Background
Hypertension affects most people older than age 65 years. The American College of Cardiology, in collaboration with several partner organizations, issued an expert consensus document on the evaluation and treatment of hypertension in seniors. The document provides consensus, rather than rigorous evidence-based guidance. Most clinical trials of hypertension treatments are based on studies with few or no older patients, or without age-specific analyses.
Conclusions
Age-related changes in vascular stiffness, atherosclerotic disease, autonomic dysregulation, and age-related declines in renal function all are implicated in the greater incidence of hypertension in seniors, compared with a younger population.
The recommended treatment target for uncomplicated hypertension in seniors is less than 140/90 mm Hg, based on expert opinion. The systolic BP target in persons over age 80 years should be 140-145 mm Hg, if tolerated. Lower BP targets recommended in other guidelines for patients with diabetes, chronic kidney disease with proteinuria, and systolic heart failure are endorsed.
Older patients are more prone to hyperkalemia than younger hypertensive adults.
Serum uric acid independently predicts cardiovascular events in older hypertensive patients.
Secondary hypertension from renal artery stenosis, obstructive sleep apnea, endocrinopathies, medications, and lifestyle issues are important considerations in elderly adults, particularly those with resistant hypertension.
Treatment-resistant hypertension is more common with advancing age and increasing duration of hypertension.
Pseudohypertension and white coat hypertension are more common in the elderly although the prevalence is not well quantified.
Hypertension pharmacotherapy is generally recommended in seniors with the caveat that there are more limited data in patients over age 80 years. Most elderly patients will need more than two medications to reach blood pressure goals.
Implementation
The diagnosis of hypertension should be based on at least three high-quality blood pressure readings obtained on two or more visits; blood pressure should be measured when the patient is in a well-supported seated position after a 5 minute rest.
A complete history and examination, electrocardiogram, and basic laboratory evaluation (urinalysis, blood chemistries with estimated glomerular filtration rate, fasting glucose, and fasting lipid profile) are suggested in the initial evaluation of hypertension in the elderly. Select patients may warrant additional initial testing.
Lifestyle changes including smoking cessation, moderation of alcohol and sodium intake, weight reduction, and increased physical activity are recommended and might be sufficient to reduce blood pressure to goal in mildly hypertensive seniors.
Antihypertensive medications should be initiated at the lowest dose and increased gradually to the maximum dose until the treatment target is reached. If the goal is not achieved or the drug is not tolerated, a second agent from a different class should be added (or substituted). Elderly patients with blood pressures greater than 20/10 mm Hg over goal usually require initiation of two medications.
A thiazide diuretic should be the first or second antihypertensive medication initiated in most seniors.
Beta-blockers should generally be reserved for combination therapy and/or treatment of patients with other specific indications for this medication class (for example, coronary artery disease, angina, or heart failure).
Alpha-blockers should not be considered first-line antihypertensives in elderly adults.
Calcium antagonists, with the exception of short-acting dihydropyridines, can be useful first-line antihypertensives or as part of combination regimens in seniors.
ACE inhibitors are useful; however, they may precipitate chronic cough or, less commonly, angioedema and rash. ACE inhibitors or angiotensin-receptor blockers should be components of the hypertension regimen in elderly patients with diabetes and heart failure.
Direct renin inhibitors have been demonstrated to be effective in combination with a thiazide, calcium antagonist, or ACE inhibitor in patients older than age 75 years.
Hydralazine and minoxidil should only be used as late additions to combination regimens in elderly patients with resistant hypertension, because of their numerous adverse effects.
Pseudohypertension should be suspected in older patients with refractory hypertension, a lack of end-organ damage or symptoms of overmedication.
Home blood pressure measurement can be very helpful in the elderly. Ambulatory blood pressure monitoring is suggested to confirm a diagnosis of white coat hypertension, when the response to medication is unclear from office measurements, and to evaluate potential symptoms of orthostasis.
Polypharmacy, drug interactions, nonadherence, and quality of life issues can be important in the development of a management plan for elderly hypertensive patients, particularly as seniors average six or more medications for chronic conditions. Multidisciplinary teams may be particularly useful in meeting the needs of this growing patient population.