-74 years and HT (SBP 160-209 mmHg and meanDBP < 115 mmHg) to receive hydrochlorothiazide 25-50 mgplus amiloride 2.5 mg or 5 mg daily, atenolol 50 mg daily, orplacebo. There was significant risk reduction in stroke (31%),coronary events (44%), and all cardiovascular events (35%)in the diuretic group compared to placebo; while the betablockergroup demonstrated no significant reduction in theseend points.[23]
  • The European Trial in Systolic HT (Syst-Eur Trial)randomized patients aged >60 years with ISH, to treatmentwith the calcium channel blocker, nitrendipine (10-40 mgdaily), with addition of enalapril (5-20 mg daily) andhydrochlorothiazide (12.5-25.0 mg daily), or matchingplacebo if required. Active treatment was associated withsignificant reduction in stroke (42%), all fatal and non-fatalcardiac endpoints including sudden death (26%) and all fataland non-fatal cardiovascular endpoints (31%). In addition,there was a non-significant reduction in cardiovascular andall-cause mortality.[24]
  • The JATOS study included elderly patients (65-85 years)treated primarily with long-acting dihydropyridine calciumantagonist (efonidipine) either to SBP < 140 mmHg or SBP>140 but < 160 mmHg. Addition of other drugs was allowedas required to reach the assigned treatment goals. The trialdemonstrated no clinical benefit of strict BP control inreducing stroke, coronary heart disease, vascular disease, orrenal impairment. Intensive BP control in elderly patientswas in fact associated an increased incidence of CV events.[27]

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A meta-analysis of these initial trials comprising more than15,000 patients older than 60 years reported that treating isolatedsystolic HT (SBP >160 and DBP < 95 mmHg) substantiallyreduced coronary events by 23%, strokes by 30%, CV deaths by18%, and total mortality by 13%. The benefit was greater in thoseolder than 70 years, males and those with previous cardiovascularcomplications or wider pulse pressure.[33] However, a subgroupmeta-analysis of patients older than 80 years from the trials ofelderly patients with HT (the INDANA subgroup) revealed thatalthough strokes were reduced by 36%, heart failure by 39%, andmajor CV events by 22%, there was a trend toward increased allcause(+14%) as well as CV mortality.[34]

Hence, despite epidemiological evidence that HT is a potentCV risk factor across all age groups, the overall benefits of treatingoctogenarians with HT remained uncertain. Therefore, based onthese data, the JNC 7,8,[13,14] and ESC 2007[35] guidelines statedthat in patients older than 80 years, benefit if any, of anti-HT drugtherapy were inconclusive and no clear-cut recommendationswere provided for them. However, results of the HYVET led to areappraisal of principles of HT management in the elderly.

The HYVET trial exclusively reported on the efficacy ofanti-HT therapy in patients >80 years.[32] Patients with SBP>160 mmHg were randomized either to placebo or nonthiazidediuretic (indapamide) plus, when required, an ACEI(perindopril). Treating to a target SBP of 150 mmHg, led tosignificant reduction in fatal and non-fatal stroke (30%), deathsdue to stroke (39%), heart failure (64%), CV mortality (23%)and all cause death (23%). Not only was drug therapy welltolerated, but fewer serious adverse events were noted in treatedelderly patients. This trial demonstrated for the 1st time thatdrug therapy for HT was beneficial in patients >80 years of age.Since the HYVET trial included only patients without associatedcardiovascular disease who were in good physical and mentalhealth, the extent to which its results can be extrapolated to morefragile elderly patients remains to be seen.

Subsequent Meta-analysis

Meta-analysis post-HYVET study revealed favorable outcomesof treating hypertensive patients older than 75-80 years.Better clinical outcomes with significant reduction in stroke(35%), heart failure (50%), and CV events (27%) were notedamong people aged ≥80 years randomized to antihypertensivedrug treatment versus placebo.[36] In patients aged >75 years,Schall et al. also concluded that treating moderate-to-severeHT reduces non-fatal strokes, cardiovascular morbidity andmortality, and heart failure even though the total mortality ratewas not affected.[37]

SPRINT study: The SPRINT study assigned 9361 patientswith SBP >130 mmHg (and an increased cardiovascular risk,but without diabetes) to an intensive treatment arm (SBP< 120 mmHg) versus standard treatment (< 140 mmHg). The trialwas prematurely terminated at median follow-up of 3.26 years dueto significantly lower primary composite outcome (myocardialinfarction, other acute coronary syndromes, stroke, heart failure,or CV death) in the intensive treatment group. The mean age ofthe SPRINT population was 68 years, and 28% of participantswere >75 years; hence, the results add to the evidence of benefitsof lowering SBP, especially in older patients with HT.[38]

