The evidence-based clinical practice guideline on the appropriate systolic blood pressure target for adults >60 years with hypertension was developed jointly by the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) and published in Annals of Internal Medicine.
The new document has provoked controversy because many other guidelines recommend that all adults, up to the age of at least 80 years, seek to lower systolic blood pressure to lower than 140 mm Hg. In addition, the high-profile 2015 SPRINT study urged that the target be even lower.
Background information in the article, authored by a team from the ACP and University of Pennsylvania Health System, notes that about 65% of those >60 years have hypertension in the United States, compared to an overall adult rate of about 29%.
“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,” said ACP President Nitin S. Damle, MD, MS, MACP. “Most benefits of targeting of less than 150 mm Hg apply to individuals regardless of whether or not they have diabetes.”
The guideline also cautions about “white coat hypertension,” whereby patients might have falsely elevated readings in clinical settings which could lead to unnecessary initiation or increase in hypertension medications.
“The most accurate measurements come from multiple blood pressure measurements made over time,” said AAFP president John Meigs, Jr., MD. “These may include multiple measurements in clinical settings or ambulatory or home-monitoring.”
While the document advises that nonpharmacologic approaches, such as dietary changes, exercise and weight loss be attempted, it also details the range of medication therapies that can be used to treat hypertension and their common side effects:
• Thiazide-type diuretics (adverse effects include electrolyte disturbances, gastrointestinal discomfort, rashes and other allergic reactions, sexual dysfunction in men, photosensitivity reactions, and orthostatic hypotension),
• ACEIs (adverse effects include cough and hyperkalemia),
• ARBs (adverse effects include dizziness, cough, and hyperkalemia), calcium-channel blockers (adverse effects include dizziness, headache, edema, and constipation), and
• Beta-blockers (adverse effects include fatigue and sexual dysfunction).
Systolic blood pressure targets might be lower, <140 mm Hg, in older pateints with a history of stroke or transient ischemic attack, according to the guidelines. The authors also recommend that 140 mm Hg be the goal if an individualized assessment indicates high cardiac risk.
The report points out that increased cardiovascular risk includes all patients with known vascular disease as well as most of those with diabetes, with chronic kidney disease with estimated glomerular filtration rate (eGFR) <45 mL/min/per 1.73 m2, with metabolic syndrome—abdominal obesity, hypertension, diabetes, and dyslipidemia—and, in some cases, who are older.
Because of similar efficacy, reduced cost, and therefore better adherence, the guidelines recommend that physicians prescribe generic formulations over brand name drugs.
Citing insufficient evidence, the ACP and AAFP did not make any recommendations about diastolic blood pressure targets.
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