Dilemma of Blood Pressure Management in Older and Younger Adults
2019; Lippincott Williams & Wilkins; Volume: 75; Issue: 1 Linguagem: Inglês
10.1161/hypertensionaha.119.14125
ISSN1524-4563
AutoresDonald Clark, Michael E. Hall, Daniel W. Jones,
Tópico(s)Cardiovascular Syncope and Autonomic Disorders
ResumoHomeHypertensionVol. 75, No. 1Dilemma of Blood Pressure Management in Older and Younger Adults Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBDilemma of Blood Pressure Management in Older and Younger Adults Donald Clark III, Michael E. Hall and Daniel W. Jones Donald Clark IIIDonald Clark III From the Department of Medicine (D.C., M.E.H., D.W.J.), University of Mississippi Medical Center, Jackson. , Michael E. HallMichael E. Hall From the Department of Medicine (D.C., M.E.H., D.W.J.), University of Mississippi Medical Center, Jackson. Department of Physiology and Biophysics (M.E.H., D.W.J.), University of Mississippi Medical Center, Jackson. and Daniel W. JonesDaniel W. Jones Correspondence to Daniel W. Jones, Department of Medicine, Mississippi Center for Obesity Research, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216. Email E-mail Address: [email protected] From the Department of Medicine (D.C., M.E.H., D.W.J.), University of Mississippi Medical Center, Jackson. Department of Physiology and Biophysics (M.E.H., D.W.J.), University of Mississippi Medical Center, Jackson. Originally published25 Nov 2019https://doi.org/10.1161/HYPERTENSIONAHA.119.14125Hypertension. 2020;75:35–37Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: November 25, 2019: Ahead of Print Over the last few decades, blood pressure (BP) control rates and the subsequent reduction of cardiovascular risk have improved remarkably due to greater awareness and treatment of hypertension.1 Effective and well-tolerated antihypertensive medications are widely available at low cost. Evidence from randomized controlled clinical trials has allowed clear guideline recommendations for lower goal BP among middle-aged patients with an increased 10-year risk for cardiovascular events.2However, among patients with stage 1 hypertension (systolic BP, 130–139, and diastolic BP, 80–89 mm Hg), clinicians have conflicting guidance managing two important groups: (1) older patients >65 years of age and (2) younger patients 160 mm Hg and did not target a systolic BP <140 mm Hg.Thus, previous guideline recommendations set higher BP treatment targets for older adults.6The antiquated term essential hypertension reflects the historical belief that elevated BP was a necessary physiological response to aging, and for years, even despite contrary evidence, many clinicians practiced by the dogma that a systolic BP of 100 plus your age was acceptable.7 This thinking was perpetuated by observational data demonstrating a J-shaped relationship between BP and cardiovascular disease risk.8 Together, this background likely informs why new recommendations from the American College of Cardiology and American Heart Association to treat older adults to a goal systolic BP 2600 ambulatory noninstitutionalized adults ≥75 years of age and demonstrated that intensive BP lowering (mean achieved systolic BP, 123 mm Hg) versus less-intensive BP lowering (mean achieved BP, 135 mm Hg) significantly reduced cardiovascular events and all-cause mortality.9 The efficacy of intensive BP control in older adults was subsequently reinforced in a meta-analysis including >10 000 patients demonstrating a significant reduction in major adverse cardiovascular events.10 Overall, clinicians should be encouraged by the clear and convincing results of the studies demonstrating benefit to systolic BP reductions to <130 mm Hg among ambulatory noninstitutionalized older adults.Cognitive effects of BP lowering in older adults were also examined in SPRINT. The SPRINT MIND trial—a prespecified substudy of SPRINT including 9361 participants with a mean age of 68 years—found that intensive BP lowering had a nonsignificant reduction in probable dementia and a significant reduction in mild cognitive impairment, a secondary outcome, over 5.1 years of follow up.11 Radiographic biomarkers, including cerebral white matter lesions, were also found to have favorable outcomes with intensive BP lowering.12 Although not definitively proven, the potential for intensive BP lowering to prevent or delay dementia could have major public health implications.13 This signal for benefit, and no evidence of harm for cognitive outcomes, should be reassuring to clinicians and further supports lower BP targets in older patients.Adverse effects of lower BP targets should be considered, especially among older adults who often have other comorbid conditions. Intensive BP lowering in SPRINT was associated with significantly higher rates of syncope, electrolyte abnormalities, and kidney failure.14 However, in the substudy among patients ≥75 years of age, of whom ≈30% were classified as frail, the overall rate of serious adverse events, including injurious falls, was not different between treatment groups.10 The adverse effect profile likely differs in the real word, outside the setting of a closely monitored clinical trial, and deserves consideration in the shared decision-making process between the clinician and patient. Importantly, SPRINT is not generalizable to institutionalized older adults or those with clinical dementia, limited life expectancy, or recent stroke, systolic heart failure, or unintentional weight loss. One important principle in BP management of older adults is the pace of change of BP. We know that the relationship between systolic BP and blood flow in all organs, including the brain, shifts upward in patients with long-standing hypertension.15 Close monitoring and slowly lowering BP over time may be considered to potentially reduce the risk of adverse effects in certain older patients.BP Management in Younger AdultsIn younger adults <40 years of age with stage 1 hypertension, there is neither evidence from event-based randomized controlled trials nor clear direction from guidelines. The 2017 American College of Cardiology/American Heart Association guideline recommends lifestyle therapy for patients with elevated BP or stage 1 hypertension and a 10-year risk of cardiovascular disease <10%. The guideline suggests reassessment at 3 to 6 months but offers no specific