What are the ACP/AAFP and JNC 8 guidelines for initiating antihypertensive therapy in older adults?

Updated: Feb 22, 2019
  • Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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2017 ACP/AAFP guidelines

The American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) released updated guidelines on the pharmacologic treatment of hypertension in adults aged 60 years and older in January 2017. [72, 99]  A few of their recommendations are outlined below.

Clinicians should initiate treatment in patients aged 60 years or older who have persistent systolic blood pressure (SBP) at or above 150 mm Hg to achieve a target of below 150 mm Hg to reduce the risk for stroke, cardiac events, and death.

If patients 60 years or older have a history of stroke or transient ischemic attack or have a high cardiovascular risk, physicians should consider starting or increasing drug therapy to achieve an SBP of less than 140 mm Hg to reduce the risk for stroke and cardiac events.

Consider initiating or intensifying pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk based on an individualized assessment, to achieve a target SBP of below 140 mm Hg to reduce the risk of stroke or cardiac events. Factors include comorbidity, medication burden, risk of adverse events, and cost. Generally, an increased cardiovascular risk includes known cardiovascular disease, diabetes, or chronic kidney disease with a glomerular filtration rate (GFR) of less than 45 mL/min/1.73 m2.

2014 "JNC 8" guidelines

The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) recommends for patients aged 60 years or older, initiate therapy in those who have SBP levels at 150 mm Hg or greater or whose diastolic BP levels are 90 mm Hg or greater and to treat to below those thresholds. [88, 89]  These guideline recommendations are based on the results of several trials demonstrating a lack of benefit for a more stringent SBP goal than 140 mm Hg. [100, 101]  However, more recently, this has been challenged by results of the Systolic Blood Pressure Intervention Trial (SPRINT) study, particularly a prespecified subgroup analysis in elderly patients older than 75 years who exhibited reduced overall mortality with an SBP target less than 120 mm Hg rather than 140 mm Hg. [102]  Although the results of the SPRINT substudy are intriguing, more research will be necessary to determine the optimal BP targets in the elderly, particularly those with diabetes or prior stroke, who were excluded from the SPRINT trial

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