Table 1.
Summary of the 34 guidelines that include thresholds for and targets of antihypertensive drug treatment in older adults
| Guideline | Year | Region | Threshold of blood pressure for initiation of antihypertensive drug treatment | Target of antihypertensive drug treatment |
|---|---|---|---|---|
| R. del Campo [24] | 2013 | Spain |
• General advice: based on risk estimation; when ≥10% (REGICOR) or whenever BP ≥180/110 mmHg • ≥80 years: when SBP ≥160 mmHg |
• <60 years: BP <140/90 mmHg • 60–80 years: follow general guidelines • ≥80 years: continue treatment if well tolerated and follow specific guideline in special situation. |
| Blacher [25] | 2013 | France |
• Whenever BP ≥180/110 mmHg • When BP ≥140/90 mmHg after LSM and a dedicated educational session with the patient |
• <80 years: 130 ≤ SBP <140/DBP <90 mmHg • ≥80 years: SBP <150 mmHg, without orthostatic hypotension |
| James [26] | 2014 | USA |
• <60 years: when SBP ≥140/90 mmHg • ≥60 years: when SBP ≥150/90 mmHg |
• <60 years: BP <140/90 mmHg • ≥60 years: BP <150/90 mmHg |
| JBS [27] | 2014 | UK |
• Whenever BP >160/100 mmHg |
• <80 years: BP <140/90 mmHg • ≥80 years: BP <150/90 mmHg |
| Mallery [28] | 2014 | Canada | • Frail elderly: consider treatment when SBP ≥160 mmHg |
• Frail elderly: 140 ≤ SBP ≤ 160 mmHg (seated and if tolerated) • Very frail elderly/short life expectancy: 160 ≤ SBP ≤ 190 mmHg |
| Seedat [29] | 2014 | South Africa |
• General advice: when BP ≥160/100 mmHg or when BP ≥140/90 mmHg after 3–6 m LSM • ≥80 years: when SBP >160 mmHg |
• <80 years: BP <140/90 mmHg • ≥80 years: 140 ≤ SBP ≤ 150 mmHg |
| Gabb [30] | 2016 | Australia | • Whenever BP ≥160/100 mmHg |
• ≤75 years: BP <140/90 mmHg • >75 years: SBP <120 mmHg if well tolerated |
| Ibrahim [31] | 2016 | Egypt |
• General advice: immediately whenever BP >210/120 mmHg when BP ≥180/110 mmHg after 1–3 w when BP ≥160/100 mmHg after 1–6 m of LSM • >65 years: when BP ≥150/95 mmHg after 3–6 w of LSM |
• ≤65 years: BP <150/95 mmHg • >65 years: BP <150/95 mmHg |
| Malachias [32] | 2016 | Brazil |
• General advice: whenever BP ≥160/100 mmHg when BP ≥140/90 mmHg after 6 m of LSM • ≥60/65 years: when SBP ≥140 mmHg and treatment is tolerated • ≥80 years: when SBP ≥160 mmHg |
• <60/65 years: BP <140 mmHg • ≥60/65 years: BP <140 mmHg if in good condition and tolerated • ≥80 years: BP <150 mmHg • Elderly with multiple non-CV morbidities, frailty or dementia: The treatment target should be less strict and individualized. |
| Piepoli [33] | 2016 | Europe |
• General advice: immediately whenever BP ≥180/110 mmHg when BP ≥140/90 mmHg and LSM fails. • >60 years: when SBP ≥160 mmHg |
• <60 years: BP <140/90 mmHg • 60–80 years: 140 ≤ SBP ≤ 150 mmHg or lower if tolerated and fit • ≥80 years: 140 ≤ SBP ≤ 150 mmHg if mentally and physically good • Frail elderly: consider careful treatment intensity/BP targets |
| Barbosa [34] | 2017 | Latin America |
• General advice: when BP ≥140/90 mmHg • Elderly: ≥140/90 mmHg when in good physical condition and without important adverse reactions |
• General advice: 130 ≤ SBP < 140/DBP <90 mmHg |
| Chiang [35] | 2017 | Taiwan | • Not mentioned |
• <75 years: BP <140/90 mmHg • ≥75 years: BP <140/90 mmHg (unattended AOBP: SBP <120 mmHg) |
| Czarnecka [36] | 2017 | Poland |
• General advice: when BP ≥160/100 mmHg when BP ≥140/90 mmHg after LSM • >60 years: when SBP ≥160 mmHg |
• ≤60 years: BP <140/90 mmHg • >60 years: SBP ≤150 mmHg or <140 mmHg and lower if tolerated • >80 years: 140 ≤ SBP ≤ 150 mmHg if mentally and physically good |
