Blood pressure management in older adults: A multiple‐choice question?

In this issue of The Journal of Clinical Hypertension, Xie and colleagues’ article titled “Stage 1 Hypertension Defined by the 2017 ACC/AHA Guideline Predicts Future Cardiovascular Events in Elderly Chinese Individuals” examined the association between stage 1 hypertension (systolic blood pressure [BP] of 130‐139 mm Hg or diastolic BP of 80‐90 mm Hg) and cardiovascular disease (CVD) and death among older adults in rural China. The authors found that persons with a stage 1 hypertension had a higher risk of stroke, myocardial infarction (MI), and CVD mortality than those with a normal BP level. They concluded that BP control in Chinese older adults with stage 1 hypertension may reduce the risk of CVD. These results are timely and of great importance because the 2017 American College of Cardiology/American Heart Association (2017 ACC/AHA) guideline1 recommended new classification of blood pressure, and whether the implementation of these new recommendations could bring health benefits to the Chinese population is largely uncertain.

Older adults are a diverse and complex population with substantially different health and functional status. Therefore, the goal of BP management among older adults is probably a multiple‐choice question with more than one correct answer. It may not be reasonable to pursue a universal BP target among this population. Instead, the scientific community need to seek to establish a personalized target for each older person based on his/her genetic information, lifestyle, and health condition. In fact, the 2017 ACC/AHA guideline recommends a holistic risk/benefit assessment of the intensity of BP lowering for hypertensive older patients with a high comorbidity burden and limited life expectancy.1

Results from two large clinical trials—the Hypertension in the Very Elderly Trial (HYVET) and the Systolic Blood Pressure Intervention Trial (SPRINT)—have demonstrated the effect of intensive BP control in reducing the risk of major cardiovascular events and mortality among older adults.2, 3 However, we need to keep in mind that older patients in trials are selective because of stringent inclusion and exclusion criteria. Therefore, general older population may not be well represented by those that meet the inclusion criteria of trials. In fact, only 19.5% and 34.6% of US adults aged 60‐74 and 75+ years were eligible for the SPRINT, respectively, and persons with an unintentional weight loss of >10%—an important clinical sign of frailty—in last 6 months were excluded.4 On the contrary, a large body of literature suggests that older adults who are frail, disabled, or have low physical functioning may not benefit from BP lowering.5, 6, 7, 8, 9 These findings are not in conflict, but represent complementary lines of evidence in the investigation of the benefits and harms of BP control among the elderly. In addition, cumulating evidence suggests that intensive BP control may lead to a high risk of adverse events including hypotension and syncope.10

In China, few studies have examined the role of health and functional status in the association between BP and outcomes. In the present study, Xie et al showed that the general older population may benefit from lower BP target. However, whether there exist heterogeneous effects of lower BP among this large and diverse population is not known. The recently released 2019 Chinese guideline for the management of hypertension in the elderly recommended that “frailty should be assessed before the antihypertensive treatment for elderly hypertensive patients, in order to assess the benefits and risks of antihypertensive treatment,11, 12, 13 especially in elderly hypertensive patients who lost more than 5% of their body weight during the past year without deliberate dieting or had a risk for falling.14, 15 If the very old patients with hypertension are classified as frail, BP ≥ 160/90 mm Hg, the drug treatment should be initiated, SBP values should be targeted to 150 mm Hg or lower, but ≥130 mm Hg as possible.” How to incorporate frailty and functional status into establishment of BP treatment target in routine clinical practice remains a highly active area of research. The authors and other researchers could advance our understanding of the benefits and harms of anti‐hypertensive treatment by carefully examining subgroups of older adults based on their functional status and disease burden and comprehensively monitoring adverse events. Findings from this line of research are highly relevant to China's rapidly growing aging population and a large number of frail older adults—over 20% of adults aged ≥80 years are frail in China.16

In conclusion, we need more evidence to evaluate the appropriateness, safety, and feasibility of adopting the 2017 ACC/AHA guideline among older adults in China. More evidence from different types of studies including clinical trials and observational studies can help us treat older adults who stand to benefit the most from aggressive BP‐lowering treatment and minimize relevant side effects and adverse events.

CONFLICT OF INTEREST

Dr Chenkai Wu provides paid consultative services to Healthkeepers, a health data analytics company in China.