Measured in mm Hg, blood pressure (BP) is reported in terms of systolic BP (SBP) over diastolic BP (DBP). For example, normal BP may be read as 120 over 80 mm Hg or written as 120/80 mm Hg. SBP is the force blood exerts on the artery walls when the heart contracts to pump blood out (pressure in the arteries when the heart is beating). DBP measures the force as the heart relaxes to allow the blood to flow into the heart (pressure in arteries while the heart rests between heartbeats). The difference between the systolic and diastolic readings is known as the pulse pressure and is an indicator of the stiffness and inflammation in blood vessel walls. A high pulse pressure in older adults is a strong indicator of heart problems.1
Changes With Age
Importance of Proper BP Technique
Hypertension Treatment Guidelines
Eighth Joint National Committee (JNC-8) Guidelines5
The JNC-8 recommendations to treat high BP to a goal of <150/90 in the general population aged 60 or older was unanimously voted upon by the panel and is clearly supported by moderate to high quality evidence from randomized controlled trials that demonstrate reductions in stroke, heart failure, and coronary heart disease. However, the increased target goal to <150/90 in patients over the age of 60 is based on lower quality evidence from two studies. These studies suggest that a target SBP goal of <140 mm Hg in this age group provides no additional benefit. BP targets from these studies were 140 to 160 mm Hg in one study and 140 to 149 mm Hg in the other.
Several members of the JNC-8 panel recommended continuing the JNC-7 SBP goal of <140 mm Hg for individuals over the age of 60 based on expert opinion. These members concluded that the evidence was insufficient to raise the SBP target from <140 to <150 mm Hg in high-risk groups, such as black persons, those with CVD including stroke, and those with multiple risk factors. The panel agreed that more research is needed to identify optimal goals of SBP for patients with high BP.
Although the recommendation to increase the target BP to <150/90 was approved, the panel included a corollary recommendation based on expert opinion that treatment for hypertension does not need to be adjusted if treatment results in SBP <140 mm Hg without associated adverse effects on health or quality of life.
Benefits and Cost Effectiveness of JNC-8
Researchers used a Cardiovascular Disease Policy Model to simulate drug treatment and monitoring costs, costs averted for the treatment of CVD, and quality-adjusted life years gained by treating previously untreated adults from 2014 through 2024. The largest benefit would be observed among the 8.6 million American adults between the ages of 35 and 74 with hypertension but without CVD who are not currently being treated (primary prevention). For these patients, treating to the BP targets would prevent approximately 41,000 cardiovascular events and 7,000 deaths from cardiovascular causes each year. The study also reported that approximately 860,000 men and women with existing CVD and untreated hypertension (secondary prevention) would be eligible for antihypertensive medications every year with treatment preventing approximately 16,000 cardiovascular events and 6,000 deaths from cardiovascular causes.6
Individualizing BP Treatment
Hypertension treatment should be individualized regardless of the treatment guideline being used. The advantages and disadvantages of aggressively treating BP need to be carefully considered for each patient. Practitioners concerned about not treating patients whose BP exceeds 140/90 due to fear of increased cardiovascular events may choose to follow stricter American College of Cardiology/American Heart Association recommendations which at this time continue to recommend a treatment goal of <140/90.
It is well established that lowering SBP reduces stress on the heart and provides significant benefit. However, excessively lowering BP, especially in an older adult, is also of concern. Treatment of patients over the age of 80 is especially complex, and overly aggressive treatment of BP may even reduce survival in these individuals.7
For the older adult, lowering BP to <120/80 is not recommended because of reduced tissue perfusion and the significant risk of side effects. Older adults, especially those over the age of 80, should always be checked for excessive orthostatic decline, and SBP <130 and DBP <65 should be avoided. In the Systolic Hypertension in Elderly Study, investigators concluded that lower DBP is of less concern for patients without CAD. However, for those patients with CAD, intensive antihypertensive therapy increases the risk of cardiovascular events when DBP is lowered to <60 mm Hg. These data were further validated in a later follow-up analysis of the Systolic Hypertension in Elderly Study, with an increase in cardiovascular events seen when treated DBP reached 70 m Hg with an even greater risk of CVE at 60 mm Hg. In another study (INVEST), the risk of cardiovascular events increased at a DBP between 60 mm Hg and 70 mm Hg.8 Additionally, elderly patients with diabetes treated to a DBP <65 mm Hg experienced an increase in mortality.3
A recent systematic review of studies published in December 2014 evaluated the benefits and harms of antihypertensive agents in adults aged 65 and older. Seven studies examined optimal BP targets. The review noted that strict control (SBP <140 mm Hg) was not consistently better than mild control (SBP <150 mm Hg) for adults aged 65 and older. Mild SBP control benefitted subjects in all age ranges over the age of 65. Older adults with hypertension had decreased cardiovascular morbidity and mortality with antihypertensives compared with no treatment. However, strict control was not consistently better than mild control in older adults.9
Tremendous evidence exists that antihypertensive treatment in the elderly patient is effective in reducing BP, total mortality, and cardiovascular events. Improving the treatment of hypertension in older adults should be implemented early and at a level sufficient to meet target BP goals, with medications adjusted to minimize excessive lowering of BP. This approach can help improve patient compliance while minimizing associated risks.
— Mark D. Coggins, PharmD, CGP, FASCP, is senior director of pharmacy services for skilled nursing centers operated by Diversicare in eight states, and is a director on the board of the American Society of Consultant Pharmacists. He was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.
2. Pannarale G. Optimal drug treatment of systolic hypertension in the elderly. Drugs Aging. 2008;25(1):1-8.
3. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol. 2011;57(20):2037-2114.
4. Handler J. The importance of accurate blood pressure measurement. Perm J. 2009;13(3):51-54.
5. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.
6. Moran AE, Odden MC, Thanataveerat A, et al. Cost-effectiveness of hypertension therapy according to 2014 guidelines. N Engl J Med. 2015;372(5):447-455.
7. Oates DJ, Berlowitz DR, Glickman ME, Silliman RA, Borzecki AM. Blood pressure and survival in the oldest old. J Am Geriatr Soc. 2007;55(3):383-388.
8. Messerli FH, Panjrath GS. The J-curve between blood pressure and coronary artery disease or essential hypertension: exactly how essential? J Am Coll Cardiol. 2009;54(20):1827-1834.
9. Goeres LM, Williams CD, Eckstrom E, Lee DS. Pharmacotherapy for hypertension in older adults: a systematic review. Drugs Aging. 2014;31(12):897-910.