January 16, 2017
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ACP, AAFP recommend ‘less aggressive’ systolic BP target for older patients with hypertension

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The ACP and American Academy of Family Physicians jointly released an evidence-based clinical guideline on the appropriate systolic BP target for adults aged 60 years and older for the treatment of hypertension, recommending that a less aggressive treatment target may be optimal for otherwise healthy patients.

“Hypertension … is a very common chronic disease in the United States,” Amir Qaseem, MD, PhD, MHA, of the ACP, and colleagues wrote. “The overall prevalence of hypertension among U.S. adults is 29%, and it increases to 64.9% in adults aged 60 years or older.”

“Appropriate management of hypertension reduces the risk for cardiovascular disease, renal disease, cerebrovascular disease and death. However, determining the most appropriate BP targets, particularly for adults aged 60 years or older, has been controversial,” they added.

The guideline, published in Annals of Internal Medicine, is based on a systematic review of 21 randomized, controlled trials and three observational studies that evaluated the benefits and harms of higher vs. lower BP goals for the treatment of hypertension in older adults. The included trials and studies also assessed outcomes including all-cause mortality, morbidity and mortality related to stroke, harms and major cardiac events such as fatal and nonfatal myocardial infarction and sudden cardiac death. The ACP and American Academy of Family Physicians (AAFP) made three essential recommendations for adults aged 60 years or older:

  • Initiate treatment in older patients with persistent systolic BP at or above 150 mm Hg to lessen the risk for mortality, stroke and cardiac events (high-quality evidence);
  • Consider initiating or intensifying pharmacologic treatment in older patients with a history of stroke or transient ischemic attack to reach a target systolic BP of less than 140 mm Hg to lessen the risk of recurrent stroke (moderate-quality evidence); and
  • Consider initiating or intensifying pharmacologic treatment in some older patients at high cardiovascular risk to reach a target systolic BP of less than 140 mm Hg to lessen the risk for stroke or cardiac events (low-quality evidence).

“The evidence showed that any additional benefit from aggressive [BP] control is small, with a lower magnitude of benefit and inconsistent results across outcomes,” Nitin S. Damle, MD, MS, MACP, president of ACP, said in a news release. “Most benefits of targeting of less than 150 mm Hg apply to individuals regardless of whether or not they have diabetes.”

The organizations noted that “white coat hypertension” or falsely elevated readings in clinical settings may occur in some patients; subsequently, physicians must ensure that they are accurately measuring BP before initiating or changing treatment for hypertension.

“The most accurate measurements come from multiple [BP] measurements made over time,” John Meigs, Jr., MD, president of AAFP, said in the release. “These may include multiple measurements in clinical settings or ambulatory or home-monitoring.”

The ACP and AAFP advised that physicians select treatment goals based on a periodic discussion of the benefits and harms of specific BP targets with the patient. They also recommended that physicians select generic formulations over brand name drugs with similar efficacy, yet lower costs when prescribing drug therapy due to better adherence rates.

Recommendations for diastolic BP targets were not made by the ACP and AAFP due to insufficient evidence. – by Alaina Tedesco

Disclosure: Qaseem and colleagues report support from the ACP operating budget. The researchers report primary funding from the U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research Development and Quality Enhancement Research Initiative.