Understanding and mastering the characteristics and clinical diagnosis and treatment process of hypertension in the elderly is helpful to control and improve the compliance rate and improve the level of diagnosis and treatment. The Geriatrics Branch of the Chinese Medical Association and the Hypertension Branch of the China Association for the Promotion of International Exchange in Health Care have updated and formulated the Expert Consensus on the Characteristics and Clinical Diagnosis and Treatment Process of Hypertension in the Elderly (2024) based on the current situation of hypertension in the elderly in mainland China and relevant diagnosis and treatment guidelines at home and abroad.
Diagnostic criteria for hypertension in older adults
- Persistent blood pressure ≥ 140/90 mmHg
1. Diagnosis
Geriatric hypertension is diagnosed ≥ age 65 years with a systolic blood pressure ≥of 140 mmHg (1 mmHg = 0.133 kPa) and/or diastolic blood pressure ≥ 90 mmHg for more than 3 consecutive or more sessions.
Older adults who have had a definite diagnosis of hypertension and are receiving antihypertensive drugs should also be diagnosed with geriatric hypertension despite a blood pressure < 140/90 mmHg.
2. Blood pressure monitoring
There are three commonly used methods of blood pressure monitoring——— office blood pressure, ambulatory blood pressure and home self-measurement of blood pressure, in addition, the new office blood pressure measurement method ——— unattended automated office blood pressure (UAOBP) should be paid attention to, and the types and clinical significance of blood pressure monitoring are shown in Table 1.
Encourage elderly patients with hypertension to carry out home self-measurement of blood pressure and ambulatory blood pressure monitoring, and regularly measure blood pressure in both upper limbs and different positions (standing and lying positions). Pay attention to blood pressure monitoring before bedtime, early morning hours, and before taking medication.
Goals for the treatment of hypertension in the elderly
- < 80 years old, gradually decrease, aiming for 130/80mmHg
1. Evaluation
Formal antihypertensive therapy must be started as soon as possible after risk stratification assessment of other cardiovascular risk factors, subclinical target organ damage, and clinical disease, and the type of acute target organ damage is the main determinant of the preferred treatment regimen, as shown in Table 2 and Figure 1.
Fig.1 Evaluation and monitoring procedures for newly diagnosed elderly patients with hypertension
注：1mmHg=0.133kPa
2. Purpose of treatment
The main goals of treatment for patients with hypertension are to improve symptoms and quality of life, reduce the occurrence of cardiocerebrorenal and vascular complications, and reduce the overall risk of death.
3. Timing and target value of treatment
➤ It is recommended to start drug therapy for high-risk patients with cardiovascular disease ≥ 65~79 years old and blood pressure 150/90 mmHg or blood pressure ≥ 140/90mmHg, and it is recommended to reduce blood pressure to <140/90mmHg, and further to <130/80mmHg if tolerated.
➤ Patients ≥ 80 years of age with systolic blood pressure ≥ 150 mmHg are recommended to start drug therapy with < 150/90 mmHg and <140/90 mmHg if tolerated.
➤ For frail older adults with a blood pressure ≥ 160/90 mmHg, antihypertensive drug therapy should be considered, and an individualized blood pressure target is recommended, but the systolic blood pressure should not be less than 130 mmHg, see Table 3.
Treatment of hypertension in the elderly
——Follow the principle of "small dose, long-acting, combined, moderate, and individualized".
1. Non-pharmacological treatment
Lifestyle changes include eating a healthy diet that is in line with the physiological characteristics of old age, exercising regularly, quitting smoking and limiting alcohol, maintaining a healthy weight, improving sleep, and avoiding sedentary lifestyles.
2. Medication
Commonly used antihypertensive drugs include angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs, C), diuretics (D), β-receptor blockers, angiotensin receptor neprilysin inhibitors (ARNIs), and single-tablet fixed combination preparations (SPCs) consisting of these drugs.
SPC is preferred for combination drug therapy, and ACE inhibitors or ARBs combined with low-dose CCBs or thiazide diuretics are preferred. β Receptor blockers are not recommended as the first choice in patients with ISH unless there is a strong indication for β blocker use, such as comorbid coronary artery disease or heart failure. In addition, for patients with benign prostatic hyperplasia and refractory hypertension, α-blockers can also be used as adjunctive drugs. ARNI is recommended as a new antihypertensive drug.
It is important to note that:
➤ Most elderly patients with more than 20 mmHg above the target value can initially use a combination of two drugs;
➤ If the combination of two drugs still fails to meet the standard, the combination of three drugs with complementary mechanisms can be used;
➤ ≥ 80 years of age and frail patients, initial low-dose monotherapy is recommended.
SPC may increase treatment adherence in older patients. The principles to be followed in lowering blood pressure: small dose, long-acting, combined, moderate, and individualized. Emphasize systolic blood pressure while avoiding excessive lowering of blood pressure.
3. Antihypertensive therapy for frail patients
Because the existing studies on hypertension in the elderly have excluded patients with frailty and other geriatric syndromes, there is a lack of evidence-based medical evidence. Therefore, it is recommended that antihypertensive therapy for elderly patients should be individualized based on concomitant diseases and close monitoring and treatment effects after assessing the frailty state, especially if the body weight loss is >5% in the past 1 year or there is a risk of falling, and some elderly patients need to maintain high blood pressure to ensure tissue and organ perfusion.
4. Follow-up and blood pressure management
Elderly patients with hypertension need follow-up and management, and it is recommended to evaluate compliance and treatment response with monthly follow-up after initiating new drugs or adjusting drug treatment, and adjust the treatment plan in time according to blood pressure levels until the blood pressure is lowered. Follow-up includes: blood pressure compliance, whether orthostatic hypotension (OH) has occurred, whether there are adverse drug reactions, compliance with treatment, lifestyle changes, whether the dose of antihypertensive drugs needs to be adjusted, laboratory tests including electrolytes, renal function and other target organ damage, etc., community support and remote management also play an important role.
Source: Geriatrics Branch of Chinese Medical Association, Hypertension Branch of China Association for the Promotion of International Exchange in Health Care, Expert Consensus on the Characteristics and Clinical Diagnosis and Treatment Process of Hypertension in the Elderly (2024). Chin J Geriatrics,2024,43(3):257-268.
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