What the new blood pressure guidelines mean for older adults (2024)

Are you taking medication to lower your blood pressure? Or are you caring for an elderly person with high blood pressure, also known as high blood pressure?

If so, you're probably wondering what the appropriate blood pressure (BP) is for older adults.

This is a good question because blood pressure guidelines have changed, mainly because of the groundbreaking findingsIntervention study on systolic blood pressure(abbreviated to "SPRINT").

SPRINT study conducted for the first timeheadlinespartly because the results seemed contradictoryexpert guidelines for high blood pressure published in December 2013, who had first suggested a higher target BP (a systolic blood pressure of less than 150 mm Hg) for most adults aged 60 years or older.

Specifically, SPRINT randomly assigned participants – all of whom were 50 years or older and at high risk of cardiovascular events – to have their systolic blood pressure (that's the highest number) treated to a target level of 140 or 120. Because from the study found that people, who were randomized to a target number of 120, experienced better health outcomes and the study was ended early.

For those of us who specialize in optimizing the health of older adults, this was clearly an important research development that could change our medical recommendations for certain older adults.

But what about you or your elderly relative? Do the SPRINT results mean you should talk to your doctor about changing your blood pressure medications?

Maybe, but maybe not. In this article, I will help you better understand the SPRINT study and results, as well as the side effects and special considerations regardingelderly people at risk of falling. This way, you will better understand how SPRINT results may impact the blood pressure goals you and your doctors want to pursue.

Here's what this post will cover:

• What is currently considered 'normal' blood pressure for older adults in their 60s, 70s and 80s
• What do the latest blood pressure guidelines recommend?
• What you need to know about the groundbreaking SPRINT blood pressure study in older adults, including who was and was not included and what type of blood pressure medications were most often used
• What the actual likelihood of benefits and harms was within the SPRINT and what you can expect if you are like the SPRINT participants
• Therefore, you should probably change the way your blood pressure is measured before considering a SPRINT-like systolic blood pressure goal of 120.
• My own approach and how to prevent overtreatment of high blood pressure

What is considered normal blood pressure for older adults?

Blood pressure is usually recorded as systolic blood pressure over diastolic blood pressure. These are measured in millimeters of mercury ("mm Hg"). The systolic measurement ("the top number") is usually much more important when it comes to stroke risk and more practical medical considerations. (For more information on the basic terminology of blood pressure, seeThis article.)

From 2017American College of Cardiology en American Heart Association(ACC/AHA) defines normal blood pressure and high blood pressure usingthe same intervals for all adults, regardless of age or gender.

Here is the definition of normal blood pressure (and hypertension) according to the ACC/AHA:

Basically, if you're wondering what "normal" blood pressure is based on age: whether someone is in their 60s, 70s, 80s, or 90s, normal blood pressure is considered blood pressure less than 120/80.

Furthermore, the definition of normal blood pressure does not vary between men and women.

Do geriatricians define normal blood pressure differently?

The American Geriatrics Society has not attempted to define normal blood pressure in older adults.

That said, this is the approach most geriatricians (myself included) take when it comes to blood pressure:

• We focus first on helping an older adult return his systolic blood pressure to the range of 140-150 mm Hg.
  • After we have reached a blood pressure around 140, we consider more intensive treatment if this seems possible and if the older person does not experience any worrying side effects from blood pressure medication.
• We are very aware of the possibility that blood pressure is too low; Some older adults feel weak or dizzy when they stand up, especially if their sitting systolic blood pressure is less than 120.

For more information on how we approach blood pressure management, see this article:6 steps to better manage high blood pressure in older adults.

I also recommend learning more about the groundbreaking SPRINT blood pressure test, which I explain later in this article.

Is there such a thing as low blood pressure?

Yes, it's called hypotension.

Interestingly enough, the ACC/AHA doesdoesn'tdefine a lower limit for normal blood pressure. Instead, hypotension is often defined as blood pressure that is "lower than expected."

In general, a value of less than 90/60 mm Hg is considered hypotension.

Older adults are also likely to experience something called orthostatic hypotension, which means they experience a drop of >20 mm Hg in systolic blood pressure or >10 mm Hg in diastolic blood pressure within minutes of standing.

Because orthostatic hypotension can be associated with falls or fainting, checking blood pressure when sitting and standing is one of the things geriatricians do after a fall. (Read more things you can do after a fall here:8 Things You Should Have the Doctor Checked After an Aging Person Falls.)

What do the latest guidelines for blood pressure treatment recommend?

