Hypertension Guideline Update

 

Hypertension represents a major modifiable risk factor for coronary artery disease, heart failure, stroke, chronic kidney disease and dementia. Two well-established clinical practice guidelines on hypertension include the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults and the 2023 European Society of Hypertension (ESH) Guidelines for the Management of Arterial Hypertension.

The ESH recommends a threshold of >140/90 mm Hg (Grade 1) for the diagnosis of hypertension, whereas the ACC/AHA guideline recommends a lower threshold of >130/80 mm Hg (Stage 1). Systolic blood pressure (SBP) ranging between 130 and 139 mm Hg or diastolic blood pressure (DBP) ranging between 80 and 89 mm Hg represent Stage 1 hypertension in the ACC/AHA guideline, whereas the ESH guidelines classify these ranges as "normal" or "high-normal" (130-139/85-89 mm Hg). Whereas the ACC/AHA guideline categorizes BP ≥140/90 mm Hg as Stage 2 hypertension, the ESH guidelines subdivide BP levels ≥140/90 mm Hg into Grades 1, 2, and 3 hypertension.

                     * Target <130/80 if tolerated

With increasing age, blood pressure rises as a consequence of arterial stiffness, caused by the biological process of ageing and arteries becoming clogged with fatty substances, otherwise known as arteriosclerosis.

Since arterial hypertension (high blood pressure in the arteries) is the most important preventable cause of cardiovascular disease, lowering blood pressure can lower the risk of heart attacks, stroke, and all-cause mortality, even in people over 80.

However, for mental abilities, age seems to play an important role. At old age, low blood pressure is associated with worse cognitive function and increased mortality than people with higher blood pressure especially when they are frail.

Thus doctors thinking about prescribing blood pressure lowering therapy in older patients should consider the specific patients. A more individual approach instead of “one size fits all” seems most appropriate and is also more patient-centered. This is especially important for very old and frail patients not just to follow the guidelines.