DynaMed Plus - Hypertension Treatment in Elderly Patients

12/10/2018 DynaMed Plus: Hypertension treatment in elderly patients
Hypertension treatment in elderly patients

Overview & Recommendations
Background
Some guidelines support modifications in the management of hypertension in elderly patients compared to
non-elderly.
There is no consensus among hypertension guidelines as to the precise definition of elderly and
recommendations are based on different age criteria.
Examples of guidelines with age cutoffs relating to target blood pressures and/or threshold for treatment
include:
≥ 60 years old in the general population is the cutoff utilized by the Eighth Joint National
Committee (JNC8) 2014 guideline
≥ 80 years old is the cutoff utilized by the National Institute for Health and Clinical Excellence
(NICE)
Treatment thresholds and blood pressure targets
Guidelines differ regarding blood pressure targets and thresholds for beginning treatment for the treatment
of hypertension in elderly patients.
More general recommendations regarding the treatment of hypertension in elderly patients include:
Consider caution when using antihypertensive medications for frail elderly patients (Weak
recommendation).
Consider lower target blood pressures for elderly patients with diabetes or end-organ damage.
Consider 1 of the following antihypertensive medications as a first-line agent when treating elderly
patients:
thiazide-type diuretics
calcium channel blockers
angiotensin-converting enzyme (ACE) inhibitors
angiotensin receptor blockers (ARBs)
Beta blockers may increase the risk of cardiovascular events when used in elderly patients.
Related Summaries
Hypertension (list of topics)
Hypertension
First-line therapy for hypertension
Hypertension treatment in patients with diabetes
Hypertension treatment in patients with chronic kidney disease
Hypertension treatment considerations for race and ethnicity
Hypertension medication selection and management
Antihypertensive drugs and dosing
Hypertension alternative treatments
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Overview
treating healthy older persons with hypertension may reduce cardiovascular morbidity and mortality (level
2 [mid-level] evidence)
target blood pressure goals
in elderly patients in absence of comorbidities, recommendations from professional organizations
vary
target systolic blood pressure < 130 mm Hg recommended for noninstitutionalized
ambulatory community-dwelling adults ≥ 65 years old by ACC/AHA
target systolic blood pressure < 150 mm Hg recommended for patients who are
≥ 60 years old by JNC8 and ACP/AAFP (JNC8 Strong recommendation, ACP/AAFP
Strong recommendation, High-quality evidence )
< 80 years old by ESH/ESC (ESH/ESC Class I, Level A)
> 80 years old if in good physical and mental condition (ESH/ESC Class I, Level B)
≥ 80 years old by NICE
target diastolic blood pressure < 90 mm Hg recommended for most elderly patients (JNC8
Strong recommendation)
for adults ≥ 65 years old with hypertension, high burden of comorbidity, and limited life expectancy,
consider clinical judgment, patient preference, and team-based approach to assess risk/benefit for
decisions regarding intensity of BP lowering (ACC/AHA Class IIa, Level C-EO)
target of < 130/80 mm Hg in patients with diabetes, cardiovascular disease, chronic kidney disease,
or high risk for cardiovascular disease (10-year risk > 10%)
intensive blood pressure targets (SBP < 120 mm Hg) may reduce cardiovascular events and
mortality compared to SBP target < 140 mm Hg in patients ≥ 75 years old, but may increase adverse
renal outcomes (level 2 [mid-level] evidence)
antihypertensive treatment
target thresholds for starting antihypertensive treatment are generally ≥ 150-160 mm Hg (systolic)
and ≥ 90-100 mm Hg (diastolic), and generally lower in patients with target organ damage and
certain concomitant medical conditions
medications with efficacy for reducing cardiovascular morbidity and mortality in elderly patients
with hypertension include
calcium channel blockers - nitrendipine (level 1 [likely reliable] evidence)
thiazide-type diuretics - chlorthalidone (level 2 [mid-level] evidence), sustained-release
indapamide (level 2 [mid-level] evidence)
beta blockers may increase risk of cardiovascular events in elderly patients (level 2 [mid-level]
evidence)
antihypertensive treatment in patients > 80 years old may reduce risk of stroke, cardiovascular
events and heart failure but not mortality (level 2 [mid-level] evidence)
recommendations for target blood pressure goals and target thresholds for starting medications may be
different for patients with comorbidities and in frail elderly patients
Lifestyle Modifications
efficacy of lifestyle modifications for patients with hypertension (not specific to elderly patients)
weight reduction may reduce blood pressure (BP) in patients with primary hypertension (level 3
[lacking direct] evidence)
sodium restriction may reduce BP by mean 5-10/2-3 mm Hg (level 3 [lacking direct] evidence) but
may not affect long-term mortality or cardiovascular outcomes (level 2 [mid-level] evidence)
Dietary Approaches to Stop Hypertension (DASH) diet (fruits, vegetables, low-fat dairy, reduced
fat) can reduce BP by 8-14 mm Hg (level 3 [lacking direct] evidence); increased adherence to
DASH-style diet associated with reduced risk for cardiovascular mortality, myocardial infarction,
and stroke (level 2 [mid-level] evidence)
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physical activity associated with reduced cardiovascular mortality in persons with high BP (level 2
[mid-level] evidence)
smoking cessation (see also Tobacco use)
see Hypertension for details
Indications for Antihypertensive Medications in Elderly

Recommendations for initiation of medications
American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention,
Detection, Evaluation, and Management of High Blood Pressure in Adults
treat hypertension with systolic blood pressure (SBP) treatment goal < 130 mm Hg in
noninstitutionalized ambulatory community-dwelling adults (≥ 65 years old) with average SBP of
130 mm Hg or higher (ACC/AHA Class I, Level A)
decisions regarding intensity of BP lowering and choice of antihypertensive drugs for adults ≥ 65
years old with hypertension, high burden of comorbidity, and limited life expectancy (ACC/AHA
Class IIa, Level C-EO)
Reference - Hypertension 2018 Jun;71(6):1269
Eighth Joint National Committee (JNC8) 2014 guideline recommends, in general population ≥ 60 years
old, starting pharmacologic treatment when blood pressure ≥ 150/90 mm Hg (JNC8 Strong
recommendation)(1)
European Society of Hypertension/European Society of Cardiology (ESH/ESC) recommendations for
elderly patients with hypertension(3)
antihypertensive drugs recommended in elderly patients > 80 years old with initial SBP ≥ 160 mm
Hg who are in good physical and mental condition (ESH/ESC Class I, Level B)
consider antihypertensive drugs in fit elderly patients < 80 years old with SBP ≥ 140 mm Hg if
treatment is well tolerated (ESH/ESC Class IIb, Level C)
in frail elderly patients, leave decision on antihypertensive therapy to treating physician and based
on monitoring of clinical effects of treatment (ESH/ESC Class I, Level C)
consider continuation of well tolerated antihypertensive drugs when patient reaches age 80 years
(ESH/ESC Class IIa, Level C)
Hypertension Canada (formerly Canadian Hypertension Education Program [CHEP]) recommendations
on pharmacological therapy for adults with hypertension without compelling indications for specific
agents(4)
consider antihypertensive therapy for all patients meeting below indications regardless of age
(Hypertension Canada Grade B)
in patients without macrovascular target organ damage or other cardiovascular risk factors,
prescribe antihypertensive therapy if
average diastolic blood pressure (DBP) ≥ 100 mg Hg (Hypertension Canada Grade A) or
average SBP ≥ 160 mm Hg (Hypertension Canada Grade A)
in patients with macrovascular target organ damage, strongly consider antihypertensive therapy if
average DBP ≥ 90 mm Hg (Hypertension Canada Grade A)
average SBP ≥ 140 mm Hg (Hypertension Canada Grade A if > 160 mm Hg, Hypertension
Canada Grade B if 140-160 mm Hg)
in patients with other independent cardiovascular risk factors, strongly consider antihypertensive
therapy if average DBP ≥ 90 mm Hg (Hypertension Canada Grade A)
National Institute for Health and Clinical Excellence (NICE) guideline on management of primary
hypertension in adults(5)
in all patients at any age, consider antihypertensive therapy if average
ambulatory or home blood pressure ≥ 150/95 mm Hg
outpatient clinic blood pressure ≥ 160/100 mm Hg
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in patients < 80 years old and with average ambulatory or home blood pressure ≥ 135/85 mm Hg
and < 150/95 mm Hg or clinic blood pressure ≥ 140/90 mm Hg and < 160/100 mm Hg, consider
antihypertensive therapy if ≥ 1 of the following present
established cardiovascular disease
diabetes
renal disease
target organ damage
10 year cardiovascular risk equivalent to ≥ 20%.
Efficacy for blood pressure lowering

