JNC 8 and Older Adults: A Review of the Evidence

Jamie Rickards, PharmD, MBA, BCPS, CPP, and Jena Ivey Burkhart, PharmD, BCPS, CPP
Published Online: Tuesday, July 15, 2014
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New Guideline for Blood Pressure Management in Older Patients

Introduction
Blood pressure (BP) goals have been the subject of ongoing debate for years and are arguably even more controversial in the elderly. Many factors must be taken into consideration, such as life expectancy, fall risk, and medication adverse effects. This article will review select special considerations in BP management in the elderly, as well as the evidence surrounding the more lenient older adult BP goal recommended in the recently published Eighth Joint National Committee (JNC 8) hypertension guideline.1

Considerations in the Elderly
Orthostatic Hypotension
Orthostatic hypotension (OH) is defined as a decrease in systolic blood pressure (SBP) by more than 20 mm Hg or a more than 10 mm Hg decrease in diastolic blood pressure (DBP) from supine to standing position.2 OH has been shown to be an independent risk factor for falls in the older adult population and is highly age dependent. This is mostly due to hardening of the arteries with age, causing a decreased baroreceptor response. OH has also been shown to be associated with a significant increase in morbidity and mortality.2-6

Isolated Systolic Hypertension
Isolated systolic hypertension (ISH) is most prevalent in the older adult population and appears to be due to hardening of the large arteries. It has been found that there is a linear increase in systolic blood pressure (SBP) with age, but that diastolic blood pressure (DBP) plateaus and may decrease around the fifth or sixth decade of life. A trial reviewing the correlation between blood pressure and coronary heart disease found that DBP was superior to pulse pressure (PP) and SBP in predicting heart disease in patients younger than 50 years, whereas SBP was superior to PP in patients older than 60 years and DBP was negatively correlated to coronary heart disease.9 Treating ISH can be challenging when the DBP is low, as it has been shown that there may be possible harm with DBP less than 55 to 60 mm Hg.2, 7-14 See Online Table 1 for a list of pre-JNC 8 guidelines.

Table 1: Previous Hypertension Guideline Recommendations
 
Guideline BP Goal
(mm Hg)
Comments
Specific for Older Adults: Yes/No
CHEP15 (Canadian Hypertension Education Program)
2013
<150/90 ·      In patients ≥ 80 years of age without diabetes and target organ damage, drug therapy should be initiated when SBP is ≥160 mm Hg to a target of <150 mm Hg (C)
·      Antihypertensives should be considered regardless of age (B)
·      Caution should be exercised in initiating antihypertensives in frail elderly patients
·      In ISH in the elderly, recommended therapy is a thiazide-like diuretic, CCB (A) or an ARB (B)
·      Avoid BB or alpha-blockers as first line therapy in ISH in the elderly (A)
Yes
(80 years of age)
ESH/ESC16 (European Society of Hypertension/European Society of Cardiology)
2013
<150/90 ·      Recommend diuretic or calcium antagonist in elderly with ISH based on SHEP17, Syst-Eur18, SystChina19 (IA)
·      Recommended to treat all elderly with SBP >160mmHg to 140 to 150mmHg (IA), largely based on HYVET20
·      Consider SBP goal of <140mmHg in fit older adult patients (IIbC)
·      However, in frail elderly patients clinical judgment is advised (IC)
Yes
 (80 years of age or fragile older adult)
NICE21 (National Institute for Health and Care Excellence)
 2011
<150/90 ·      Same medications should be offered for patients’ ≥ 80 years of age as younger patients, based on comorbidities
·      Not recommended to initiate treatment in patients ≥80 years of age if only stage I HTN (<160/100 mm Hg)
Yes
 (≥ 80 years of age)
JNC 7 2 (Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure)
2003
<140/90 ·      ISH is the predominant form of HTN in older adults
·      Alpha and non-selective beta-blockers can cause ISH
·      Treating HTN in the elderly has been shown to be beneficial via multiple trials including SHEP,20 Syst-Eur,21 Staessen et al meta-analysis,22 Hansson et al,23 Gueyffier et al,24 and Neal et al25
·      SBP provides more appropriate classification in the older adult population versus DBP
·      Weight loss and reduced sodium intake are particularly beneficial in the elderly, based on the TONE26 trial
·      Diuretics have been found to be associated with a decreased risk of hip fracture
No
 
 
 
ARB = angiotensin receptor blocker; CCB = calcium channel blocker; DBP = diastolic blood pressure; ISH = isolated systolic hypertension; SBP = systolic blood pressure; HTN = hypertension; HYVET = Hypertension in the Very Elderly Trial; SBP = systolic blood pressure; TONE = Trial of Nonpharmacologic Interventions in Elderly.



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