People with hypertension who are to take antihypertensive medication should be:
Whelton PK, Carey RM, Aronow WS, Casey Jr DE, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith Jr SC, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams Sr KA, Williamson JD, Wright Jr JT, 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, Journal of the American College of Cardiology (2017), doi: 10.1016/j.jacc.2017.11.006
For older adults (≥65 years of age) with hypertension and a high burden of
comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs.
National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults – 2016. Melbourne: National Heart Foundation of Australia, 2016.
Any of the first-line antihypertensive drugs can be used in older patients with hypertension.
When starting treatment in older patients, drugs should be commenced at the lowest dose and titrated slowly as adverse effects increase with age.
In older persons where treatment is being targeted to < 120 mmHg systolic, close follow-up of patients is recommended to identify treatment -related adverse effects including hypotension, syncope, electrolyte abnormalities and acute kidney injury.
Clinical judgement should be used to assess the benefit of treatment against the risk of adverse effects in all older patients with lower grades of hypertension.
Leung AA, Nerenberg K, Daskalopoulou SS, et al. Hypertension Canada’s 2016 Canadian Hypertension Education Program Guidelines for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension. Can J Cardiol. 2016; 32(5): 569-588. doi: 10.1016/j.cjca.2016.02.066.
Therapy adjustment should be considered in patients with a mean 24-hour ambulatory BP monitoring SBP of >= 130 mm Hg and/or DBP of >= 80 mm Hg, or a mean awake SBP of >= 135 mm Hg and/or DBP of >= 85 mm Hg (Grade D).
National Institute for Health and Care Excellence (NICE). Hypertension in adults: Diagnosis and management 2011. Available from: nice.org.uk/guidance/cg127. Accessed: August 2017.
Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following:
- target organ damage
- established cardiovascular disease
- renal disease
- a 10-year cardiovascular risk equivalent to 20% or greater.
Where possible, recommend treatment with drugs taken only once a day.
Prescribe non-proprietary drugs where these are appropriate and minimise cost.
Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure.
Offer people aged 80 years and over the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities.
Provide appropriate guidance and materials about the benefits of drugs and the unwanted side effects sometimes experienced in order to help people make informed choices.
James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5): 507-520. doi:10.1001/jama.2013.284427
In the general population aged 60 years or older, if pharmacologic treatment for high BP results in lower achieved SBP (for example, <140mmHg) and treatment is not associated with adverse effects on health or quality of life, treatment does not need to be adjusted.
Mancia G, Fagard R, Narkiewicz K, et al. 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. J Hypertens. 2013; 31(10): 1925–1938. DOI:10.1097/HJH.0b013e328364ca4c
In frail elderly patients, it is recommended to leave decisions on antihypertensive therapy to the treating physician, and based on monitoring of the clinical effects of treatment.
Drug treatment of severe hypertension in pregnancy (SBP >160 mmHg or DBP >110 mmHg) is recommended.
Drug treatment may also be considered in pregnant women with persistent elevation of BP ≥150/95 mmHg, and in those with BP ≥140/90 mmHg in the presence of gestational hypertension, subclinical OD or symptoms.
It is recommended that individual drug choice takes comorbidities into account.
In hypertensive patients with a history of stroke or TIA, a SBP goal of <140 mmHg should be considered.
In resistant hypertensive patients it is recommended that physicians check whether the drugs included in the existing multiple drug regimen have any BP lowering effect, and withdraw them if their effect is absent or minimal.