treating healthy older persons with hypertension may reduce cardiovascular morbidity and
mortality (level 2 [mid-level] evidence)
based on Cochrane review of trials with methodologic limitations
systematic review of 15 randomized trials of ≥ 1 year duration comparing antihypertensive
medications vs. placebo or no treatment in 24,055 patients ≥ 60 years old with moderate-to-severe
hypertension
patients in trials generally had fewer comorbidities and risk factors than general population of
hypertensive elderly patients
most patients were aged 60-80 years; most trials evaluated first-line thiazide diuretic therapy
over mean 4.5 years
11 trials had unclear sequence generation; 10 trials had unclear allocation concealment
antihypertensive medication associated with
reduced risk of overall mortality (risk ratio [RR] 0.9, 95% CI 0.84-0.97, NNT 45-238
assuming 14% mortality in controls) in analysis of 12 trials with 23,119 patients
reduced risk of cardiovascular mortality (RR 0.77, 95% CI 0.68-0.86, NNT 63-143 assuming
5% cardiovascular mortality in controls) in analysis of 10 trials with 22,948 patients
reduced risk of cardiovascular event (morbidity or mortality) (RR 0.72, 95% CI 0.68-0.77,
NNT 16-22 assuming 20% event rate in controls) in analysis of 13 trials with 23,094 patients,
results limited by significant heterogeneity (p < 0.0001)
similar reductions in cardiovascular events found in subgroup analyses of patients ≥ 80
years old and in patients with isolated systolic hypertension
increased risk of withdrawal due to adverse events (RR 1.71, 95% CI 1.45-2, NNH 14-31
assuming withdrawal due to adverse event in 7% of controls) in analysis of 3 trials with 6,914
patients
Reference - Cochrane Database Syst Rev 2009 Oct 7;(4):CD000028
similar conclusions reported in earlier meta-analysis by same lead authors (JAMA 1994 Dec
28;272(24):1932)
consistent results in systematic review of 18 randomized trials evaluating antihypertensive
medication in 114,854 elderly persons (Heart 2014 Feb;100(4):317)
blood pressure lowering associated with similar relative risk reductions in major cardiovascular
events in younger (< 65 years) and older (≥ 65 years) adults (level 2 [mid-level] evidence)
based on systematic review without assessment of trial quality
systematic review of 31 randomized trials evaluating antihypertensive regimens in 190,606 adults
49.4% of patients aged ≥ 65 years
mean age 57 years among patients < 65 years old and 72 years among patients ≥ 65 years old
no significant difference in cardiovascular outcomes or blood pressure changes between patients
aged < 65 years and ≥ 65 years with any antihypertensive therapy
Reference - BMJ 2008 May 17;336(7653):1121 full-text, commentary can be found in ACP J Club
2008 Sep 16;149(3):10
treatment of isolated systolic hypertension in the elderly appears to reduce morbidity and mortality
(level 2 [mid-level] evidence)
based on systematic review without description of systematic bibliographic search
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systematic review of 8 trials with 15,693 patients > 60 years old with systolic blood pressure (SBP)
> 160 mm Hg and diastolic blood pressure (DBP) < 95 mm Hg
49.5% of patients aged ≥ 70 years
median follow-up 3.8 years
all-cause mortality associated with SBP (p < 0.001) with hazard ratio 1.26 (95% CI 1.13-1.4) for
each 10 mm Hg increase in SBP
increased pulse pressure also associated with increased mortality
active treatment associated with mean reduction of SBP of 10.4 mm Hg
active treatment associated with reduced rates of
total mortality (13% odds ratio reduction, NNT 59 [95% CI 55-64])
cardiovascular mortality (18% odds ratio reduction, NNT 79 [95% CI 72-89])
all cardiovascular complications (26% odds ratio reduction, NNT 26 [95% CI 25-27])
stroke (30% odds ratio reduction, NNT 48 [95% CI 45-51])
coronary events (23% odds ratio reduction, NNT 64 [95% CI 59-70])
treatment effects greater for men, patients > 70 years old, and patients with previous cardiovascular
complications
Reference - Lancet 2000 Mar 11;355(9207):865, correction can be found in Lancet 2001 Mar
3;357(9257):724
antihypertensive treatment in patients > 80 years old may reduce risk of stroke, cardiovascular
events, and heart failure but not mortality (level 2 [mid-level] evidence)
based on systematic review limited by heterogeneity
systematic review of 8 randomized trials comparing hypertension medication vs. placebo/no
treatment in 6,701 patients > 80 years old with hypertension
hypertensive drug treatment associated with reduced risk of
stroke (relative risk [RR] 0.65, 95% CI 0.52-0.83) in analysis of 7 trials
heart failure (RR 0.5, 95% CI 0.33-0.76) in analysis of 6 trials
cardiovascular events (RR 0.73, 95% CI 0.62-0.86) in analysis of 6 trials
no significant difference in overall mortality in analysis of all trials, results limited by significant
heterogeneity (p = 0.07)
Reference - J Hypertens 2010 Jul;28(7):1366, editorial can be found in J Hypertens 2010
Jul;28(7):1373
Target Blood Pressure in Elderly

Recommendations (target BP)
systolic blood pressure (SBP) treatment goal < 130 mm Hg in noninstitutionalized ambulatory
community-dwelling adults (≥ 65 years old) with average SBP of 130 mm Hg or higher (ACC/AHA
Class I, Level A)
decisions regarding intensity of BP lowering and choice of antihypertensive drugs for adults ≥ 65
years old with hypertension, high burden of comorbidity, and limited life expectancy (ACC/AHA
Class IIa, Level C-EO)
Eighth Joint National Committee (JNC8) 2014 guideline(1)
in general population ≥ 60 years old, treat to blood pressure (BP) goal of < 150/90 mm Hg (JNC8
Strong recommendation)
if treatment with medications results in lower blood pressures (below the 150/90 mm Hg target) and
treatment is well tolerated, treatment does not need to be adjusted because of new targets with this
guideline (JNC8 Expert opinion)
5/26
target clinic blood pressure
140/90 mm Hg for patients < 80 years old
150/90 mm Hg for patients ≥ 80 years old
target ambulatory blood pressure or home blood pressure
135/85 mm Hg for patients < 80 years old
145/85 mm Hg for patients ≥ 80 years old
American College of Cardiology Foundation/American Heart Association Expert Consensus on
Hypertension in the Elderly(2)
systolic blood pressure (SBP) < 140 mm Hg recommended for most patients ≤ 79 years old
SBP 140-145 mm Hg, if tolerated, is acceptable for patients ≥ 80 years old
blood pressure < 130/80 mm Hg recommended if diabetes mellitus, chronic kidney disease,
coronary artery disease, carotid artery disease, peripheral arterial disease, abdominal aortic
aneurysm, or high risk for cardiovascular disease (10-year risk > 10%)
blood pressure < 120/80 mm Hg recommended if left ventricular dysfunction
European Society of Hypertension/European Society of Cardiology (ESH/ESC) recommendations(3)
if age < 80 years and SBP ≥ 160 mm Hg, recommended SBP goal 140-150 mm Hg (ESH/ESC Class
I, Level A)
if age > 80 years and SBP ≥ 160 mm Hg, recommended SBP goal 140-150 mm Hg if patient is in
good physical and mental condition (ESH/ESC Class I, Level B)
in fit elderly patients < 80 years old with hypertension, SBP < 140 mm Hg may be considered
(ESH/ESC Class IIb, Level C)
in frail elderly patients, adapt SBP goals to individual tolerability (ESH/ESC Class IIb, Level C)
Hypertension Canada (formerly Canadian Hypertension Education Program [CHEP]) recommendations(4)
blood pressure treatment goals in adults without compelling indications for specific drugs
SBP < 140 mm Hg (Hypertension Canada Grade C)
diastolic blood pressure < 90 mm Hg (Hypertension Canada Grade A)
except for diabetes (with target blood pressure < 130/80 mm Hg), target blood pressure in adults
with other compelling indications is also < 140/90 mm Hg
American College of Physicians and the American Academy of Family Physicians (ACP/AAFP)
recommendations
in adults ≥ 60 years old
if persistent systolic blood pressure ≥ 150 mm Hg, initiate treatment to target systolic blood
pressure < 150 mm Hg to reduce risk for mortality, stroke, and cardiac events (ACP/AAFP
Strong recommendation, High-quality evidence )
if history of stroke or transient ischemic attack, consider initiating or intensifying treatment to
target systolic blood pressure < 140 mm Hg to reduce risk for recurrent stroke (ACP/AAFP
Weak recommendation, Moderate-quality evidence )
if high cardiovascular risk, based on individualized assessment, consider initiating or
intensifying treatment to target systolic blood pressure < 140 mm Hg to reduce risk for stroke
or cardiac events (ACP/AAFP Weak recommendation, Low-quality evidence )
Reference - Ann Intern Med 2017 Mar 21;166(6):430 full-text
Evidence (target BP)

