Muhammad Hanif Ahmad, Raja Isteri Pengiran Anak Saleha Hospital, Shyh Poh Teo, Raja Isteri Pengiran Anak Saleha Hospital
2019 Geriatrics Gerontology and Aging  
Systolic hypertension of 160 mmHg and above is common in older people, as a result of reduction in vascular compliance. Although uncomplicated hypertension is not unusual in geriatric clinical practice, high-quality evidence has demonstrated increased rates of premature disability, all-cause mortality, stroke, and cardiac events in older patients with untreated moderate-to-severe hypertension. 1,2 For every 20-mmHg increase in systolic blood pressure (BP) and 10-mmHg increase in diastolic BP,
more » ... ere is an associated doubling of the risk of death from stroke and coronary artery disease. 1 A recent paper on hypertension also revealed the increasing prevalence of hypertension in older people, especially for those with multiple comorbidities. 2 A systematic population-based approach is required to optimally manage hypertension and its associated cardiovascular risks. In this paper, we share our considerations in developing or adapting guidelines for treatment of hypertension among older people (i.e., age 65 years and older) in primary care settings in Brunei. There are no local studies on hypertension and its treatment among older people in Brunei. We reviewed available international guidelines and identified variability in recommendations for hypertension treatment targets for this age group. For example, the American College of Cardiology (ACC) advises treatment to a systolic BP below 130 mmHg, 3 the European Society of Cardiology (ESC) recommends a target systolic BP between 130 and 139, 4 while the UK National Institute for Health and Care Excellence (NICE) specifies a target BP below 140/90 mmHg for those under 80 years and below 150/90 mmHg for those over 80. 5 Despite these variations, adapting these guidelines to different population settings would require expert consensus and further discussion regarding which would be more appropriate for implementation. In addition, the Systolic Blood Pressure Intervention (SPRINT) trial advocates treating patients at high risk of cardiovascular events without diabetes to a target systolic BP of less than 120 mmHg, as compared to less than 140 mmHg, which resulted in lower rates of fatal and non-fatal major cardiovascular events and death from any cause. This has not been reflected in guidelines, possibly due to apprehension concerning adverse effects. 6 For the local guidelines, we wanted to emphasize treatment of hypertension, given its association with mortality from cardiac and cerebrovascular events. Apprehension or uncertainty among clinicians regarding hypertension treatment in older people may lead to undertreatment. In our setting, the ESC approach was adapted so that there is a specific goal for primary care clinicians to aim towards (systolic BP between 130 and 139 mmHg; diastolic BP < 80 mmHg), taking into account patient tolerability. 4 There are several reasons for preferring the ESC approach. Although the SPRINT trial demonstrated that more intensive BP-lowering treatment (mean 124/62 mmHg) significantly reduced cardiovascular events and mortality compared to standard treatment (mean 135/67 mmHg), the BP measurement technique used generated lower values than those provided by conventional office measurement. It is suggested that the mean systolic BP achieved in intensively treated older people more closely reflects a conventional office systolic BP range of 130-139 mmHg. 6,7 In our setting, there have also been cases of older people over-treated for hypertension, resulting in adverse events, particularly falls and orthostatic hypotension (unpublished local data). Therefore, it was felt that a target range (130)(131)(132)(133)(134)(135)(136)(137)(138)(139)
doi:10.5327/z2447-211520191900048 fatcat:olpm3pyaxbd73ay7s27rk6z2ka