‘How low to go?’ Top transatlantic research journals debate antihypertensive treatment in older people

The scientific journal of the British Geriatrics Society, Age and Ageing, and the Journal of the American Geriatrics Society have launched a joint initiative, publishing two articles debating the relative benefits and risks of treating hypertension in older people.

It is widely recognised that raised blood pressure is probably the single most important treatable risk factor for cardiovascular disease in later life. The evidence that older people can benefit from antihypertensive drugs has accumulated with a succession of randomised controlled trials over the past 35 years. These trials have shown reduced risk of stroke and myocardial infarction, as well as decreased total mortality. However, despite the extensive evidence that is now available, questions remain about who to treat and on optimal blood pressure targets. Consequently practice varies widely and many clinicians are uncertain about what best to recommend for their older patients.

The article in Age and Ageing, written by Professors Simon Conroy, Rudi Westendorp and Miles Witham, points out the benefits of treatment of hypertension in older people, particularly in reducing stroke rates, however, these authors emphasise the need to consider adverse effects and warn about problems caused by over-aggressive blood pressure lowering in older people. The authors reviewed a variety of studies and noted that the participants in these trials were not as affected by multi-morbidity, frailty and polypharmacy as many older people are in the general population, including in general practice settings. They further emphasise the need for shared decision making with patients regarding whether or how aggressively to treat. These authors advise clinicians to consider a patient’s likely longevity and tailor treatment decisions.

In their article in the Journal of the American Geriatrics Society, authors Professors William Cushman and Karen Johnson present a discussion of the recent American College of Cardiology and American Heart Association guidelines for managing high-blood pressure with a special focus on managing this disorder in older people. The article presents a detailed rationale for why the US guidelines now recommend lower targets for blood pressure management in older people. Although these authors do express concern over the adverse effects of blood pressure lowering, their emphasis rests more on the need for clinicians to understand that the recent guidelines warrant a more aggressive approach to treatment goals in older people, particularly those who have a high risk of cardiovascular disease.

Professor David Stott, Editor of Age and Ageing, and Professor Bill Applegate co-authored a bridging editorial ‘Perspectives on hypertension treatment in older persons’.

David Stott said: “For some older people blood pressure lowering for prevention of vascular disease will be a high priority, with the potential for substantial gains from setting a low treatment target. However for others antihypertensive treatment will be irrelevant or even harmful. The decision whether or not to treat hypertension in older age, and ‘how low to go’ remain a matter of expert clinical judgement, tailoring recommendations for antihypertensive treatment to the individual older person’s specific characteristics and wishes”

Bill Applegate said: “Results of the recent SPRINT trial and its subgroup analyses indicate that clinicians should consider adopting more aggressive blood pressure lowering goals for many older persons.”

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