intensive blood pressure-lowering strategies may reduce cardiovascular mortality and heart failure
compared to less-intensive blood pressure-lowering strategies in patients ≥ 65 years old with
hypertension (level 2 [mid-level] evidence)
based on systematic review with inconsistent results in individual trials
systematic review of 4 randomized trials comparing intensive blood pressure-lowering strategies vs.
standard strategies in 10,857 patients ≥ 65 years old with hypertension
comparisons of intensive vs. standard blood pressure-lowering strategies included
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systolic blood pressure (SBP) < 120 mm Hg vs. SBP < 140 mm Hg in patients ≥ 75 years old
with hypertension and increased risk for cardiovascular disease (SPRINT-SENIOR trial)
SBP < 140 mm Hg vs. SBP 140-149 mm Hg in
patients aged 70-85 years with isolated systolic hypertension in Japan (VALISH trial)
patients ≥ 70 years old with essential hypertension in China
SBP < 140 mm Hg vs. SBP 140-159 mm Hg in patients aged 65-85 years with essential
hypertension in Japan (JATOS trial)
median follow-up ranged from 2 to 4 years
intensive blood pressure-lowering strategies associated with
reduced cardiovascular mortality in analysis of all trials
risk ratio (RR) 0.67 (95% CI 0.45-0.98)
NNT 107-2,942 with cardiovascular mortality 1.7% in standard strategy group
inconsistent results with
no significant benefit of intensive blood pressure-lowering strategies in 2 trials
with 7,497 patients (VALISH and JATOS trials; control event rate ranged from
0.2% to 0.7%)
significant or nonsignificant benefit with blood pressure-lowering strategies in 2
trials with 3,360 patients (SPRINT-SENIOR trial and trial in China; control event
rate ranged from 2.2% to 13.9%)
reduced risk of heart failure in analysis of 3 trials with 7,778 patients
RR 0.63 (95% CI 0.43-0.99)
NNT 88-5,000 with heart failure in 2% of standard strategy group
inconsistent results with
no significant benefit of intensive blood pressure-lowering strategy in 1 trial with
4,418 patients (JATOS trial; control event rate 0.3%)
significant benefit with blood pressure-lowering strategies in 2 trials with 3,360
patients (SPRINT-SENIOR trial and trial in China; control event rates ranged
from 4.2% to 4.4%)
no significant differences in
stroke (RR 0.8, 95% CI 0.61-1.05) in analysis of all trials
myocardial infarction (RR 0.79, 95% CI 0.56-1.12) in analysis of all trials
serious adverse events (RR 1.02, 95% CI 0.94-1.09) in analysis of 3 trials with 10,133
patients
renal failure (RR 1.81, 95% CI 0.86-3.8) in analysis of 3 trials with 10,116 patients
Reference - J Am Coll Cardiol 2017 Feb 7;69(5):486 editorial can be found in J Am Coll Cardiol
2017 Feb 7;69(5):494
intensive blood pressure targets (SBP < 120 mm Hg) may reduce cardiovascular events and
mortality compared to SBP target < 140 mm Hg in patients ≥ 75 years old, but may increase adverse
renal outcomes (level 2 [mid-level] evidence)
based on prespecified subgroup analysis of SPRINT trial without stratification by age
2,636 community-dwelling patients ≥ 75 years old (mean age 80 years, 62% male) with
hypertension but without diabetes from SPRINT trial were assessed
potential baseline differences comparing intensive therapy vs. standard therapy at baseline (no p
values reported)
aspirin use in 62.3% vs. 58%
frail status (frailty index > 0.21) in 33.4% vs. 28.4%
6.1% discontinued intervention (but continued follow-up) and 4.8% withdrew consent or were lost
to follow-up, but all patients were included in analysis
mean systolic blood pressure was 123.4 mm Hg with intensive therapy vs. 134.8 mm Hg with
standard therapy throughout follow-up
mean number of blood pressure medications was 2.6 with intensive therapy vs. 1.8 with standard
therapy
primary outcome was composite of myocardial infarction, acute coronary syndrome, stroke, acute
decompensated heart failure, and cardiovascular death
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efficacy outcomes comparing intensive therapy vs. standard therapy at median follow-up 3.14 years
primary outcome in 7.7% vs. 11.2% (p = 0.001, NNT for 3 years 29)
all-cause mortality 5.5% vs. 8.1% (p = 0.009, NNT for 3 years 39)
cardiovascular mortality 1.4% vs. 2.2% (p = 0.09)
myocardial infarction in 2.8% vs. 4% (p = 0.09)
acute coronary syndrome (not resulting in myocardial infarction) in 1.3% vs. 1.3% (not
significant)
stroke in 2.1% vs. 2.6% (not significant)
heart failure in 2.7% vs. 4.2% (p = 0.03, NNT for 3 years 67)
no significant associations between primary outcome or all-cause mortality and frailty status or gait
speed
serious adverse event rates comparing intensive therapy vs. standard therapy
overall in 48.4% vs. 48.3% (not significant)
acute kidney injury or acute renal failure in 5.5% vs. 4% (p = 0.061)
hypotension in 2.4% vs. 1.4% (p = 0.066)
electrolyte abnormality in 4% vs. 2.7% (p = 0.058)
no significant differences in syncope, bradycardia, or injurious fall
in patients without chronic kidney disease at baseline, secondary chronic kidney disease developed
in 5.1% with intensive therapy vs. 1.8% with standard therapy (p < 0.001, NNH for 3 years 30)
in patients with chronic kidney disease at baseline, no significant differences in primary chronic
kidney disease outcomes or incident albuminuria
Reference - SPRINT-SENIOR trial (JAMA 2016 Jun 28;315(24):2673, editorial can be found in
JAMA 2016 Jun 28;315(24):2669 )
strict blood pressure control (SBP < 140 mm Hg) may not reduce cardiovascular mortality or
morbidity compared to moderate blood pressure control (SBP ≥ 140 mm Hg to < 160 mm Hg) in
older Japanese patients with hypertension (level 2 [mid-level] evidence)
based on 1 trial without blinding and 1 trial with wide confidence intervals
randomized trial without blinding of patients
4,418 patients aged 65-85 years with SBP > 160 mm Hg randomized to strict blood pressure
(BP) control (< 140 mm Hg) vs. mild blood pressure control (≥ 140 mm Hg to < 160 mm Hg)
for 2 years
all patients received efonidipine and other antihypertensive drugs if needed
comparing strict vs. mild blood pressure control at 2 years
mean blood pressure 135.9/74.8 mm Hg vs. 145.6/78.1 mm Hg (p < 0.001)
cardiovascular mortality 0.27% vs. 0.18% (not significant)
cerebrovascular disease in 2.35% vs. 2.22% (not significant)
cardiac and vascular disease in 1.18% vs. 1.27% (not significant)
renal failure in 0.36% vs. 0.41% (not significant)
Reference - JATOS trial (Hypertens Res 2008 Dec;31(12):2115)
randomized trial with wide confidence intervals
3,260 patients aged 70-84 years with isolated SBP (sitting blood pressure 160-199 mm Hg)
randomized to strict blood pressure control (< 140 mm Hg) vs. moderate blood pressure
control (≥ 140 mm Hg to < 150 mm Hg) and followed for mean 2.85 years
all patients received valsartan and other antihypertensive agents if needed
94.4% of patients included in analysis
comparing strict vs. moderate blood pressure control
mean blood pressure 136.6/74.8 mm Hg vs. 142/76.5 mm Hg (p < 0.001)
all-cause mortality 1.55% vs. 1.96% (hazard ratio [HR] 0.78, 95% CI 0.46-1.33), not
significant but CI includes possibility of benefit or harm
cardiovascular mortality 0.71% vs. 0.72% (HR 0.97, 95% CI 0.42-2.25), not significant
but CI includes possibility of benefit or harm
renal insufficiency in 0.32% vs. 0.13% (HR 2.45, 95% CI 0.48-12.64), not significant
but CI includes possibility of benefit or harm
8/26
no significant differences in sudden death, fatal and nonfatal stroke, fatal and nonfatal
myocardial infarction, and unplanned hospitalization
Reference - VALISH trial (Hypertension 2010 Aug;56(2):196 full-text)
lower SBP associated with increased all-cause mortality in adults aged ≥ 85 years taking
antihypertensive medications
based on prospective population-based cohort study
570 adults aged ≥ 85 years in the Netherlands with no prior history of cardiovascular disease were
followed for 5 years
cognitive function assessed using Mini-Mental State Examination (MMSE), score range 0-30 points
with ≥ 24 points indicating normal function
44% were prescribed antihypertensive therapy at baseline
46% died during follow-up
among adults taking antihypertensives, lower SBP associated with
increased all-cause mortality (adjusted hazard ratio [HR] 1.29 per 10 mm Hg lower SBP, 95%
CI 1.15-1.46)
accelerated cognitive decline (annual mean decrease in MMSE score 0.35 points per 10 mm
Hg lower SBP, 95% CI 0.11-0.6)
among adults not prescribed antihypertensive treatment
lower SBP associated with nonsignificant increase in all-cause mortality (adjusted HR 1.08
per 10 mm Hg lower SBP, 95% CI 1-1.18)
no significant difference in rate of cognitive change with lower blood pressure
Reference - Age Ageing 2018 May 8 early online
SBP < 120 mm Hg associated with increased all-cause mortality compared to SBP 120-139 mm Hg
in older nursing home residents
based on prospective cohort study
406 nursing home residents (mean age 85 years, 71% women) in Sweden who had standard blood
pressure measurements taken every 6 months were categorized into 1 of 4 groups based on baseline
SBP and followed for 30 months
SBP < 120 mm Hg (27%)
SBP 120-139 mm Hg (34%)
SBP 140-159 mm Hg (25%)
SBP ≥ 160 mm Hg (14%)
at baseline, mean SBP 127 mm Hg in men vs. 136 mm Hg in women (p < 0.001)
43% died overall
SBP < 120 mm Hg associated with increased all-cause mortality compared to SBP 120-139 mm Hg
(adjusted hazard ratio 1.56, 95% CI 1.08-2.27)
no significant difference in all-cause mortality comparing SBP 140-159 mm Hg or SBP ≥ 160 mm
Hg to SBP 120-139 mm Hg
in 180 patients eligible for measurements, SBP decreased from mean 135 mm Hg to mean 130 mm
Hg over 18 months regardless of changes in antihypertensive treatment
Reference - Age Ageing 2016 Nov;45(6):826
Drug Choices
Recommendations
no separate recommendations made regarding which medication should be used in elderly patients
general recommendations for adults
recommended first-line antihypertensive drugs include thiazide diuretics, calcium channel
blockers (CCBs), and angiotensin-converting enzyme (ACE) inhibitors or angiotensin
receptor blockers (ARBs) (ACC/AHA Class I, Level A)
9/26
for stage 1 hypertension with BP goal < 130/80 mm Hg, consider initiation of single
antihypertensive drug with dosage titration and sequential addition of other agents to achieve
BP target (ACC/AHA Class IIa, Level C-EO)
for stage 2 hypertension and average BP > 20 mm Hg systolic/10 mm Hg diastolic above their
BP target, initiate antihypertensive drug therapy with 2 first-line drugs of different classes
(either as separate drugs or in fixed-dose combination) (ACC/AHA Class I, Level C-EO)
for black adults
in black adults with hypertension but without heart failure or chronic kidney disease
(including those with diabetes mellitus), initial antihypertensive treatment should include a
calcium channel blocker or thiazide-type diuretic (ACC/AHA Class I, Level B-R)
≥ 2 antihypertensive medications recommended to achieve BP target of < 130/80 mm Hg in
most adults with hypertension, particularly in black adults with hypertension (ACC/AHA
Class I, Level C-LD)
Eighth Joint National Committee (JNC8) 2014 guideline(1)
no separate recommendation was made regarding which medication should be used in elderly
patients
in general, initial antihypertensive treatment can include any of the following
in nonblack population (JNC8 Moderate recommendation)
calcium-channel blockers
angiotensin-converting enzyme (ACE) inhibitor
angiotensin receptor blocker (ARB)
in black patients (JNC8 Moderate recommendation; JNC8 Weak recommendation for black
patients with diabetes)
calcium-channel blockers
American College of Cardiology Foundation/American Heart Association Expert Consensus on
Hypertension in the Elderly(2)
consider nonpharmacological interventions in all elderly patients with hypertension before starting
drug therapy
initial drug choices
thiazide diuretic (hydrochlorothiazide, chlorthalidone, or bendrofluazide) recommended for
initial therapy
other options for initial therapy (if not compelling indications for specific drug selection) are
ACE inhibitor, ARB, or calcium channel blocker
if diuretic not used as initial therapy, diuretic usually indicated if second drug needed
initial therapy for hypertension in elderly if specific comorbidities
systolic heart failure should be treated with diuretic, beta blocker, ACE inhibitor (or
ARB), and aldosterone antagonist
after myocardial infarction - beta blocker, ACE inhibitor (or ARB), aldosterone
antagonist
coronary artery disease or high risk for cardiovascular disease (10-year risk > 10%) -
thiazide diuretic, beta blocker, ACE inhibitor, calcium channel blocker
angina - beta blocker, calcium channel blocker
aortic aneurysm - beta blocker, ARB, ACE inhibitor, thiazide diuretic, calcium channel
blocker
diabetes - ACE inhibitor (or ARB), calcium channel blocker, thiazide diuretic, beta
blocker
chronic kidney disease - ACE inhibitor (or ARB)
stroke or transient ischemic attack - thiazide diuretic, ACE inhibitor (or ARB), calcium
channel blocker
alpha blockers NOT recommended for first-line therapy
start drug therapy at lowest dose and gradually increase
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if blood pressure not controlled at maximum tolerated dose, add a drug from another class
if blood pressure > 20/10 mm Hg above goal, consider starting 2 drugs at initiation of drug
treatment
European Society of Hypertension/European Society of Cardiology (ESH/ESC) recommendations(3)
all antihypertensive drugs can be used in elderly, but diuretics and calcium channel blockers may be
preferred in isolated systolic hypertension (ESH/ESC Class I, Level A)
Hypertension Canada (formerly Canadian Hypertension Education Program [CHEP]) recommendations(4)
initial therapy should be monotherapy with 1 of
thiazide/thiazide-like diuretic (Hypertension Canada Grade A) but avoid hypokalemia
(Hypertension Canada Grade C)
ACE inhibitor (in nonblack patients) (Hypertension Canada Grade B)
long-acting calcium channel blocker (Hypertension Canada Grade B)
ARB (Hypertension Canada Grade B)
beta blockers not recommended as first-line therapy for uncomplicated hypertension (or isolated
systolic hypertension) in patients ≥ 60 years old (Hypertension Canada Grade A)
in patients > 55 years old with hypertension, first choice for initial therapy should be calcium
channel blocker or thiazide-like diuretic if calcium channel blocker is not appropriate or poorly
tolerated
patients > 80 years old should be offered same antihypertensive medications treatment as people
aged 55-80 years old while taking into account any comorbidities
Diuretics
Chlorthalidone
stepped antihypertensive treatment (starting with chlorthalidone) may reduce 5-year rates of major
cardiovascular disease events (level 2 [mid-level] evidence)
based on randomized trial without description of randomization
4,736 patients > 60 years old with isolated systolic hypertension randomized to stepped
antihypertensive treatment vs. placebo
step 1 of intervention included chlorthalidone 12.5-25 mg/day
step 2 of intervention included atenolol 25-50 mg/day, or reserpine 0.05-10 mg/day if atenolol
was not tolerated
isolated systolic hypertension defined as systolic blood pressure ≥ 160 mm Hg and diastolic blood
pressure < 90 mm Hg
diabetes defined as one or more of
physician diagnosis
maintenance on oral hypoglycemic drugs
fasting glucose level ≥ 7.8 mmol/L (140 mg/dL)
primary composite outcome of major cardiovascular events defined as nonfatal plus fatal stroke,
nonfatal myocardial infarction and fatal coronary heart disease (CHD), major CHD events, and all-
cause mortality
all data reported as adjusted for age, sex and race
comparing stepped antihypertensive treatment vs. placebo for 4,149 patients without diabetes
major cardiovascular event in 11.1% vs. 15.9% (NNT 21)
5-year cumulative rate of major cardiovascular events 13.3% vs. 18.4% (p < 0.05, NNT 20)
5-year cumulative rate of nonfatal and fatal stroke 4.4% vs. 7.5% (p < 0.05, NNT 33)
5-year cumulative rate of nonfatal myocardial infarction and fatal CHD 5.1% vs. 5.7% (not
significant)
5-year cumulative rate of major coronary heart disease events 6.9% vs.7.6% (not significant)
5-year cumulative rate of all-cause mortality 9.7% vs. 10.9% (not significant)
11/26
comparing stepped antihypertensive treatment vs. placebo for 583 patients with diabetes
major cardiovascular event in 20.1% vs. 27.6% (NNT 14)
5-year cumulative rate of major cardiovascular events 21.4% vs. 31.5% (p < 0.05, NNT 10)
5-year cumulative rate of nonfatal and fatal stroke 9.7% vs. 14.4% (not significant)
5-year cumulative rate of nonfatal myocardial infarction and fatal CHD in 7.7% vs. 13.1% (p
< 0.05, NNT 19)
5-year cumulative rate of major coronary heart disease events in 9.2% vs. 16.1% (p < 0.05,
NNT 15)
5-year cumulative rate of all-cause mortality 17.5% vs. 17.8% (not significant)
Reference - SHEP trial (JAMA 1996 Dec 18;276(23):1886 ), correction can be found in JAMA
1997 May 7;277(17):1356
stepped antihypertensive treatment (starting with chlorthalidone) may reduce cardiovascular
mortality at 22 years (level 2 [mid-level] evidence)
based on 22-year follow-up of 4,736 patients enrolled in SHEP trial
comparing stepped antihypertensive treatment vs. placebo
overall mortality 59.9% vs. 60.5% (not significant)
cardiovascular mortality 28.3% vs. 31% (p < 0.05, NNT 37)
Reference - JAMA 2011 Dec 21;306(23):2588
stepped antihypertensive treatment (starting with chlorthalidone) may reduce cardiovascular
mortality at 14 years (level 2 [mid-level] evidence)
based on 14-year follow-up of 4,732 patients enrolled in SHEP trial
comparing stepped antihypertensive treatment vs. placebo
overall mortality 41% vs. 43% (not significant)
cardiovascular mortality 19% vs. 22% (NNT 36, 95% CI 21-186)
Reference - Am J Cardiol 2005 Jan 1;95(1):29 in ACP J Club 2005 May-Jun;142(3):64
stepped antihypertensive treatment (starting with chlorthalidone) may reduce incidence of
heart failure (level 2 [mid-level] evidence)
based on follow-up of 4,736 patients enrolled in SHEP trial
mean follow-up 4.5 years
fatal or nonfatal heart failure occurred in 2.3% intervention patients vs. 4.4% placebo patients
(p < 0.001, NNT 48)
NNT 15 among patients with history of prior myocardial infarction (based on history or
electrocardiographic evidence) (p = 0.002)
Reference - JAMA 1997 Jul 16;278(3):212
chlorthalidone might reduce risk of fracture compared to lisinopril, but not compared to amlodipine
in patients ≥ 55 years old with hypertension (level 2 [mid-level] evidence)
based on post hoc secondary analysis of ALLHAT trial
22,180 patients (66%) ≥ 55 years old with hypertension and at least 1 other cardiac risk factor were
randomized to chlorthalidone 12.5-25 mg/day vs. amlodipine 2.5-10 mg/day vs. lisinopril 10-40
mg/day for mean 4.9 years
75% had claims data available for up to 5 years after trial end (total mean follow-up 7.8 years)
in analysis of all patients (in-trial cohort)
chlorthalidone associated with reduced risk of hip or pelvic fractures compared to lisinopril
(adjusted hazard ratio 0.75, 95% CI 0.58-0.98)
no significant difference in risk of hip or pelvic fractures comparing chlorthalidone to
amlodipine
in analysis of patients with posttrial follow-up data, no significant difference in risk of hip or pelvic
fractures comparing chlorthalidone to each of lisinopril or amlodipine
Reference - JAMA Intern Med 2017 Jan 1;177(1):67, editorial can be found in JAMA Intern Med
2017 Jan 1;177(1):77
Indapamide
12/26
sustained-release indapamide (with or without perindopril) may reduce mortality and