In the US yesAmerican College of Cardiology/American Heart Association (ACC/AHA) onderzoekis very prominent. They were last updated in 2017.

For older adults, the ACC/AHA guidelines state:
“Treatment of hypertension with a systolic blood pressure treatment goal of less than 130 mm Hg is recommended for non-institutionalized adults in the outpatient community (≥65 years) with a mean SBP of 130 mm Hg or greater.”

They also state: “For older adults (≥65 years) with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to risk-benefit analysis are reasonable for decisions about the intensity of the treatment. of blood pressure lowering and choice of antihypertensive medications."

In other words:

• Older adults (not in nursing homes) aged 65 and over should be treated for high blood pressure if their mean systolic blood pressure is greater than 130 mm Hg. The goal should be to get them below 130 mm Hg.
• In older adults who are chronically ill and may have only a few years to live, the goal of getting blood pressure below 130 should be reconsidered.

Men i 2017 udstedte American College of Physicians en American Academy of Family Practicejoint hypertension guidelines that endorse a slightly higher treatment goal for most older adults. In particular, they recommended the following:

• Older adults aged 60 years and older with systolic blood pressure greater than 150 mm Hg should be treated to bring blood pressure below 150.
• Consider additional treatment for older adults at high cardiovascular risk to achieve a systolic blood pressure lower than 140.
• Treatment goals should be based on periodic discussion of the benefits and harms of specific blood pressure goals

The American Academy of Family Practice subsequently issued aupdated guidance in December 2022, which concluded: “The AAFP recommends that primary care physicians treat adults with hypertension to a standard blood pressure goal (less than 140/90 mm Hg). The AAFP also recommends that primary care physicians treat adults with hypertension to lower blood pressure. goal (less than 135/85 mm Hg) to reduce the risk of myocardial infarction." (This specific guideline did not make a specific recommendation for older adults.)

What you need to know about the SPRINT trial

Who was and was not examined in the SPRINT blood pressure study

Current guidelines for blood pressure treatment for older adults are closely related to the results of the SPRINT study. So it may be helpful to understand this groundbreaking study.

Special: Do the research results apply to you or your elderly relative? This is one of the two most important questions to ask yourself when you hear exciting news about clinical research. (The second question to ask is: "What is"number to be processed", which corresponds to your chances of actually benefiting from it; more on that below.)

Why? Because a well-conducted medical study tells us what health outcomes occurred when we applied a particular intervention to a particular group of people. If you're not like the people studied, you're more likely not to experience the benefits that the study participants did.

So who was in SPRINT? Here are the criteria the researchers used to define the study group and enroll participants.

The SPRINT participants were:

• 50 years or older, with a systolic blood pressure of 130-180 mm Hg, and
• With an increased risk of cardiovascular disease, defined by meeting one of the following conditions:
  • 75 years or older. Yes, that in itself puts people at risk.
  • A 10-year CVD risk of 15% or more based on the Framingham risk score. You can check your ownFramingham risk score here; you need to know your total cholesterol, HDL cholesterol and systolic blood pressure.
  • Chronic kidney disease, defined by aestimated glomerular filtration rate(eGFR) van 20-60.
  • Clinical or subclinical cardiovascular diseaseother than a stroke. This means things like a history of heart attack, bypass surgery, peripheral artery disease, carotid artery stent placement or surgery, or a test considered "positive" for cardiovascular disease. See the supplementary material of the published study for a full list of criteriaher.

It's just as important to remember who was thereruled outfrom SPRINT. You may have heard that SPRINT didn't apply to people with diabetes or stroke, but the exclusion list is much longer than that. (To seestudy supplementfor the full detailed list.)

This is not what the SPRINT participants were like:Elderly people with any of the following diagnoses, conditions or conditions were not eligible for the study:

• Diabetes
• Previous stroke
• Clinical diagnosis of dementia and/or the use of dementia medication
• People who live in a nursing home. (Help was okay.)
• Substance abuse (active or within the past 12 months)
• Symptomatic heart failure within the past 6 months or left ventricular ejection fraction (by any means) < 35%
• Polycystic kidney disease or eGFR < 20
• “Significant history of poor medication adherence or attendance at clinic visits.”

As you can see, quite a few common diagnoses and conditions were grounds for exclusion from the SPRINT study.

Ultimately, 9,361 people were registered between November 2010 and March 2013. The average age was 68 years and 28% of participants were 75 years or older.

