Hypertension in the elderly: which are the blood pressure threshold values? (2024)

. 2019 Mar 29;21(Suppl B):B105–B106. doi: 10.1093/eurheartj/suz023

By the year 2050 one-fifth of the world population will surpass 80 years of age.1

The prevalence of arterial hypertension (AH) increases with aging. In fact, the vast majority of the elderly are affected with AH. The Framingham study demonstrated that almost two-thirds of males and three quarter of females develop AH by the age of 70 years.2,3

Managing blood pressure is often difficult in the elderly, not only because of comorbidities, but also due to vascular remodelling and the changes in the renal and endocrine physiology. The structural and functional arterial modifications lead to impaired vessel’s compliance and increased systolic blood pressure (SBP), often with reduction of diastolic blood pressure (DBP). Hence isolated systolic hypertension, characterized by SBP >140 mmHg and DBP <90 mmHg, is more common in the elderly.4,5 In the old patient with AH common comorbidity are coronary artery disease (CAD), heart failure, renal dysfunction, cerebrovascular disease, peripheral arterial disease, and cognitive disorders, all interfering with the natural history of AH and complicating both the therapeutic management and the prognosis.2

Data concerning patients over the age of 80 years and ‘frail’ patients are more controversial. The latter, albeit at higher risk for cardiovascular diseases (CVD), seem to benefit less from antihypertensive treatment while often incurring in the side effects of treatment. Recent studies suggest a tempering of the correlation between high blood pressure and mortality in ‘frail’ patients, identified by slow walking (surrogate marker of frailty).6

The latest guidelines of the European Society of Hypertension (ESH)/European Society of Cardiology (ESC), incorporating the evidences suggesting antihypertensive treatment in the elderly only for SBP ≥160 mmHg, recommended a blood pressure target for SBP <150 mmHg, reaching cautiously a level of <140 mmHg whenever possible. Nonetheless, for patients under the age of 80 years, antihypertensive treatment can be considered for SBP >140 mmHg, with the goal to reach values <140 mmHg in suitable patients tolerating the treatment well. On the other hand, elderly ‘frail’ patients should be treated with caution, carefully considering their comorbidities. Protracting the treatment over the 80 years of age, when well tolerated, could be considered.7

The ideal target for DBP in the elderly is a still unanswered question. In the SHEP study, cardiovascular risk increased in treated patients for DBP <70 mmHg. The Syst-Eur Trial revealed that in patients with CAD, a reduction of DBP <70 mmHg carried a higher risk of CVD.8,9 The ‘J’ curve phenomenon has been the object of debate since its introduction by Cruickshank in 1979. Several evidences suggest an increased risk of myocardial infarction, but not of renal diseases, particularly in patients with pre-existing CAD, when the DBP is <85/90 mmHg. Some epidemiologic study would suggest DBP levels higher for certain groups of elderly. It is plausible that ‘frail’ elderly (patients with previous cerebrovascular events) would benefit from higher blood pressure to keep a satisfactory perfusion of the target organs.10 A sensible clinical practice could be treating hypertension in the elderly by cautiously reaching a target SBP of 140 mmHg, whereas carefully avoiding a DBP <70 mmHg, as to maintain tissue perfusion.

Figure1 shows the prevalence of AH treated according to various SBP targets in the outpatient population at the Sant’Andrea Hospital-University of Rome ‘la Sapienza’. More than 60% of the patients over 65 years of age reached a SBP <150 mmHg. The number increases to almost 70% for patients over the age of 80 years. About 40% of hypertensive patients over the age of 65 years, once treated, reach a SBP <140 mmHg, and more than 20% SBP <130 mmHg.

Considering all available data, the recommendation for a blood pressure target in the elderly should be cautious, taking into account more the individual characteristics than a general guidelines. Epidemiology data reporting significant benefit in treating elderly ‘healthy’ patients are solid, but we are all well aware that treating ‘frail’ elderly patient, with all their comorbidities and susceptibility to the side effect of drug treatment, could be challenging. The ‘biologic’ age appears to be more important than the ‘anagraphic’ age, and it should take precedence in considering antihypertensive treatment, which should be effectively ‘personalized’ in the elderly. Whether some patients over the age of 65 years could tolerate well intensive antihypertensive treatment, with therapeutic targets similar to the younger patients, for other patients a less ambitious target, such as <150/90 mmHg, could be reasonable, particularly in the ‘over 80’, until more specific data will become available.

Conflict of interest: none declared.

References

  • 1.Aronow WS, Fleg JL, Pepine CJ.. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on clinical expert consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of hypertension. J Am Soc Hypertens 2011;5:259–352. [DOI] [PubMed] [Google Scholar]
  • 2.Kelly R, Hayward C, Avolio A, O'Rourke M.. Noninvasive determination of age-related changes in the human arterial pulse. Circulation 1989;80:1652–1659. [DOI] [PubMed] [Google Scholar]
  • 3.Seals DR, Esler MD.. Human ageing and the sympathoadrenal system. J Physiol 2000;528:407–417. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results from the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;265:3255–3264. [PubMed] [Google Scholar]
  • 5.Brown D, Giles W, Greenlund K.. Blood pressure parameters and risk of fatal stroke, NHANES II mortality study. Am J Hypertens 2007;20:338–341. [DOI] [PubMed] [Google Scholar]
  • 6.Odden MC, Peralta CA, Haan MN, Covinsky KE.. Rethinking the association of high blood pressure with mortality in elderly adults. Arch Intern Med 2012;172:1162–1168. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Mancia G, Fagard R, Narkiewicz K.. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the management of arterial hyper- tension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013;34:2159–2219. [DOI] [PubMed] [Google Scholar]
  • 8.Somes GW, Pahor M, Shorr RI, Cushman WC, Applegate WB.. The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 1999;159:2004–2009. [DOI] [PubMed] [Google Scholar]
  • 9.Fagard RH, Staessen JA, Thijs L.. On-treatment diastolic blood pressure and prognosis in systolic hypertension. Arch Intern Med 2007;167:1884–1891. [DOI] [PubMed] [Google Scholar]
  • 10.Goodwin JS. Gait speed. An important vital sign in old age. Arch Intern Med 2012;172:1168–1169. [DOI] [PubMed] [Google Scholar]
Hypertension in the elderly: which are the blood pressure threshold values? (2024)
Top Articles
Latest Posts
Recommended Articles
Article information

Author: Golda Nolan II

Last Updated:

Views: 6166

Rating: 4.8 / 5 (78 voted)

Reviews: 93% of readers found this page helpful

Author information

Name: Golda Nolan II

Birthday: 1998-05-14

Address: Suite 369 9754 Roberts Pines, West Benitaburgh, NM 69180-7958

Phone: +522993866487

Job: Sales Executive

Hobby: Worldbuilding, Shopping, Quilting, Cooking, Homebrewing, Leather crafting, Pet

Introduction: My name is Golda Nolan II, I am a thoughtful, clever, cute, jolly, brave, powerful, splendid person who loves writing and wants to share my knowledge and understanding with you.