cardiovascular events in persons ≥ 80 years old with hypertension (level 2 [mid-level] evidence)
based on randomized trial with allocation concealment not stated
3,845 patients ≥ 80 years old with sustained systolic blood pressure ≥ 160 mm Hg were randomized
to sustained-release indapamide 1.5 mg vs. placebo, with or without perindopril (or matching
placebo) to achieve target blood pressure 150/80 mm Hg
median follow-up 1.8 years
at 2 years, 24% of patients took concomitant perindopril 2 mg and 50% of patients took concomitant
perindopril 4 mg
431 deaths occurred
comparing indapamide vs. placebo at 2 years
primary endpoint (fatal or nonfatal stroke) 51 vs. 69 events (p = 0.06, NNT 94)
death from any cause 10% vs. 12.3% (p = 0.02, NNT 44)
death from cardiovascular cause 5.1% vs. 6.3% (p = 0.06)
any heart failure 22 vs. 57 events (p < 0.001)
any cardiovascular event 138 vs. 193 events (p < 0.001)
any myocardial infarction 9 vs. 12 events (not significant)
target blood pressure reached in 48% vs. 19.9% (p < 0.001, NNT 4)
Reference - HYVET trial (N Engl J Med 2008 May 1;358(18):1887), editorial can be found in N
Engl J Med 2008 May 1;358(18):1958, commentary can be found in ACP J Club 2008 Aug
19;149(2):10, N Engl J Med 2008 Aug 28;359(9):971, J Am Geriatr Soc 2009 Mar;57(3):570
indapamide (with or without perindopril) might reduce risk of fracture in elderly patients
based on nonsignificant outcome from post hoc analysis of HYVET trial
fractures occurred in 1.96% of indapamide group vs. 2.72% of placebo group (p = 0.05)
Reference - Age Ageing 2010 Sep;39(5):609
continuing indapamide to 3 years associated with reduced all-cause and cardiovascular
mortality (level 2 [mid-level] evidence)
based on nonrandomized extension of HYVET trial
1,712 patients on double blind treatment at time of final visit in original trial assigned to
continue sustained-release indapamide 1.5 mg or begin indapamide 1.5 mg for 1 year
perindopril 2-4 mg added if necessary to achieve target blood pressure of < 150/80 mm Hg
at end of double-blind trial, 28% of patients took concomitant perindopril 2 mg and 45% of
patients took concomitant perindopril 4 mg
cardiovascular events included cardiovascular mortality, nonfatal myocardial infarction,
nonfatal stroke, and nonfatal heart failure
comparing 3 years vs. 1 year of indapamide treatment
all-cause mortality 17 events vs. 30 events (p = 0.02)
cardiovascular mortality 2 events vs. 9 events (p = 0.03)
fatal and nonfatal stroke 9 events vs. 4 events (not significant)
cardiovascular events 12 events vs. 13 events (not significant)
Reference - BMJ 2012 Jan 4;344:d7541 full-text, editorial can be found in BMJ 2012 Jan
4;344:d7293
no additional trials found in systematic review evaluating antihypertensive treatments in persons ≥
80 years old (JAMA 2015 Jul 14;314(2):170), correction can be found in JAMA 2015 Aug
11;314(6):628
Calcium channel blockers
Nitrendipine
stepped antihypertensive treatment (starting with nitrendipine) reduces rates of cardiovascular

