Hypertension Management at Older Age: An Update
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REVIEW ARTICLE
Hypertension Management at Older Age: An Update Rita Del Pinto1 · Claudio Ferri1 Received: 3 October 2018 / Accepted: 19 November 2018 / Published online: 22 November 2018 © Springer Nature Switzerland AG 2018
Abstract Hypertension is a risk factor for cardiovascular morbidity and mortality with increasing prevalence with age, whose treatment is associated with benefits over fatal and non-fatal cardiovascular events even later in life. However, there are persistent concerns on the short- and long-term weighted benefits of treating hypertension in the very old, particularly in those with specific clinical features. In fact, a broad range of clinical scenarios can be observed at older ages, spanning from the healthy to the frailest patient, and hypertension clinical trials have traditionally excluded the latter, thus preventing the unconditioned application to these patients of the same recommendations as in younger ages. Persistent issues regarding high blood pressure management in the very old adult are mainly related to treatment threshold and targets, which have been differently addressed by American and European guidelines. Herein, we will examine the challenges related to high blood pressure treatment in healthy and frail older and very old adults. We will discuss the evidence behind current recommendations. Finally, we will recapitulate the recommended treatment options for high blood pressure in these patients in the light of the most recent guidelines. Keywords Aging · Hypertension · Antihypertensive agents · Cardiovascular diseases · Cerebrovascular diseases · Frailty
1 Introduction With the constant increase in the lifespan of the recent years, reducing the burden of unsuccessful aging represents a challenge with critical socioeconomic implications. High blood pressure (BP), the first cardiovascular risk factor, is a condition typical of older adults [1]. With aging, large artery stiffness determines a linear increase in systolic BP, while diastolic BP slowly decreases [2]. Together, these changes translate into a steep rise in pulse pressure. At older ages, isolated systolic hypertension (i.e. systolic BP ≥ 160 mmHg with variable diastolic BP ≤ 90, ≤ 95, or ≤ 110 mmHg) and high pulse pressure are more accurate independent predictors of cardiovascular risk [2]. There is evidence that reducing BP is associated with decreased risk of cardiovascular events and disability even in octogenarians [3, 4], and guidelines recommendations have been progressively updated to reflect this data. However, since older hypertensive patients
with comorbidities have been traditionally excluded from interventional trials, there is limited evidence regarding the extent to which they should be treated for this condition. In addition, there is concrete concern about the risk for a greater burden of adverse effects of hypertension treatment in the very old, including the risk of falls, impaired renal function, cognitive decline, adverse effects of medications, and for their relative impact on quality of life. R
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