New Suggestions for Managing High Blood Pressure in Senior Citizens

The American College of Cardiology and the American Heart Association have issued the first suggestions specifically for the treatment of high blood pressure in patients 65 and older. In the past, most research studies excluded patients 65 or older so it was difficult to extrapolate suggestions for treating younger patients to older patients.  The Hypertension in the Very Elderly (HYVET) trial changed that. It showed that when we lower the blood pressure in patients 80 years and older there is a decrease in deaths from stroke, a decrease in heart failure deaths and, decrease in death from all causes.

The consensus panel made the following suggestions:

1.  The general targeted blood pressure is less than 140/90

2.  Patients with coronary artery disease, diabetes and chronic kidney disease should aim for a BP less than 130/80 mm Hg.

3.  Lifestyle changes should be encouraged to manage milder forms of hypertension. This includes increasing exercise, reducing salt intake, controlling weight, stopping smoking and limiting alcohol to 2 drinks or less per day.  If this doesn’t work then medication treatment is indicated

The group supported the use of the “step care medication choice program” with the introduction of a thiazide diuretic as the first step in blood pressure medication usage.  They then went on to describe the appropriate usage of two medications at once, the use of beta blockers in cardiac patients and the use of calcium channel blockers.

They also supported screening patients’ urine for the presence of protein which would indicate that kidney problems need evaluation.  The group further suggested that the diagnosis of high blood pressure be made based on at least 3 blood pressure readings performed at two or more office visits.

The suggestions were not the more formal evidence based guidelines we have become accustomed to. They were a compromise agreement of a panel of experts from two organizations.  They encouraged further studies of these suggestions in the elderly so that they can accumulate the data they need to make future, firm, evidence-based guidelines.

For the average patient, nothing should change dramatically. As physicians, we will need to identify patients with elevated blood pressure and convince many of the elderly that there are significant benefits to taking medication to control their hypertension. This has been exceptionally difficult in the healthy elderly who develop hypertension in their mid to late 70’s and do not want to deal with the cost or side effect profile of taking “another pill.” Improving their lifestyle will always be the first option to control the elevated blood pressure.  However, the use of medications was strongly supported to control the pressure in those who need additional treatment.

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