events (level 1 [likely reliable] evidence)
13/26
based on randomized trial

4,695 patients > 60 years old with isolated systolic hypertension randomized to stepped
antihypertensive treatment vs. placebo
step 1 intervention included nitrendipine 10-40 mg/day
step 2 intervention included enalapril 5-20 mg/day and/or hydrochlorothiazide 12.5-25
mg/day
drugs were stepwise titrated to maintain systolic blood pressure < 150 mm Hg
drugs causing intolerable side effects were substituted by next-line study medication
isolated systolic hypertension defined as sitting systolic blood pressure 160-219 mm Hg and
diastolic blood pressure < 95 mm Hg
median follow-up 2 years (range 1-97 months)
reduction in sitting blood pressure comparing treatment vs. placebo
systolic 23 mm Hg vs. 13 mm Hg
diastolic 7 mm Hg vs. 2 mm Hg
annual rates of cardiovascular outcomes comparing treatment vs. placebo
any cardiovascular endpoint (stroke, heart failure or myocardial infarction) 2.33% vs. 3.39%
(p < 0.001, NNT 94 patient-years)
stroke 0.79% vs. 1.37% (p = 0.003, NNT 172 patient-years)
any cardiac endpoint 1.51% vs. 2.05% (p = 0.03, NNT 185 patient-years)
heart failure 0.62% vs. 0.87% (not significant)
myocardial infarction 0.55% vs. 0.8% (not significant)
cardiovascular-related mortality 0.98% vs. 1.35% (p = 0.07)
all-cause mortality 2.05% vs. 2.4% (not significant)
Reference - Syst-Eur trial (Lancet 1997 Sep 13;350(9080):757 )
DynaMed commentary -- 83 patients need to be treated for 2 years or 33 for 5 years to prevent 1
stroke
stepped antihypertensive treatment (starting with nitrendipine) may reduce rates of
cardiovascular events in patients with and without diabetes (level 2 [mid-level] evidence)
based on subgroup analysis of Syst-Eur trial
492 patients (10.5%) had diabetes
comparing treatment vs. placebo in diabetic patients
all cardiovascular events in 5.2% vs. 12.9% (p = 0.002, NNT 13)
stroke in 2% vs. 6.3% (p = 0.02, NNT 24)
cardiac events in 2.8% vs. 6.3% (p = 0.06)
overall mortality 6.3% vs. 10.8% (p = 0.09)
comparing treatment vs. placebo in nondiabetic patients
all cardiovascular events in 5.8% vs. 7.5% (p = 0.02, NNT 59)
stroke in 2% vs. 3% (p = 0.02, NNT 100)
cardiac events in 3.8% vs. 4.8% (not significant)
overall mortality 5% vs. 5.4% (not significant)
Reference - N Engl J Med 1999 Mar 4;340(9):677 full-text , commentary can be found in N
Engl J Med 1999 Jul 29;341(5):372
stepped antihypertensive treatment (starting with nitrendipine) may reduce rate of dementia
based on subgroup analysis of 2,418 patients without dementia at baseline from Syst-Eur trial
cognitive function assessed by mini-mental state examination (MMSE)
if MMSE score ≤ 23, diagnostic tests for dementia (Diagnostic and Statistical Manual of
Mental Disorders III [DSM-III] criteria) performed
comparing treatment vs. placebo
dementia developed in 0.9% vs. 1.8% (p = 0.06)
incidence of dementia 0.38%/year vs. 0.77%/year (p = 0.05, NNT 256 patient-years)
Reference - Lancet 1998 Oct 24;352(9137):1347, commentary can be found in Lancet 1999
Jan 16;353(9148):235, Lancet 1999 Apr 3;353(9159):1184. ACP J Club 1999 May-
Jun;130(3):57
14/26
based on extended (3.9 year) follow-up examination of 2,902 patients (including more
patients enrolled in trial)
incidence of dementia 0.33%/year with treatment vs. 0.74%/year with placebo (p =
0.05, NNT 243 patient-years)
Reference - Arch Intern Med 2002 Oct 14;162(18):2046 full-text, correction can be
found in Arch Intern Med 2003 Jan 27;163(2):241
stepped antihypertensive treatment (starting with nitrendipine) may reduce mortality and
cardiovascular events in Chinese patients (level 2 [mid-level] evidence)
based on randomized trial without description of randomization
2,394 Chinese patients > 60 years old with sitting systolic blood pressure 160-219 mm Hg and
diastolic blood pressure < 95 mm Hg were alternately assigned to stepped antihypertensive
treatment vs. placebo
step 1 for intervention patients was nitrendipine 10-40 mg/day
step 2 for intervention patients was captopril 12.5-50 mg/day and/or hydrochlorothiazide
12.5-50 mg/day
drugs were stepwise titrated and combined to reduce sitting systolic blood pressure by 20 mm
Hg or more to < 150 mm Hg
drugs causing intolerable side effects were substituted by next-line study medication
median follow-up 3 years (range 1-94 months)
comparing intervention vs. placebo
decrease in blood pressure at 2 years 20/5 mm Hg vs. 11/2 mm Hg (p ≤ 0.001)
total mortality 4.8% vs. 7.2% (NNT 42)
total mortality 17.4 vs. 28.4 total deaths per 1,000 patient-years (p < 0.05, NNT 111 patient-
years)
overall rate of fatal and nonfatal cardiovascular endpoints 5.9% vs. 8.2% (p < 0.01, NNT 44)
overall rate of fatal and nonfatal cardiovascular endpoints 21.4 vs. 33.3 per 1,000 patient-
years (p < 0.05, NNT 84 patient-years)
Reference - Arch Intern Med 2000 Jan 24;160(2):211, editorial can be found in Arch Intern Med
2000 Jan 24;160(2):149
Other calcium antagonists
addition of calcium channel blocker to olmesartan may lower blood pressure (level 3 [lacking direct]
evidence) but may not reduce cardiovascular events (level 2 [mid-level] evidence) compared to high-
dose olmesartan in elderly Japanese patients with hypertension uncontrolled with standard-dose
olmesartan
based on randomized trial without blinding
1,164 Japanese patients aged 65-84 years with uncontrolled hypertension following run-in treatment
with olmesartan 20 mg/day (standard dose) were randomized to combination therapy with
olmesartan 20 mg/day plus a calcium channel blocker vs. high-dose olmesartan (40 mg/day)
calcium channel blocker was amlodipine (2.5 or 5 mg/day) or azelnidipine (8 or 16 mg/day)
69.8% had cardiovascular disease and 30.2% had type 2 diabetes at baseline
outcome assessors were blinded
median follow-up 3 years
comparing amlodipine or azelnidipine plus olmesartan vs. high-dose olmesartan in intention-to-treat
analysis
target blood pressure (< 140/90 mm Hg) achieved in 70.5% vs. 62.1% (p = 0.003, NNT 12)
cardiovascular events (including death) in 6.3% vs. 8.5% (not significant)
cardiovascular events or noncardiovascular death in 8.19% vs. 10.03% (not significant)
in prespecified subgroup analysis of 812 patients with cardiovascular disease, combination therapy
associated with reduction in composite of cardiovascular events and noncardiovascular death
(hazard ratio 1.63, 95% CI 1.06-2.52)
Reference - OSCAR trial (Am J Med 2012 Oct;125(10):981)
15/26
Beta blockers
beta blockers associated with increased risk of major cardiovascular outcomes in elderly patients
based on systematic review without assessment of trial quality
systematic review of 21 randomized trials with 145,811 patients, stratified by mean age of trial
participants
major cardiovascular outcomes included stroke, myocardial infarction, or death
in trials with mean age < 60 years
beta blockers associated with reduced rate of major cardiovascular outcomes compared to
placebo (risk ratio [RR] 0.86, 95% CI 0.74-0.99) in analysis of 2 trials with 19,414 patients
no significant difference in rate of major cardiovascular outcomes between beta blockers and
active comparators in analysis of 5 trials with 30,412 patients
in trials with mean age > 60 years
no significant difference in rate of major cardiovascular outcomes between beta blockers and
placebo in analysis of 5 trials with 8,019 patients
beta blockers associated with higher risk of major cardiovascular outcomes than other
antihypertensive agents (RR 1.06, 95% CI 1.01-1.1) in analysis of 7 trials with 79,775
patients
Reference - CMAJ 2006 Jun 6;174(12):1737 full-text, commentary can be found in ACP J Club
2006 Nov-Dec;145(3):60, J Fam Pract 2008 Jan;57(1):18, CMAJ 2007 Mar 27;176(7):971,
correction can be found in CMAJ 2007 Mar 27;176(7):976
Angiotensin-converting enzyme (ACE) inhibitors
combination of perindopril plus indapamide reduces mortality in patients with type 2 diabetes (level
1 [likely reliable] evidence) and may reduce mortality in elderly patients with type 2 diabetes (level 2
[mid-level] evidence)
based on randomized trial and post hoc analysis
12,877 patients > 55 years old with type 2 diabetes diagnosed after age 30 years and with history of
or risk factor for cardiovascular disease entered 6-week run in period with fixed combination tablet
of perindopril 2 mg (an angiotensin-converting enzyme [ACE] inhibitor) plus indapamide 0.625 mg
(a diuretic)
11,140 (86.5%) who adhered to and tolerated study drug were randomized to combination
tablet vs. placebo, dose doubled after 3 months
patients also randomized to intensive glucose control with gliclazide modified release-based
regimen (target HbA1c ≤ 6.5%) vs. standard glucose control
mean follow-up 4.3 years, range 1 month to 5.6 years
major macrovascular events defined as cardiovascular death, nonfatal myocardial infarction,
or nonfatal stroke
major microvascular events defined as new or worsening nephropathy (macroalbuminuria,
doubling of serum creatinine to ≥ 200 mcmol/L [2.26 mg/dL], renal replacement therapy, or
death from renal disease) or retinopathy (proliferative retinopathy, macular edema, diabetes-
related blindness, or retinal photocoagulation therapy)
comparing perindopril/indapamide vs. placebo for adherence
83% vs. 87% continued treatment during follow-up
73% vs. 74% adherent to treatment at end of follow-up
3.3% vs. 1.3% discontinued due to cough (NNH 50)
1.2% vs. 0.4% discontinued due to hypotension or dizziness (NNH 125)
comparing perindopril/indapamide vs. placebo for mortality and macrovascular outcomes
all-cause mortality 7.3% vs. 8.5% (p = 0.025, NNT 79 over 5 years, 95% CI 43-483)
cardiovascular mortality 3.8% vs. 4.6% (p = 0.027, NNT 125)
major macrovascular event in 8.6% vs. 9.3% (not significant)
16/26
total coronary event rate (major events plus hospitalization for unstable angina,
coronary revascularization, or silent myocardial infarction) 8.4% vs. 9.6% (p = 0.02,
NNT 75 over 5 years, 95% CI 41-453)
total cerebrovascular event rate 5.1% vs. 5.4% (not significant)
comparing perindopril/indapamide vs. placebo for microvascular outcomes
major microvascular event in 7.9% vs. 8.6% (not significant)
new or worsening nephropathy in 3.3% vs. 3.9% (p = 0.055)
new microalbuminuria in 19.6% vs. 23.6% (p < 0.0001, NNT 25)
new or worsening retinopathy in 5.2% vs. 5.1% (not significant)
visual deterioration in 43.9% vs. 45.1% (p = 0.1)
major macrovascular or major microvascular event in 15.5% vs. 16.8% (p = 0.041,
NNT 66 over 5 years, 95% CI 34-1,068)
Reference - ADVANCE trial (Lancet 2007 Sep 8;370(9590):829), editorial can be found in
Lancet 2007 Sep 8;370(9590):804, Ann Intern Med 2008 Mar 4;148(5):400, commentary can
be found in Lancet 2008 Jan 5;371(9606):25, Evid Based Med 2008 Apr;13(2):49
1,008 patients ≥ 75 years old were included in post hoc analysis with mean 4.3-year follow-up
comparing perindopril/indapamide vs. placebo
all-cause mortality 18.2% vs. 19.8% (not significant)
cardiovascular mortality 7.9% vs. 11.8% (p < 0.05, NNT 26)
major macrovascular events in 14.1% vs. 17.5% (not significant)
Reference - J Hypertens 2010 Jun;28(6):1141
approximately 75% of patients in HYVET trial took perindopril
Angiotensin receptor blockers (ARBs)