Surprisingly, the average baseline systolic blood pressure was 140, which seemed to me to provide better blood pressure control than average older adults. And only 34% of participants had a systolic blood pressure higher than 145 at the start of the study. (For comparisonThis is reported by the CDCthat only about 1 in 4 adults with hypertension have their blood pressure under control.)

At the start of the study, participants took an average of two blood pressure medications.

What did the SPRINT intervention entail?

SPRINT participants were randomly assigned to be treated with a systolic blood pressure target of 140 or 120.

Participants were seen once a month for the first three months and every three months thereafter.

To treat blood pressure, SPRINT provided all major classes of blood pressure medications for free, and also allowed physicians to use other blood pressure medications as they saw fit. Here are the main classes of medications used; I have roughly ordered them based on how often they were used (according to Table S2 iAppendix).

Blood pressure medications used in SPRINT:

• Angiotensine-converting enzyme (ACE)-remmersInangiotensine II-receptorblokkers (ARB's), f.eks. lisinopril, losartan
• Diuretic,f.eks. chlorthalidone, hydrochlorothiazide, furosemide, spironolactone
• Calcium channel blockers,e.g. diltiazem, amlodipine
• Beta blockers (encouraged for people with coronary artery disease), e.g. metoprolol, atenolol
• Alpha-one blockers,e.g. doxazosin
• Direct vasodilators,e.g.hydralazine,minoxidil
• Alpha-to-agonists,e.g.clonidine

The last three classes of blood pressure medications were used in 10% of people or less, which makes sense because none of these medications are recommended as first-line medications for high blood pressure, heart disease, or kidney disease.

What about non-medical methods to control high blood pressure?

In the scientific publication, the SPRINT researchers say that "lifestyle changes were encouraged as part of the management strategy", but they do not provide more details about what changes were encouraged and how. So it's difficult to know how any non-drug methods – diet, exercise, salt reduction, stress reduction – played a role in this study.

Advantages and disadvantages observed in SPRINT

SPRINT randomly divided participants into an intensive treatment group, which aimed for a systolic blood pressure of less than 120, and a standard treatment group, which aimed for a systolic blood pressure of less than 140.

After one year, the mean systolic blood pressure in the intensive care group was 121, compared with 136 in the standard care group. The intensive group required an average of 2.8 medications to reach their lower blood pressure goal; the standard group required an average of 1.8 medications.

The follow-up period averaged approximately three years.

Benefits of intensive BP treatment:

During follow-up, 1.65% per year of people in the intensive care group and 2.19% per year of people in the standard care group experienced a significant cardiovascular "outcome event": a heart attack, stroke, acute decompensated heart failure, or passing away. due to cardiovascular causes.

The study authors calculated that "the numbers needed to treat to prevent a primary outcome, death from any cause, and death from cardiovascular causes during the median 3.26 years of the study, were 61, respectively , 90 and 172."

In other words, if you are like the study participants, and if you decide to switch from a systolic blood pressure goal of 140 to a goal of 120, in a few years you will:

• A 1 in 61 (1.6%) chance of avoiding a cardiovascular event
• A 1 in 90 (1.1%) chance of avoiding death from any cause
• A 1 in 172 (0.6%) chance of preventing death from cardiovascular causes

(For more on the wonderfully useful statistic, the number to process, seethis informative NYT articleand also the websitewww.thennt.com.)

Damage from intensive BP treatment

The SPRINT researchers were careful to detect side effects and complications. They found that serious adverse events occurred in 38.3% of the intensive treatment group and 37.1% of the standard treatment group.

Side effects included problems such as hypotension (low blood pressure), syncope (fainting), electrolyte problems, decreased kidney function and harmful falls. Most problems affected 1-7% of participants, with the exception of orthostatic hypotension – which means blood pressure drops when standing – which affected 16-18% of participants. (Standing BP was monitored at baseline, at 1, 6, and 12 months, and annually thereafter.)

Although many side effects occurred slightly more often in the intensively treated group,harmful falls occurred equally often in both treatment groups,and affected 7.1% of participants.

This finding is indeed consistent with what was reported in a2014 study on serious falls(e.g. bone breaking falls) in older people with high blood pressure. In that study, researchers classified people as taking no blood pressure medication, moderate-intensity treatment, or high-intensity treatment. Moderate- and high-intensity treatment were associated with a nearly equal risk of falling over three years (about 8.5%), while 7.1% of older adults not taking blood pressure medications had a major fall.