| De Oliveira [37] | 2017 | Intercontinental |
• Whenever BP ≥160/100 mmHg • When BP ≥140/90 mmHg after LSM for 3–6 months |
• <80 years: BP <140/90 mmHg • ≥80 years: BP <145/85 mmHg |
| Qaseem [38] | 2017 | USA |
• ≥60 years: when SBP ≥150 mmHg and use shared decision-making |
• ≥60 years: SBP <150 mmHg |
| SIGN [39] | 2017 | Scotland |
• General advice: when BP ≥160/100 mmHg |
• General advice: BP <140/90 mmHg, but adapt in the frail or elderly in light of medicine tolerance. |
| Tay [40] | 2017 | Singapore |
• General advice: when BP ≥140/90 mmHg • Older patients (age not specified): when SBP ≥160 mmHg |
• <80 years: BP <140/90 mmHg • Older patients <80 years: SBP <140 mmHg if tolerated • ≥80 years: BP <150/90 mmHg • Fragile elderly: adapt SBP goals to individual tolerability |
| Whelton [41] | 2017 | USA |
• General advice: when BP ≥140/90 mmHg • ≥65 years and Noninstitutionalized: when SBP ≥130 mmHg • ≥65 years with limited life expectancy: use shared decision making |
• <65 years: BP <130/80 mmHg • ≥65 years and Noninstitutionalized: SBP <130 mmHg • ≥65 years and high burden of comorbidities or limited life expectancy: assess risk/benefit |
| Kinoshita [42] | 2018 | Japan | • Not mentioned |
• <75 years: BP <140/90 mmHg • ≥75 years: BP <150/90 mmHg and <140/90 mmHg if tolerated |
| MsH, MOH & AMM [43] | 2018 | Malaysia |
• General advice: whenever BP ≥160/100 mmHg when BP ≥140/90 mmHg after 3–6 m LSM • ≥65 years: when SBP ≥160 mmHg |
• <65 years: BP <140/90 mmHg • 65–80 years: SBP <140 mmHg and consider SBP <130 mmHg • >80 years: SBP <150 mmHg • Frail, institutionalized, functional and cognitive impairment: consider less strict treatment and consider de-prescribing |
| Williams [44] | 2018 | Europe |
• General advice: whenever BP ≥160/100 mmHg when BP ≥140/90 mmHg after 3–6 m LSM • Fit and 65–80 years: when BP ≥140/90 mmHg and if tolerated • Fit elderly ≥ 80 years: when BP ≥160/90 mmHg |
• <65 years: 120 ≤ SBP < 130/70 ≤ DBP <80 mmHg if tolerated • ≥65 years: 130 ≤ SBP < 140/70 ≤ DBP < 80 mmHg if tolerated • Frail older patients: BP targets may need to be modified |
| Liu [45] | 2019 | China |
• General advice: when BP ≥160/100 mmHg when BP ≥140/90 mmHg after 1–3 m LSM • 65–79 years: start treatment when BP ≥150/90 mmHg and consider treatment when BP ≥140/90 mmHg • ≥80 years: when SBP >160 mmHg |
• General advice: BP <140/90 mmHg, BP <130/80 mmHg if tolerated • 65–79 years: BP <150/90 mmHg If tolerated BP <140/90 mmHg • ≥80 years: BP <150/90 mmHg |
| Feitosa- Filho [46] | 2019 | Brazil |
• ≥80 years: when SBP >160 mmHg |
• ≥65 years without frailty: SBP ≤ 130 mmHg • ≤80 years without frailty: SBP <140 mmHg • >80 years and with SBP ≥ 160 mmHg: 140 ≤ SBP ≤ 150 mmHg • Fragile elderly or patients with multiple comorbidities: individualize the therapeutic goal considering risk–benefit ratio |
| Hua [47] | 2019 | China |
• 65–79 years: when BP ≥140/90 mmHg • ≥80 years: when BP ≥150/90 mmHg • In the very old Frail: when BP ≥160/90 mmHg |
• ≥65 years: BP <140/90 mmHg • ≥80 years: BP <150/90 mmHg if tolerated BP <140/90 mmHg • Very old and Frail: 130 ≤ SBP ≤ 150 mmHg |
| Jimbo [48] | 2019 | USA |
• Whenever BP ≥160/100 mmHg • When BP ≥140/90 mmHg after LSM (up to 12 m) |
• General advice: BP <140/90 mmHg • Male sex ≥ 60 years or Female ≥ 70 years: BP <130/80 mmHg • If high risk for hypotension: BP <140/90 mmHg |
| Lee [49] | 2019 | South Korea |