Recommendations regarding drug therapy: It is importantto individualize drug therapy in elderly patients because theyare predisposed to develop drug-induced adverse effects dueto altered drug pharmacokinetics and excretion secondary tounderlying renal and hepatic dysfunction. Since elderly patientstolerate rapid changes in BP poorly, drugs should be started inthe lowest possible doses and gradually uptitrated, dependingon BP response before adding a second agent. If a drug fromanother class has been prescribed as the first line, the seconddrug should always be a diuretic.[4] In cases of inadequate BPresponse even after reaching a maximally tolerated dose of thefirst drug, the second drug from another class may be added. Thethird drug from a different class should be added if the bloodpressure remains outside the optimal range on two drugs. Beforechanging or adding new drugs, possible reasons for inadequateBP response including drug or diet non-compliance, volumeoverload, and white coat and pseudo-HT should be ruled out.

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Although most elderly persons with HT will require >2 drugs toachieve optimal control of blood pressure, the usual strategy ofinitiating two drugs when the baseline BP is >20 mmHg abovegoal should probably be avoided to reduce the risk of adverseeffects.

The choice of initial drug used is less important than thedegree of BP reduction achieved, and different classes ofantihypertensive drugs have been shown to be equally effectivein reducing clinical outcomes in both young and old patients.[39]The use of specific classes of drugs is often influenced by thepresence of any compelling indications (outlined below) aswell as known adverse effects to individual drugs or drugcombinations.

The ACCF/AHA guidelines recommended that for elderlypatients with Stage 1 HT (SBP 140-159 and DBP 90-99 mmHg),the first-line treatment may include an angiotensin-convertingenzyme (ACE) inhibitor, an angiotensin receptor blocker(ARB), a calcium channel blocker, a diuretic, or a combinationthereof.[4] However, beta-blockers should not be used as the firstlinetherapy without a compelling indication to do so (e.g. suchas coronary heart disease, myocardial infarction, congestivefailure, or associated arrhythmias).

For those with Stage 2 HT (SBP >160 and DBP >100mmHg), most patients will require two or more drugs toadequately control the BP. This is especially likely if the initialBP is >20 mmHg higher than the target BP and considerationmust be given to start with combination therapy. The advantagesof combination therapy include better patient compliance andsuperior efficacy at lower doses of individual drugs, leading toreduction in adverse effects. However, whenever combinationtherapy is used in elderly patients, caution must be exercised toavoid orthostatic hypotension. Of the various drug combinations,evidence for clinical outcome reduction is available with diuretic-ACEI, diuretic-ARB, and diuretic-CCB and recently with ACEICCBcombination.[4,40,41]

The NICE 2011 guidelines[28] recommend that for all patientsolder than 55 years, the initial treatment should be with a CCB ora "thiazide-like" diuretic (indapamide/chlorthalidone) in case ofadverse effects or intolerance with the former. An ACEI or ARBmay be added as the second drug if BP remains uncontrolled

Indications for the Use of Specific Drug Classes


In elderly patients with HT and associated CAD/previousmyocardial infarction, beta-blockers are the drug of choice,followed by addition of a long-acting dihydropyridine calciumchannel blocker if required. An ACEI may be added in patientswith impaired LV function/heart failure. Although it is advisableto lower BP to < 130/80 mmHg in patients with CAD, there islimited evidence to support this lower target in elderly patientswith CAD. Among individuals aged 70-80 years, higher riskwas observed if BP is lowered < 135/75 mmHg, while for those>80 years of age, nadir BP for higher risk was 140/70 mmHg.[42]

Heart failure

Drugs of choice for elderly patients with HT include diuretics,beta-blockers, ACEI (ARB if intolerant to ACEI), and analdosterone antagonist if needed. In patients with recurrent orrefractory heart failure, renal artery stenosis should be activelyruled out.


Optimal BP control is necessary to reduce the macrovascularand microvascular complications in elderly hypertensives withconcomitant diabetics; specific drug choice is dictated by theassociated comorbidities. Elderly patients with HT, diabetes,and nephropathy should be treated initially with ACEIs orARBs. Although thiazides may potentially increase the riskof hyperglycemia, in the ALLHAT trial, diuretics conferred asimilar degree of benefit in reducing coronary events in patientswith preexisting diabetes mellitus as compared to those withoutdiabetes.[43]

Renal Impairment

Although specific trial data on clinical outcomes in elderlypatients with HT and CKD are not available, ACEIs/ARBsmay be preferred especially in those with associated proteinuria.Efforts should be made to lower the BP to < 130/80 mmHg, iftolerated.

Previous Stroke

In these cases, initial treatment choices include a diuretic plus anACEI. It is important to remember that reduction of stroke risk isrelated more BP reduction, rather than the use of a specific classof antihypertensive drug.