How blood pressure was measured in SPRINT

Blood pressure was measured very carefully, nothing moreseveralof the way patients normally have their blood pressure measured by their doctor. This is what they did in SPRINT:

• Have people sit and rest for five minutes before checking their blood pressure
• Blood pressure checked three times in a row using an automated blood pressure monitor (Omron 907)
• Used the average of these three blood pressure measurements to assess the person's blood pressure and determine whether the medication needed to be adjusted up or down.

Clearly, this is not the experience most people have in the doctor's office, and it has likely resulted in lower blood pressure readings than those under normal circ*mstances.

If you are like a SPRINT participant and are considering a lower blood pressure goal, make sure you ask to have your blood pressure checked in a similar manner. In reality, that is a much healthier basis for changing a patient's medication, but it is not a routine concern at this time.

And remember: Even if you're like the SPRINT participants — and you may not — aiming for the lower blood pressure goal probably gives you a 0.5%-1.5% chance of a poor health outcome to prevent. (While you have a very high percentage chance of needing to take more medications each day.)

If you want to know more about SPRINT:

SPRINT was a truly fascinating research effort and led to several interesting partial analyses. Here you can find more information about SPRINT results, specifically in people over 75 years of age:Important blood pressure screening: what you need to know about SPRINT-Senior.

Do I usually try to get my older patients to a 'normal' blood pressure?

Given the results of SPRINT and the guidelines, you may be wondering how I personally approach the treatment of high blood pressure in my patients.

In terms of my personal practice, I see a lot of older people concerned about falls, and a well-conducted 2014 study found that blood pressure treatment was associated with serious falls, such as broken bones. (Read my coverage of this studyher.)

I also find that many of my patients have difficulty managing multiple medications and are at risk for interactions with their medications. For example, all medications used in SPRINT have side effects to be aware of, and many medications can interact with other medications or chronic diseases.

There is actually good scientific evidence that in older adults with systolic blood pressure around 160 or higher, lowering systolic blood pressure around 140 reduces the risk of stroke and other serious cardiovascular diseases. (To seeherInher.) So it is certainly important to identify and, if possible, treat severe hypertension in older adults.

However, given the relatively small absolute benefit of aiming for a systolic blood pressure of 120, I have found that it is reasonable to aim for a systolic blood pressure of 140 for most of my patients.

Now you're probably still wondering what the right blood pressure goal is for you or your older family member. I can't tell you with certainty for your specific situation. But here's more information about why it's worth being cautious about over-treating high blood pressure, and why I agree with the December 2013 guidelines recommending a systolic blood pressure goal of 150 for most seniors.

Why older adults should be careful about overtreating high blood pressure

In my experience, many older adults take more blood pressure medications than they need, meaning they have reached a point where the risks and burdens outweigh the benefits (compared to less aggressive high blood pressure treatment).

This can cause falls or dizziness due to orthostatic hypotension, and one of the most common medication changes I make as a geriatrician is tapering off blood pressure medications.

How can you know if you may be over-treating high blood pressure? Here are the steps I recommend:

1. Check the elder's blood pressure and know what his/her systolic blood pressure is.The best way to do this is to use a high-quality blood pressure monitor and have your blood pressure checked at the same time for 3-7 days in a row. If possible, check twice a day instead of once a day. (For more information about managing blood pressure at home, seethis post.)

• Because blood pressure in the body is constantly changing slightly, a series of measurements gives a more accurate picture of where a person's blood pressure normally is.
• Home-based blood pressure checks have been found to correlate better with a person's actual blood pressure than occasional office blood pressure checks.
• If there is a drop or if systolic blood pressure is less than 120, consider monitoring blood pressure both while sitting and standing. If blood pressure drops a lot when the person stands (which is a sign of orthostatic hypotension), you can ask the doctor to address this.

2.Plan to talk to the older person's doctor about revising the blood pressure treatment plan.This is especially important if:

• Sitting systolic blood pressure is less than 130 mm Hg, and you notice a drop of 20 mm Hg or more when the older person stands.
• The sitting systolic blood pressure is less than 120 mm Hg and you are afraid of falling.
• Sitting systolic blood pressure is less than 110 mm Hg.
• Sitting systolic blood pressure is often greater than 150 mm Hg (in which case we may be dealing with undertreatment of hypertension).

Free cheat sheet: Get a handy cheat sheet to help you review a senior's blood pressure treatment plan.Click here.

For more information on how to find blood pressure treatment for people in their 60s, 70s, 80s or 90s, visit here:6 steps to better manage high blood pressure in older adults.

[This article was first published in 2015. It has been continuously reviewed and updated, most recently in November 2023.]