recommendation for next steps if BP does not meet the goal systolic BP <130 mm Hg.2 In contrast, the recent American Academy of Pediatrics Management of High Blood Pressure Guideline recommends antihypertensive drug therapy if BP is not at goal within 6 months of lifestyle therapy.16Guideline groups generally confine themselves to recommendations based on randomized controlled clinical trials. Randomized controlled clinical trials with hard clinical outcomes are unlikely to be conducted in young adults given the long time horizon and resources required for such a study. In the absence of evidence from event-based randomized trials and clear guideline recommendations, there are key questions clinicians can address that help in the application of clinical judgment. It is important to consider the lifetime risk of cardiovascular disease from hypertension. While the use of the 10-year risk assessment is a logical approach to decision-making among older patients, it is not a validated or recommended tool in treatment decisions in younger adults <40 years of age, most of whom have a low 10-year risk but high lifetime risk.17 We know from observational data that BP in young adulthood is very predictive of lifetime risk of cardiovascular disease, more so than glucose levels and lipid levels, and time correlation analysis supports the concept of damage accrual, such that there is a cumulative effect of the total historical exposure to elevated BP.18 Family history of atherosclerosis and risk factors for cardiovascular disease may also be helpful to inform BP management decisions in young adults.Early pharmacological treatment of BP can prevent progression to more severe stages of hypertension.19 Moreover, trials evaluating biologically important intermediate end points among low-risk patients demonstrate favorable outcomes. For example, the Prevention of Hypertension in Patients with Prehypertension trial randomized 730 individuals aged 30 to 70 years with systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg to low-dose combination chlorthalidone/amiloride versus placebo. Over 18 months, the intervention arm had a significant reduction in electrocardiographic measures of left ventricular mass and lower risk of incident hypertension, defined as BP ≥140/90 mm Hg.20 While it is important to acknowledge the limitations of intermediate end points, these findings support the concept that antihypertensive drug therapy can avert the deleterious subclinical pathophysiologic responses to high BP.Collectively, the well-established benefit in older populations, long-term epidemiological data, and available randomized trial data suggest that BP-lowering medication may be considered prudent in younger adults with stage 1 hypertension who fail to achieve goal BP with lifestyle therapy—a position supported by the 2018 European Society of Cardiology/European Society of Hypertension guideline.21 Shared decision-making, always useful, is particularly beneficial in this circumstance.ConclusionsBP management in older and younger adults can be approached with confidence applying a few key considerations:Treat older adults according to the 2017 American College of Cardiology/American Heart Association guidelines.Consider lowering BP slowly in older adults.Monitor BP carefully while lowering BP in older adults including seated and standing BP, office and out-of-office measurements including home BP monitoring, and ambulatory BP monitoring.In younger adults with stage 1 hypertension, but failure to achieve and maintain BP below goal with lifestyle therapy, consider use of antihypertensive medication. Use best clinical judgment considering lifetime risk and family history. Use shared decision-making for decisions about use of medication.Shifting from long-time dogma is not easy. Clinicians must face their bias on the topic, both conscious and unconscious. The evidence from recent randomized controlled trials provides strong evidence for benefit of further lowering of BP, and clinicians can and should embrace this paradigm shift with confidence.Sources of FundingNone.DisclosuresThe authors (D. Clark, M.E. Hall, and D.W. Jones) are supported by the National Institutes of Health (NIH)/National Institute of General Medical Sciences grant 5U54GM115428. D. Clark is also funded by an American Heart Associated Career Development Grant 19CDA34760232, and M.E. Hall is funded by the NIH/National Institute of Diabetes and Digestive and Kidney Diseases 1K08DK099415-01A1.FootnotesThe opinions expressed in this article are not necessarily those of the American Heart Association.Correspondence to Daniel W. Jones, Department of Medicine, Mississippi Center for Obesity Research, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216. Email [email protected]eduReferences1. (NCD-RisC) NRFC. Long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries: an analysis of 123 nationally representative surveys.Lancet. 2019; 394:639–651. doi: 10.1016/S0140-6736(19)31145-6CrossrefMedlineGoogle Scholar2. 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Effectiveness of chlorthalidone plus amiloride for the prevention of hypertension: the PREVER-Prevention randomized clinical trial.J Am Heart Assoc. 2016; 5:e004248. doi: 10.1161/JAHA.116.004248LinkGoogle Scholar21. Williams B, Mancia G, Spiering W, et al; ESC Scientific Document Group. 2018 ESC/ESH Guidelines for the management of arterial hypertension.Eur Heart J. 2018; 39:3021–3104. doi: 10.1093/eurheartj/ehy339CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByJones D, Whelton P, Allen N, Clark D, Gidding S, Muntner P, Nesbitt S, Mitchell N, Townsend R and Falkner B (2021) Management of Stage 1 Hypertension in Adults With a Low 10-Year Risk for Cardiovascular Disease: Filling a Guidance Gap: A Scientific Statement From the American Heart Association, Hypertension, 77:6, (e58-e67), Online publication date: 1-Jun-2021. Jones D and Clark D (2020) Hypertension (Blood Pressure) and Lifetime Risk of Target Organ Damage, Current Hypertension Reports, 10.1007/s11906-020-01086-6, 22:10, Online publication date: 1-Oct-2020. January 2020Vol 75, Issue 1 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.119.14125PMID: 31760885 Originally publishedNovember 25, 2019 PDF download Advertisement SubjectsHypertension
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