losartan associated with lower cardiovascular events than atenolol in elderly patients with
hypertension and left ventricular hypertrophy (level 2 [mid-level] evidence)
based on cohort analysis of LIFE trial
9,193 patients (aged 45-83 years) with hypertension and left ventricular hypertrophy who were
randomized to losartan-based vs. atenolol-based antihypertensive treatment were followed for mean
4.8 years
53.2% were ≥ 67 years old
composite end point defined as cardiovascular death, nonfatal stroke or myocardial infarction, and
25% relative risk reduction in stroke with similar reduction in blood pressure
comparing losartan vs. atenolol
composite end point rate per 1,000 patient-years among patients aged ≥ 67 years 30.2 vs. 38.4
(p = 0.001)
composite end point rate per 1,000 patient-years among patients aged < 67 years 15.4 vs. 14.9
(not significant)
losartan use associated with decreased risk of composite end point in analysis of patients stratified
by age
median age ≥ 67 (hazard ratio [HR] 0.79, 95% CI 0.69-0.91)
median age ≥ 71 (HR 0.78, 95% CI 0.66-0.92)
median age ≥ 73 (HR 0.75, 95% CI 0.62-0.91)
median age ≥ 74 (HR 0.81, 95% CI 0.66-0.98)
Reference - J Hypertens 2012 Jun;30(6):1252
strict blood pressure control (SBP < 140 mm Hg) with valsartan may not reduce cardiovascular
mortality or morbidity compared to moderate blood pressure control (SBP ≥ 140 mm Hg to < 150
mm Hg) in older Japanese patients with hypertension (level 2 [mid-level] evidence)
based on randomized trial with wide confidence intervals
3,260 patients aged 70-84 years with isolated SBP (sitting blood pressure 160-199 mm Hg) were
randomized to strict blood pressure control (< 140 mm Hg) vs. moderate blood pressure control (≥
140 mm Hg to < 150 mm Hg) and followed for mean 2.85 years
17/26
all patients received valsartan and other antihypertensive agents if needed

94.4% of patients included in analysis
comparing strict vs. moderate blood pressure control
mean blood pressure 136.6/74.8 mm Hg vs. 142/76.5 mm Hg (p < 0.001)
all-cause mortality 1.55% vs. 1.96% (hazard ratio [HR] 0.78, 95% CI 0.46-1.33), not
significant but CI includes possibility of benefit or harm
cardiovascular mortality 0.71% vs. 0.72% (HR 0.97, 95% CI 0.42-2.25), not significant but
CI includes possibility of benefit or harm
renal insufficiency in 0.32% vs. 0.13% (HR 2.45, 95% CI 0.48-12.64), not significant but CI
includes possibility of benefit or harm
no significant differences in sudden death, fatal and nonfatal stroke, fatal and nonfatal myocardial
infarction, and unplanned hospitalization
Reference - VALISH trial (Hypertension 2010 Aug;56(2):196 full-text)
Adverse Effects
see also individual drug topics or adverse effects sections by drug class in Hypertension medication
selection and management
orthostatic hypotension(2)
occurs in 7% men > 70 years old
associated with increase in age-adjusted mortality
medications causing orthostatic hypotension include
alpha-adrenergic blockers
alpha beta blockers
diuretics (can lead to volume depletion)
other examples of potential adverse effects(2)
electrolyte disturbances and renal impairment with diuretics, angiotensin-converting enzyme (ACE)
inhibitors and angiotensin receptor blockers (ARBs)
gout with thiazide and loop diuretics
bradycardia with beta blockers, alpha-beta adrenergic blockers, and nondihydropyridine calcium-
channel blockers
heart block with beta blockers and nondihydropyridine calcium-channel blockers
bronchospasm with beta blockers
heart failure with beta blockers, calcium-channel blockers
hyperglycemia with thiazide diuretics, loop diuretics, and beta blockers
possible drug interactions in elderly population often taking multiple medications
combination of systolic blood pressure < 130 mm Hg plus treatment with ≥ 2 antihypertensive
medications associated with increased risk of death in frail nursing home residents ≥ 80 years old
based on cohort study
1,127 frail nursing home residents ≥ 80 years old (78% women) had systolic blood pressure (SBP)
measurement at baseline (calculated as mean of 3 morning and 3 evening measurements over 3
consecutive days) and were assessed for antihypertensive treatments
2-year all-cause mortality
32.2% of 227 patients with SBP < 130 mm Hg and taking ≥ 2 antihypertensive medications
(adjusted hazard ratio 1.78, 95% CI 1.34-2.37 vs. other groups)
17.5% of 149 patients with SBP < 130 mm Hg and taking fewer antihypertensives
20.1% of 423 patients with SBP ≥ 130 mm Hg and taking ≥ 2 antihypertensives
20.1% of 328 patients with SBP ≥ 130 mm Hg and taking fewer antihypertensives
systolic blood pressure < 130 mm Hg with ≥ 2 antihypertensive medications associated with
increased risk of 2-year all-cause mortality
18/26
Reference - JAMA Intern Med 2015 Jun 1;175(6):989
initiation of antihypertensive medication reported to increase risk of hip fracture within 45 days
compared with pre- and posttreatment periods in elderly patients (level 3 [lacking direct] evidence)
based on population-based case series
301,591 newly treated hypertensive community-dwelling elderly patients observed during risk
period (first 45 days following initiation of antihypertensive therapy), with control periods of
observation before and after treatment for a total of 450 days of observation
1,463 hip fractures occurred during total observation period
compared with pre- and posttreatment observation periods, initiation of antihypertensive medication
associated with increased risk of hip fracture within 45 days (incidence rate ratio 1.43, 95% CI 1.19-
1.72)
Reference - Arch Intern Med 2012 Dec 10;172(22):1739 , commentary can be found in JAMA
Intern Med 2013 May 27;173(10):934
combination therapy with angiotensin-converting enzyme (ACE) inhibitor and angiotensin receptor
blocker (ARB) associated with increased risk of renal dysfunction and hyperkalemia compared to
either monotherapy in elderly patients (level 3 [lacking direct] evidence)
based on nonclinical outcomes in cohort of 32,312 patients (mean age 76 years) who initiated
treatment with ACE inhibitor and/or ARB
1,750 (5.4%) patients received combination therapy
comparing combination therapy vs. monotherapy
rate of renal dysfunction (per 1,000 patients/month) 5.2 events vs. 2.4 events (p < 0.05)
rate of hyperkalemia (per 1,000 patients/month) 2.5 events vs. 0.9 events (p < 0.05)
Reference - CMAJ 2011 Apr 5;183(6):655 full-text, editorial can be found in CMAJ 2011 Apr
5;183(6):E309
overtreatment
treatment deintensification rates < 20% following low blood pressure measurements (< 130/65
mm Hg) in elderly patients with diabetes (level 2 [mid-level] evidence)
based on retrospective cohort study
211,667 military veterans ≥ 70 years old (98.7% men) with diabetes receiving active
treatment for blood pressure control with medications other than angiotensin-converting
enzyme inhibitors or angiotensin receptor blockers were assessed
patients were eligible for treatment deintensification (defined as discontinuation or dose
reduction within 6 months of last measurement) if low blood pressure (defined as systolic
blood pressure [SBP] < 130 mm Hg or diastolic blood pressure [DBP] < 65 mm Hg) at last
measurement
38.4% had SBP < 120 mm Hg or DBP < 65 mm Hg (very low), 12.3% had SBP 120-129 mm
Hg or DBP < 65 mm Hg (moderately low), and 49.3% had SBP ≥ 130 mm Hg and DBP ≥ 65
mm Hg
treatment deintensified in (no p values reported)
18.8% of patients with very low blood pressure
16% of patients with moderately low blood pressure
15.1% of patients without low blood pressure
Reference - JAMA Intern Med 2015 Dec 1;175(12):1942, editorial can be found in JAMA
Intern Med 2015 Dec 1;175(12):1949
Quality Improvement
Choosing Wisely
AMDA - Society for Post-Acute and Long-Term Care Medicine recommends against initiating
antihypertensive treatment in patients ≥ 60 years old for systolic blood pressure (SBP) < 150 mm Hg or
19/26
diastolic blood pressure (DBP) < 90 mm Hg (Choosing Wisely 2015 Mar 20)
Guidelines and Resources