• General advice: whenever BP ≥160/100 mmHg when BP ≥140/90 mmHg after LSM • Fit and >65–80 years: when SBP >140 mmHg • Frail and old or >80 years: when SBP >160 mmHg |
• General advice: BP <140/90 mmHg • >65 years: BP <140/90 mmHg (if DBP <70 mmHg: be careful) |
| MOPHQa [50] | 2019 | Qatar |
• 18–80 years: consider treatment when BP ≥140/90 mmHg consider treatment when BP levels close to 140/90 mmHg and lifestyle interventions are ineffective. • Any age: whenever BP ≥160/100 mmHg |
• General advice: BP <140/90 mmHg and strive to <130/80 mmHg but SBP ≥120 mmHg and DBP ≥70 mmHg • <65 years: 120 ≤ SBP < 130 mmHg • >65 years: 130 ≤ SBP < 140 mmHg • >80 years: 130 ≤ SBP < 140 mmHg and DBP <80 mmHg |
| NICE [51] | 2019 | UK |
• General advice: whenever BP ≥160/100 mmHg • <60 years: consider treatment when BP ≥140/90 mmHg • >80 years: consider treatment when BP ≥150/90 mmHg • People with frailty or multimorbidity: use clinical judgement |
• <80 years: BP <140/90 mmHg • ≥80 years: BP <150/90 mmHg • People with frailty or multimorbidity: use clinical judgement |
| Tykarski [52] | 2019 | Poland |
• General advice: when BP ≥160/100 mmHg when BP ≥140/90 mmHg after 3–6 m LSM • 65–80 years: according to general principles • ≥80 years: when BP ≥160/90 mmHg • Patients with frailty syndrome: individualize decision to treat |
• <65 years: BP <140/80 mmHg and strive to BP <130/80 mmHg but SBP ≥120 mmHg and DBP ≥70 mmHg • 65–80 years: 130 ≤ SBP <140/70 ≤ DBP <80 mmHg • >80 years: 130 ≤ SBP <150/70 ≤ DBP < 80 mmHg |
| Umemura [53] | 2019 | Japan |
• General advice: whenever BP ≥180/110 mmHg (female) whenever BP ≥160/100 mmHg (male) when BP ≥140/90 mmHg after 1 m LSM • Older patients: whenever BP ≥140/90 mmHg • Frail, dementia, nursed, end of life or >75 years: when 140 ≤ SBP < 150 mmHg: add individual assessment |
• <75 years: BP <130/80 mmHg if tolerated • ≥75 years: BP <140/90 mmHg • Frailty or requiring nursing: individualize BP target |
| Rabi [54] | 2020 | Canada |
• General advice: when BP ≥160/100 mmHg • ≥75 years: when SBP ≥130 mmHg |
• <75 years: BP <140/90 mmHg • ≥75 years: SBP <120 mmHg (with unattended AOBP) |
| Shah [55] | 2020 | India |
• When BP ≥140/90 mmHg after 1 m LSM • When BP ≥160/100 mmHg after a shorter period than one month |
• General advice: Individualize according to age, activity level and other concomitant diseases therapies. Never <120/70 mmHg. • <60 years: BP ≤130/80 mmHg • >60 years: 130 ≤ SBP ≤ 140/80 ≤ DBP ≤90 mmHg • Frail elderly, postural hypotension and at risk of falls: A higher target BP may be acceptable. |
| Unger [56] | 2020 | Intercontinental |
• Whenever BP ≥160/100 mmHg • When BP ≥140/90 mmHg after LSM for 3–6 months (If drug availability is limited: only in those aged 50–80 years) |
Essential standards (low resource): • General advice: BP <140/90 mmHg Optimal standards: • <65 years: 120 ≤ SBP < 130/70 ≤ DBP ≤80 mmHg if tolerated • ≥65 years: BP <140/90 mmHg if tolerated • In context of frailty (and independence/tolerability): Consider individualized BP Target. |
| VA/DoD [57] | 2020 | USA |
• Whenever BP ≥130/90 mmHg (after confirmation, if appropriate and if patient is willing to engage in pharmacotherapy) |
• General advice: SBP <130/90 mmHg • ≥60 years: SBP <150/90 mmHg with added benefit lowering SBP to between 130 and 150 mmHg |
AOBP: Automated office blood pressure. BP: Blood pressure. CV: Cardiovascular. DBP: Diastolic blood pressure. LSM: Lifestyle management. REGICOR: Registre Gironí del cor. SBP: Systolic blood pressure.