Risks associated with intensive blood pressure control in older patients

Abstract

Hypertension management forms a cornerstone of cardiovascular prevention. Strong evidence is available supporting the benefits of blood pressure (BP) lowering in older adults, and recent studies indicate that intensive BP control may provide additional advantages concerning cardiovascular and mortality risk, also at older ages. Yet, in older adults, the cardiovascular benefit of intensive treatment may come at the expense of an increase in adverse events. Indeed, advanced age and frailty may modify the risk/benefit ratio of BP lowering due to a greater predisposition to hypotension and more severe consequences deriving from treatment-related adverse effects. This mostly applies to individuals with poor health status and limited life expectancy, in whom aggressive BP lowering may not lead to cardiovascular benefits but rather increase the risk of short-term treatment-related complications. Furthermore, potential harms of intensive BP control might be underestimated in clinical trials due to exclusion criteria that preclude patients with frailty and multimorbidity from being eligible. Syncope and falls are the most frequently mentioned safety concerns related to antihypertensive treatment, but aggressive BP lowering may affect negatively also renal function, cognitive performance, quality of life, and survival. With the growing emphasis on intensive treatment strategies, raising the awareness of potential harms associated with aggressive BP lowering might help improve hypertension management in older adults and encourage implementation of clinical research on safety. Given these premises, we present a narrative review illustrating the most relevant risks associated with intensive BP control in older patients.

Interventions aimed to increase average 24-h systolic blood pressure reduce blood pressure drops in patients with reflex syncope and orthostatic intolerance

“… 11 , 12 However, a meta-analysis clearly showed that the lower is the BP achieved by antihypertensive treatment, the higher is the number of patients discontinuing treatment because of side effects (including hypotension) and thus remaining without cardiovascular protection. 13 Despite the evidence that intensive treatment is associated with an increased risk of hypotension and syncope, 14 few clinical trials have investigated when and how medications should be discontinued or at least downtitrated in patients with hypotensive adverse events. 15 Most of existing studies focus on antihypertensive deprescribing in frailer, older adults, 16–18 while a paucity of data in this regard is available in patients with a history of syncope and hypotensive episodes.…”

A Non-Coronary, Peripheral Arterial Atherosclerotic Disease (Carotid, Renal, Lower Limb) in Elderly Patients—A Review PART II—Pharmacological Approach for Management of Elderly Patients with Peripheral Atherosclerotic Lesions outside Coronary Territory

“…BP control aims at reducing the risk of death and the development of cardiovascular disease, kidney disease, and dementia [ 114 , 115 ]. According to the guidelines of national consultants in family medicine, hypertensiology, and cardiology, the recommended BP during home measurements for individuals ≥ 65 years of age should not be greater than 135/85 mmHg, while for in-office measurements BP should not exceed 130–139 mmHg systolic and 70–79 mmHg diastolic.…”

Tolerability of Antihypertensive Medications: The Influence of Age

“…The HYVET trial reported a 40% prevalence of drug-related AEs among subjects aged 80 or older receiving antihypertensive therapy [ 10 ]. Despite the known predisposition of older patients to drug-related AEs, the influence of age on tolerability of antihypertensive medications has been poorly investigated to date, except for the well-known risk of hypotension, electrolyte imbalances and renal function worsening [ 11 , 12 ]. Therefore, although treatment tolerability can significantly influence patients’ compliance and therapeutic management, the risk and predisposing factors for antihypertensive-related AEs in older adults remain currently unclear [ 13 ].…”