Ten most important things to learn from the ACCF/AHA 2011 expert consensus document on hypertension in the elderly

Abstract

The American College of Cardiology Foundation/American Heart Association 2011 Expert Consensus Document on Hypertension in the Elderly has been published in the Journal of the American College of Cardiology and in Circulation, and will be published in the Journal of the American Society of Hypertension and the Journal of Geriatric Cardiology. This document has also been developed in collaboration with the American Academy of Neurology, the American Geriatrics Society, the American Society of Preventive Cardiology, the American Society of Hypertension, the American Society of Nephrology, the Association of Black Cardiologists, and the European Society of Hypertension. The present article is a short summary emphasizing the 10 most important things to learn from this document.

Key Words::

• antihypertensive therapy
• blood pressure
• elderly
• hypertension

Introduction

Adequate control of hypertension in the elderly can significantly reduce cardiovascular events and mortality and is much more cost effective than treating cardiovascular events that result from uncontrolled hypertension (1). The American College of Cardiology Foundation/American Heart Association 2011 Expert Consensus Document on Hypertension in the Elderly has been published in the Journal of the American College of Cardiology (2) and in Circulation (3), and will be published in the Journal of the American Society of Hypertension and the Journal of Geriatric Cardiology. This document has also been developed in collaboration with the American Academy of Neurology, the American Geriatrics Society, the American Society of Preventive Cardiology, the American Society of Hypertension, the American Society of Nephrology, the Association of Black Cardiologists, and the European Society of Hypertension. The present article is a short summary emphasizing the 10 most important things to learn from this document.

1. There is a marked increase in the prevalence of hypertension with aging. The age-adjusted prevalence of hypertension in 1999–2002 in the USA was 64% of elderly men and 78% of elderly women (4).

2. Hypertension in elderly persons is characterized by an increased systolic blood pressure with a normal or low diastolic blood pressure related to age-associated stiffening of the large arteries (5).

3. Hypertension is a major risk factor for cardiovascular disease in the elderly. Hypertension is present in approximately 69% of patients with a first myocardial infarction (4), in approximately 77% of patients with a first stroke (4), in approximately 74% of patients with chronic heart failure (4), and in 60% of patients with peripheral arterial disease (6). Hypertension is also a major risk factor in elderly persons for a dissecting aortic aneurysm, sudden cardiac death, angina pectoris, atrial fibrillation, diabetes mellitus, the metabolic syndrome, chronic kidney disease, thoracic and abdominal aortic aneurysms, left ventricular hypertrophy, vascular dementia, Alzheimer's disease, and ophthalmologic disorders (2,3).

4. Numerous randomized trials have demonstrated substantial reductions in cardiovascular outcomes in persons aged 60–79 years treated with antihypertensive drug therapy (2,3). At 1.8-year follow-up of 3845 patients aged 80 years and older with hypertension in the Hypertension in the Very Elderly Trial (HYVET), patients randomized to antihypertensive drug therapy had a 21% significant reduction in all-cause mortality (p = 0.02), a 30% insignificant reduction in stroke (p = 0.06), a 39% significant reduction in fatal stroke (p = 0.05), a 23% insignificant reduction in cardiovascular death (p = 0.06), and a 64% significant reduction in heart failure (p < 0.001) (7).

5. Although increases in the treatment and control of hypertension in elderly hypertensive adults have occurred in the past two decades, blood pressure control rates remain suboptimal in the elderly (2,3). Blood pressure is adequately controlled in 36% of men and 28% of women aged 60–79 years, and in 38% of men and 23% of women aged 80 years and older (8). Prevalent comorbidities, polypharmacy, and high cost of medications contribute to lower blood pressure control rates in the elderly (9).

6. Non-pharmacologic lifestyle measures should be encouraged in older adults both to prevent development of hypertension and as adjunctive therapy in those with hypertension. These measures include sodium restriction, regular physical activity, weight control, smoking cessation, and avoidance of excessive alcohol intake (2,3,10,11).

7. Antihypertensive therapy should be initiated in persons aged 65–79 years with a systolic blood pressure of 140 mmHg or higher or a diastolic blood pressure of 90 mmHg or higher and in persons aged 80 years and older with a systolic blood pressure of 150 mmHg or higher (2,3,7).

8. Diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium-channel blockers, and beta-blockers have all shown benefit in reducing cardiovascular outcomes in randomized trials among elderly persons (2,3,12–15). The choice of specific drugs is dictated by efficacy, tolerability, presence of specific comorbidities, and cost. Treatment-related adverse effects such as electrolyte disturbances, renal dysfunction, and excessive orthostatic blood pressure reduction should be avoided (2,3,11–15). Most elderly persons with hypertension will need at least two drugs to control their hypertension (2,3,9,11).

9. Initiation of antihypertensive drug therapy in the elderly should generally be at the lowest dose with gradual increments as tolerated (2,3,11).

10. Although the optimal blood pressure treatment goal in the elderly has not been determined, a therapeutic target of < 140/90 mmHg in persons aged 65–79 years and a systolic blood pressure of 140–145 mmHg if tolerated in persons aged 80 years and older is reasonable (2,3). We should also be careful to avoid intensive lowering of the blood pressure in elderly persons, especially those with diabetes and coronary artery disease, as this might be poorly tolerated and might increase cardiovascular events (the J-curve phenomenon). However, until additional data from randomized controlled trials (including the Systolic Blood PRessure INtervention Trial – SPRINT) comparing various blood pressure targets in the elderly become available, existing epidemiologic and clinical trial data suggest a diagnostic and therapeutic threshold for hypertension of 140/90 mmHg remains reasonable in adults 65–79 years of age (2,3,16).

Declaration of Interest: Drs Aronow and Banach have no conflicts of interest. No funding was provided for preparation of this manuscript.