Consensus document advises treating hypertension in those age 80 or older

Major medical organizations last week released an expert consensus document to help clinicians manage older patients with or at risk for hypertension.

While 64% of U.S. men and 78% of U.S. women older than age 80 years have high blood pressure, only one in three men and one in four women have adequate control of their blood pressure, the document noted. Results from the Hypertension in the Very Elderly Trial (HYVET) in 2008 showed clear benefits for using antihypertensive therapy in people age 80 years and older, including a 30% reduction in stroke, 23% reduction in cardiac death, 64% reduction in heart failure and 21% reduction in all-cause mortality. That study became the main impetus for the new consensus document, which was published online April 25.

Some of the consensus recommendations addressed in the consensus document include the following:

• Targeting blood pressure less than 140/90 mm Hg in persons age 65 to 79 years and a maximum systolic blood pressure between 140 and 145 mm Hg in persons 80 years and older (if tolerated) was discussed.
• Angiotensin-converting enzyme inhibitors, beta-blockers, angiotensin-receptor blockers, diuretics and calcium-channel blockers are all effective in lowering blood pressure and reducing cardiovascular events among the elderly. The choice between drugs should be based on efficacy, tolerability, comorbidities and cost.
• Antihypertensive drugs should generally be started at the lowest dose, then increased in gradual increments as tolerated. If the first drug reaches its maximum dose, then a second should be added—a diuretic if it wasn't the first drug. If the antihypertensive response is inadequate after reaching full doses of two classes of drugs, a third drug from another class should be added. When blood pressure is more than 20/10 mm Hg above goal, therapy should be initiated with two antihypertensive drugs. Consider reasons for inadequate response, including polypharmacy, nonadherence and potential drug interactions.
• Conduct routine monitoring of blood pressure, including taking blood pressure measures in the standing position.
• Lifestyle changes may be all that are needed for milder hypertension, and may allow reduction of drug doses. This includes regular physical activity, restriction of salt, weight control, smoking cessation and avoidance of excessive alcohol intake (more than two drinks for men and one drink for women daily).
• The high cost of blood pressure-lowering medications contributes to low rates of blood pressure control in the elderly and should be discussed with patients.

The American College of Cardiology (ACC) and the American Heart Association (AHA) released the expert consensus document, which was developed with other medical societies.