Guidelines
see Hypertension for full list of guidelines
United States guidelines
American College of Cardiology/American Heart Association/American Academy of Physician

Assistants/Association of Black Cardiologists/American College of Preventive Medicine/American
Geriatrics Society/American Pharmacists Association/American Society of Hypertension/American
Society for Preventive Cardiology/National Medical Association/Preventive Cardiovascular Nurses
Association (ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA) guideline on
prevention, detection, evaluation, and management of high blood pressure in adults can be found in
Hypertension 2018 Jun;71(6):e13
American College of Cardiology/American Heart Association (ACC/AHA) 2011 expert consensus on

hypertension in elderly can be found in Circulation 2011 May 31;123(21):2434 full-text, J Am Coll
Cardiol 2011 May 17;57(20):2037, J Am Soc Hypertens 2011 Jul-Aug;5(4):259, corrections can be found
in Circulation 2011 May 31;123(21):e616, Circulation 2011 Aug 2;124(5):e175
American Heart Association scientific statement on secondary prevention of coronary heart disease in
elderly (with emphasis on patients ≥ 75 years old) can be found in Circulation 2002 Apr
9;105(14):1735 full-text
Eighth Joint National Committee (JNC 8) 2014 evidence-based guideline on management of high blood
pressure in adults can be found in JAMA 2014 Feb 5;311(5):507, correction can be found in JAMA 2014
May 7;311(17):1809, editorial can be found in JAMA 2014 Feb 5;311(5):472, commentary can be found
in Hypertension 2016 May;67(5):1053
comparison of JNC 8 to JNC 7 guidelines can be found in JAMA 2014 Apr 9;311(14):1424, correction
can be found in JAMA 2014 Aug 27;312(8):848, commentary can be found in JAMA 2014 Aug
27;312(8):846
American College of Physicians/American Academy of Family Physicians (ACP/AAFP) clinical practice

guideline on pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus
lower blood pressure targets can be found in Ann Intern Med 2017 Mar 21;166(6):430
United Kingdom guidelines
National Institute for Health and Clinical Excellence (NICE) guideline on clinical management of primary
hypertension in adults can be found at NICE 2011 Aug:CG127 PDF, summary can be found in BMJ 2011
Aug 25;343:d4891
Canadian guidelines
Hypertension Canada 2017 guideline update for pharmacists can be found in Can Pharm J (Ott) 2018 Jan-
Feb;151(1):33 full-text
Hypertension Canada guideline on diagnosis, risk assessment, prevention, and treatment of hypertension
in adults can be found in Can J Cardiol 2017 May;33(5):557, correction can be found in Can J Cardiol
2017 Dec;33(12):1733
20/26
European guidelines
European Society of Hypertension/European Society of Cardiology (ESH/ESC) guideline on management

of arterial hypertension can be found in Eur Heart J 2013 Jul;34(28):2159
Quality indicators
14 quality indicators for care of hypertension in vulnerable elders can be found in J Am Geriatr Soc 2007
Oct;55 Suppl 2:S359, commentary can be found in J Am Geriatr Soc 2008 Jul;56(7):1357
Review articles
review of hypertension treatment in elderly patients can be found in JAMA 2013 Sep
25;310(12):1274 full-text
review of treatment of hypertension in the elderly can be found in Compr Ther 2008 Fall-Winter;34(3-
4):171
review of treatment of hypertension in the elderly can be found in Geriatrics 2008 Oct;63(10):21
review of management of hypertension in the elderly can be found in Am J Med 2008 Aug;121 Suppl
8:S23
review of hypertension control in the elderly can be found in J Clin Hypertens (Greenwich) 2008 Jan;10(1
Suppl 1):33
review of hypertension management in patients > 80 years old can be found in Hypertension 2004
Dec;44(6):800 full-text
review of drug treatment of systolic hypertension in the elderly can be found in Drugs Aging 2008;25(1):1
review of isolated systolic hypertension in elderly can be found in N Engl J Med 2007 Aug 23;357(8):789,
commentary can be found in N Engl J Med 2007 Nov 29;357(22):2307
review of hypertension management in elderly can be found in Am Fam Physician 2005 Feb
1;71(3):469 full-text
discussion of reducing antihypertensive medication use in nursing home patients can be found in Arch
Fam Med 2000 Apr;9(4):378 full-text
discussion of "A Rational Approach to the Treatment of Hypertension in Special Populations" can be
found in Am Fam Physician 1999 Jul;60(1):156 full-text
Patient Information
handout on hypertension in the elderly from the American Geriatrics Society
handout from the National Institute on Aging
References
General references used
1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High
Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National
Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20 full-text, correction can be found in JAMA 2014
May 7;311(17):1809, commentary can be found in J Am Soc Nephrol 2014 Nov;25(11):2419
2. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF Task Force. ACCF/AHA 2011 expert consensus
document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task
Force on Clinical Expert Consensus Documents. Circulation. 2011 May 31;123(21):2434-506 full-text,
corrections can be found in Circulation 2011 May 31;123(21):e616, Circulation 2011 Aug 2;124(5):e175,
J Am Coll Cardiol 2011 May 17;57(20):2037, J Am Soc Hypertens 2011 Jul-Aug;5(4):259
21/26
3. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial
hypertension: The Task Force for the management of arterial hypertension of the European Society of
Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013
Jul;34(28):2159-219 full-text
4. Leung AA, Daskalopoulou SS, Dasgupta K, et al. Hypertension Canada's 2017 Guidelines for
Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults. Can J Cardiol. 2017
May;33(5):557-576 or at Hypertension Canada 2017 PDF
5. National Clinical Guideline Centre. Hypertension. Clinical management of primary hypertension in
adults. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Aug. 36 p.
(Clinical guideline; no. 127). NICE 2011 Aug:CG127 PDF, summary can be found in BMJ 2011 Aug
25;343:d4891 full-text
Recommendation grading systems used

American College of Cardiology/American Heart Association (ACC/AHA) grading system for
recommendations
classifications of recommendations
Class I - procedure or treatment should be performed or administered
Class IIa - reasonable to perform procedure or administer treatment, but additional studies
with focused objectives needed
Class IIb - procedure or treatment may be considered; additional studies with broad objectives
needed, additional registry data would be useful
Class III - procedure or treatment should not be performed or administered because it is not
helpful or may be harmful
Class III ratings may be subclassified as Class III No Benefit or Class III Harm
levels of evidence
Level A - high-quality evidence from > 1 randomized controlled trial or meta-analysis of
high-quality randomized controlled trials
Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or meta-analysis
of moderate-quality randomized controlled trials
Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized trial,
observational studies, or registry studies, or meta-analysis of such studies
Level C-LD - randomized or nonrandomized studies with methodological limitations or meta-
analyses of such studies
Level C-EO - consensus of expert opinion based on clinical experience
Reference - ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline on
prevention, detection, evaluation, and management of high blood pressure in adults (Hypertension
2018 Jun;71(6):e13)
Hypertension Canada (formerly Canadian Hypertension Education Program [CHEP]) grades of

recommendations
Grade A - recommendations based on randomized trials (or systematic reviews) with high levels of
internal validity and statistical precision for which study results can be directly applied to patients
because of similar clinical characteristics and clinical evidence of study outcomes
Grade B - recommendations based on randomized trials, systematic reviews, or prespecified
subgroup analyses of randomized trials that have lower precision, or if there is a need to extrapolate
from studies because of differing populations or reporting of validated intermediate/surrogate
outcomes rather than clinically important outcomes
Grade C - recommendations from trials with lower levels of internal validity and/or precision, or
that report unvalidated surrogate outcomes, or results from nonrandomized observational studies
Grade D - recommendations based on expert opinion alone
detailed algorithms for assigning evidence grades to recommendations can be found in Can J
Cardiol 2006 May 15;22(7):559 full-text
22/26
Reference - Hypertension Canada recommendations on diagnosis, risk assessment, prevention, and

treatment of hypertension in adults (Can J Cardiol 2017 May;33(5):557)
Eighth Joint National Committee (JNC 8) 2014 grades of recommendation