Goals of Therapy

Target recommendations vary with different guidelines andusually reducing the SBP < 150 mmHg in fit elderly patients isreasonable (if not associated with side effects) and is supportedby JNC 8 and the 2013 ESC/ESH guidelines.

The treatment goals for the elderly as recommended by theACCF/AHA guidelines differ from those of JNC (according towhich target BP for the elderly was similar to that of the generalpopulation).
  • For patients < 80 years of age, goal BP of < 140/90 mmHgis advisable. When SBP < 150 mmHg is readily and safelyobtained with 1 or 2 drugs, further treatment intensification to< 140 mmHg could be considered in patients aged < 80 years.For patients ≥80 years, while the ACC recommends a goal of140-145 mmHg as acceptable.[4]
  • The ESH-ESC 2009[18] and NICE 2011[28] guidelines alsorecommend target SBP < 150 mmHg in patients older than80 years since target BP of < 140 mmHg in these patients maybe associated with intolerable adverse effects.
  • The lowest safely achieved SBP ≥150 mmHg is acceptable forpatients under three circumstances:
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  • Goal is not achieved despite taking a regimen of four wellselectedand appropriately dosed drugs;
  • Prescribed therapy is causing unacceptable side effects;
  • The DBP is being reduced to a potentially dangerous levelof < 65 mmHg.

According to the ESC 2013 guidelines, in elderlyhypertensives < 80 years old with SBP ≥160 mmHg, it isrecommended that SBP be reduced to 140-150 mmHg. In fitelderly patients, < 80 years old, antihypertensive drugs may beconsidered at SBP >140 mmHg with a target SBP < 140 mmHgif no side effects are noted and the treatment is well tolerated.In patients >80 years, with an initial SBP >160 mmHg, it isrecommended to reduce SBP to 140-150 mmHg, providedthey are fit physically and mentally. In the frail elderly, SBP goalsshould be individualized.[44]

How Low To Go?

Although the usual recommended BP goal in uncomplicatedHT is < 140/90 mmHg (with lower intended targets for peoplewith established cardiovascular or renal disease or diabetes),the efficacy and safety of such targets in patients older than80 years have been an area of concern. In a retrospective cohortstudy of more than 4000 patients with HT and aged >80 years,it was observed that lower BP targets (SBP < 139 and DBP < 89mmHg) were associated with lower 5-year survival.[45] Whetherelderly patients with associated comorbidities (includingchronic renal disease, heart failure, and diabetes) require moreintensive BP targets also remain unanswered. The Cardio-Sisstudy demonstrated that elderly patients (65-74 years) treatedto a target SBP < 130 mmHg had lower event rates than thosewith SBP < 140 mmHg.[46] However, the ACCORD study incontrast which reported no reduction in fatal and non-fatal majorCV events among older patients with type 2 diabetes mellitustargeting SBP < 120 mmHg, as compared with those with targetBP < 140 mmHg.[47]

The importance of lowering the DBP below a certain levelalso cannot be overemphasized. Although the optimum DBP tobe achieved by treatment is not clear, the risk of adverse eventsrises when DBP is lowered to < 55 or 60 mmHg, especially inthose with CAD.[48,49] Excessive reduction of BP can increasecardiovascular risk and adversely affect quality of life, especiallyin the elderly and as a general guideline one should avoidlowering SBP below 130 and DBP below 65-70 mmHg.


All elderly patients irrespective of their blood pressure levelsare at risk of cardiovascular events, not only due to their agebut also due to existent comorbid medical conditions. Highblood pressure is an important modifiable CV risk factor inthe older patient population and anti-HT therapy should beconsidered in all aging hypertensive patients, including the veryelderly (>80 years old). Before initiating drug therapy, it may benecessary to confirm HT with ABPM due to higher prevalenceof white coat effect in the elderly. Guideline-directed medicaltreatment is safe and reduces clinical outcomes includingstroke, heart failure, coronary heart disease, as well as CV andall-cause mortality. Available evidence indicates that althoughmost antihypertensive drugs can be safely used in elderly, betablockersshould be avoided as the first-line agents in the absenceof any compelling indications. Most patients need multiple drugsor combination therapy to achieve recommended BP goals.Drugs should be started in lowest possible doses and graduallyuptitrated while closely monitoring for adverse effects. Despitethe data from SPRINT and the 2017 ACC/AHA guidelineswhich state that BP-lowering goals in elderly need not differ fromthose in persons < 65 years of age, for most elderly hypertensivesthe goal BP should be below 140/90 mmHg. For those olderthan 80 years, an achieved SBP 140-145 mmHg is reasonable. Itis vital to remember that in elderly an excessive fall in BP couldbe hazardous and important factors to remember in care forthe elderly are frailty, the presence of comorbidities, and safetyprofile of the drugs being used.

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