May 10, 2011

By: WILLIAM E. GOLDEN, M.D., AND ROBERT H. HOPKINS, M.D.

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.

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