Strong recommendation - Grade A - high certainty based on evidence that net benefit is substantial
Moderate recommendation - Grade B - moderate certainty based on evidence that net benefit is
moderate-to-substantial OR high certainty that net benefit is moderate
Weak recommendation - Grade C - at least moderate certainty based on evidence that there is small
net benefit
Recommendation against - Grade D - at least moderate certainty based on evidence that no net
benefit or that risks/harms outweigh benefits
Expert opinion - Grade E - "There is insufficient evidence or evidence is unclear or conflicting, but
this is what the committee recommends", net benefit unclear
No recommendation for or against - Grade N - "There is insufficient evidence or evidence is unclear
or conflicting", net benefit unclear
Reference - JNC8 2014 evidence-based guideline for the management of high blood pressure in
adults (JAMA 2014 Feb 5;311(5):507)
European Society of Hypertension/European Society of Cardiology (ESH/ESC) grading system

classifications of recommendations
Class I - evidence and/or general agreement that procedure or treatment is beneficial, useful,
effective
Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of
given treatment of procedure
Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
Class IIb - usefulness/efficacy less well established by evidence/opinion
Class III - evidence or general agreement that procedure or treatment is not useful/effective,
and in some cases may be harmful
levels of evidence
Level A - data derived from multiple randomized clinical trials or meta-analyses
Level B - data derived from single randomized trial or large nonrandomized studies
Level C - consensus opinions of experts, and/or small studies, retrospective studies, or
registries
Reference - ESH/ESC guideline on management of arterial hypertension (Eur Heart J 2013
Jul;34(28):2159 full-text)
American College of Physicians/American Academy of Family Physicians (ACP/AAFP) uses Grading of

Recommendations Assessment, Development and Evaluation (GRADE) grading system
strength of recommendation
Strong - benefits clearly outweigh risks and burden, or risks and burden clearly outweigh
benefits
Weak - benefits closely balanced with risks and burden
Insufficient - balance of benefits and risks cannot be determined
quality of evidence
High - randomized trials without important limitations, or overwhelming evidence from
observational studies
Moderate - randomized trials with important limitations (inconsistent results, methodologic
flaws, indirect, or imprecise), or exceptionally strong evidence from observational studies
Low - observational studies or case series
Insufficient - evidence is conflicting, poor quality, or lacking
Reference - ACP/AAFP clinical practice guideline on pharmacologic treatment of hypertension in
adults ≥ 60 years old to higher versus lower blood pressure targets (Ann Intern Med 2017 Mar
21;166(6):430)
23/26
Synthesized Recommendation Grading System for DynaMed Plus
DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid
relevant evidence to support clinical decision-making (see 7-Step Evidence-Based Methodology).
Guideline recommendations summarized in the body of a DynaMed topic are provided with the
recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see
where guidelines agree and where guidelines differ from each other and from the current evidence.
In DynaMed Plus (DMP), we synthesize the current evidence, current guidelines from leading authorities,
and clinical expertise to provide recommendations to support clinical decision-making in the Overview &
Recommendations section.
We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify
synthesized recommendations as Strong or Weak.
Strong recommendations are used when, based on the available evidence, clinicians (without
conflicts of interest) consistently have a high degree of confidence that the desirable consequences
(health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs,
burdens).
Weak recommendations are used when, based on the available evidence, clinicians believe that
desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about
the magnitude of expected consequences (benefits and harms). Weak recommendations are used
when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in
their judgments. Weak recommendations are also used when the range of patient values and
preferences suggests that informed patients are likely to make different choices.
DynaMed Plus (DMP) synthesized recommendations (in the Overview & Recommendations section) are
determined with a systematic methodology:
Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological
expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and
harms, and the recommendations from guidelines.
Recommendations are phrased to match the strength of recommendation. Strong recommendations
use "should do" phrasing, or phrasing implying an expectation to perform the recommended action
for most patients. Weak recommendations use "consider" or "suggested" phrasing.
Recommendations are explicitly labeled as Strong recommendations or Weak recommendations
when a qualified group has explicitly deliberated on making such a recommendation. Group
deliberation may occur during guideline development. When group deliberation occurs through
DynaMed-initiated groups:
Clinical questions will be formulated using the PICO (Population, Intervention, Comparison,
Outcome) framework for all outcomes of interest specific to the recommendation to be
developed.
Systematic searches will be conducted for any clinical questions where systematic searches
were not already completed through DynaMed content development.
Evidence will be summarized for recommendation panel review including for each outcome,
the relative importance of the outcome, the estimated effects comparing intervention and
comparison, the sample size, and the overall quality rating for the body of evidence.
Recommendation panel members will be selected to include at least 3 members that together
have sufficient clinical expertise for the subject(s) pertinent to the recommendation,
methodological expertise for the evidence being considered, and experience with guideline
development.
All recommendation panel members must disclose any potential conflicts of interest
(professional, intellectual, and financial), and will not be included for the specific panel if a
significant conflict exists for the recommendation in question.
Panel members will make Strong recommendations if and only if there is consistent
agreement in a high confidence in the likelihood that desirable consequences outweigh
undesirable consequences across the majority of expected patient values and preferences.
Panel members will make Weak recommendations if there is limited confidence (or
inconsistent assessment or dissenting opinions) that desirable consequences outweigh
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undesirable consequences across the majority of expected patient values and preferences. No
recommendation will be made if there is insufficient confidence to make a recommendation.
All steps in this process (including evidence summaries which were shared with the panel,
and identification of panel members) will be transparent and accessible in support of the
recommendation.
Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in
recommendation drafting or development, with explicit confirmation that Strong recommendations
are adequately supported.
Recommendations are published only after consensus is established with agreement in phrasing and
strength of recommendation by all editors.
If consensus cannot be reached then the recommendation can be published with a notation of
"dissenting commentary" and the dissenting commentary is included in the topic details.
If recommendations are questioned during peer review or post publication by a qualified individual,
or reevaluation is warranted based on new information detected through systematic literature
surveillance, the recommendation is subject to additional internal review.
DynaMed editorial process

DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
All editorial team members and reviewers have declared that they have no financial or other competing
interests related to this topic, unless otherwise indicated.
DynaMed provides Practice-Changing DynaMed Updates, with support from our partners, McMaster
University and F1000.
Special acknowledgements
Maria Sciammarella, MD (Associate Clinical Professor, University of California, San Francisco;

California, United States)
Dr. Sciammarella declares no relevant financial conflicts of interest.
Esther Jolanda van Zuuren, MD (Head of Allergy, Dermatology, and Venereology, Leiden University
Medical Centre; Netherlands; Editor, Cochrane Skin Group)
Dr. van Zuuren declares no relevant financial conflicts of interest.
Peter Oettgen MD, FACC, FAHA, FACP (Editor in Chief; Cardiologist, Beth Israel Deaconess Medical
Center; Associate Professor of Medicine, Harvard Medical School, Massachusetts, United States)
Dr. Oettgen declares no relevant financial conflicts of interest.
DynaMed Plus topics are written and edited through the collaborative efforts of the above individuals.
Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice.
Recommendations Editors are actively involved in development and/or evaluation of guidelines.
Editorial Team role definitions

Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and
suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic
Editors also serve as consultants for the internal DynaMed Plus Editorial Team during the writing and
editing process, and review the final topic drafts prior to publication.
Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the
review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical
literature.
Recommendations Editors provide explicit review of DynaMed Plus Overview and Recommendations
sections to ensure that all recommendations are sound, supported, and evidence-based. This process is
described in "Synthesized Recommendation Grading."
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Deputy Editors are employees of DynaMed and oversee DynaMed Plus internal publishing groups. Each
is responsible for all content published within that group, including supervising topic development at all
stages of the writing and editing process, final review of all topics prior to publication, and direction of
an internal team.
How to cite
National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):
DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No.
483094, Hypertension treatment in elderly patients; [updated 2018 Aug 14, cited place cited date
here]; [about 19 screens]. Available from http://www.dynamed.com/login.aspx?
direct=true&site=DynaMed&id=483094. Registration and login required.
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12/10/2018 DynaMed Plus: Hypertension treatment in elderly patients

Hypertension treatment in elderly patients

Treatment thresholds and blood pressure targets

Indications for Antihypertensive Medications in Elderly

Efficacy for blood pressure lowering

Target Blood Pressure in Elderly

Evidence (target BP)

sustained-release indapamide (with or without perindopril) may reduce mortality and

Calcium channel blockers

stepped antihypertensive treatment (starting with nitrendipine) reduces rates of cardiovascular

based on randomized trial

Other calcium antagonists

Angiotensin-converting enzyme (ACE) inhibitors

approximately 75% of patients in HYVET trial took perindopril

Angiotensin receptor blockers (ARBs)

all patients received valsartan and other antihypertensive agents if needed

Reference - JAMA Intern Med 2015 Jun 1;175(6):989

Guidelines and Resources

see Hypertension for full list of guidelines

United States guidelines

American College of Cardiology/American Heart Association/American Academy of Physician

American College of Cardiology/American Heart Association (ACC/AHA) 2011 expert consensus on

American College of Physicians/American Academy of Family Physicians (ACP/AAFP) clinical practice

United Kingdom guidelines

European Society of Hypertension/European Society of Cardiology (ESH/ESC) guideline on management

Recommendation grading systems used

Hypertension Canada (formerly Canadian Hypertension Education Program [CHEP]) grades of

Reference - Hypertension Canada recommendations on diagnosis, risk assessment, prevention, and

Eighth Joint National Committee (JNC 8) 2014 grades of recommendation

European Society of Hypertension/European Society of Cardiology (ESH/ESC) grading system

American College of Physicians/American Academy of Family Physicians (ACP/AAFP) uses Grading of

Synthesized Recommendation Grading System for DynaMed Plus

DynaMed editorial process

Maria Sciammarella, MD (Associate Clinical Professor, University of California, San Francisco;

Editorial Team role definitions

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