ACP, AAFP release guidelines on treating older adults with hypertension

Adults who are 60 years old or older and have a systolic blood pressure of at least 150 mm Hg should receive treatment to lower their blood pressure and reduce their risk for mortality, stroke and cardiac events, according to new guidelines from the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP).

The guidance was published online Jan. 16 in the Annals of Internal Medicine.

The authors mentioned that in the U.S., 29 percent of all adults and 64.9 percent of adults who are 60 years or older have hypertension, which was associated with $46 billion in healthcare services, medications and missed days of work in the U.S. in 2011.

The Portland VA Health Care System Evidence-based Synthesis Program conducted the evidence review for the guidelines. Lead researcher Jessica Weiss, MD, of Oregon Health & Science University in Portland, Oregon, and colleagues also published their results online Jan. 16 in the Annals of Internal Medicine.

The researchers searched multiple databases through January 2015 and the MEDLINE database to Sept. 2016. They identified 21 randomized, controlled trials, including eight that compared blood pressure targets and 13 that assigned patients to more versus less intensive antihypertensive therapy. They also found three observational studies that assessed harms.

The guidelines’ authors defined mild hypertension as a systolic blood pressure below 160 mm Hg and moderate to severe hypertension as a systolic blood pressure of 160 mm Hg or higher.

For patients who had moderate to severe hypertension at baseline, nine studies found high-strength evidence that achieving a blood pressure of less than 150/90 mm Hg led to a 10 percent relative risk reduction in mortality, a 23 percent relative risk reduction in cardiac events and a 26 percent relative risk reduction in stroke.

Meanwhile, six studies showed there was low- to moderate-strength evidence that a blood pressure target of 140/85 mm Hg or lower was associated with an 18 percent relative risk reduction in cardiac events, a 21 percent relative risk reduction in stroke and a 14 percent lower relative risk reduction in mortality.

The authors said that high-quality evidence showed that treating hypertension in older adults to a target of less than 150 mm Hg reduced mortality, stroke and cardiac events. The absolute benefit was greatest in adults with a systolic blood pressure of greater than 160 mm Hg at baseline.

“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,” Nitin S. Damle, MD, MS, president of the ACP, said in a news release. “Most benefits of targeting of less than 150 mm Hg apply to individuals regardless of whether or not they have diabetes.”

The guidelines did not address or compare treatment options for hypertension. However, the authors noted nonpharmacologic treatments include weight loss and an increase in physical activity. Pharmacologic options include antihypertensive medications such as thiazide-type diuretics, ACE inhibitors, ARBs, calcium-channel blockers and beta-blockers.

The ACP and AAFP also recommended that clinicians considering initiating or intensifying pharmacologic treatment in adults who are 60 years old or older and have 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. The authors found that moderate-quality evidence showed treating such patients to a systolic blood pressure target of 130 to 140 mm Hg reduced stroke recurrence, but it did not significantly decrease cardiac events or all-cause mortality.

In addition, the ACP and AAFP recommended that clinicians consider a systolic blood pressure target of less than 140 mm Hg to reduce the risk for stroke and cardiac events in some adults who are 60 years old or older and have high cardiovascular risk. However, the authors said the target depended on numerous factors such as comorbidity, medication burden, risk for adverse events and cost. They mentioned that people with increased cardiovascular risk typically includes people with known vascular disease, diabetes or chronic kidney disease and older people.

The authors noted that clinicians should choose generic medications over brand name drugs and should consider patients’ treatment burdens.

“The balance of benefits and harms identified in our evidence report is based in part on rigorous and accurate assessment of [blood pressure],” they wrote. “Some patients may have falsely elevated readings in clinical settings (known as “white-coat hypertension”). Therefore, it is important to ensure accurate [blood pressure] measurement before initiating or changing treatment of hypertension. The most accurate measurements come from multiple [blood pressure] measurements made over time.”