Canadian Journal of Cardiology 33 (2017) 591e593
Editorial
Application of Hypertension Guidelines in the Elderly:
Revisiting Where the Bridge to Nowhere Might Actually
Be Going
Ross D. Feldman, MD, FRCPC,a and Raj S. Padwal, MD, FRCPCb
a
Memorial University of Newfoundland, St John’s, Newfoundland and Labrador, Canada
b
University of Alberta, Edmonton, Alberta, Canada
A man is as old as his arteries.
dThomas Sydenham (1624-1689)
Individuals aged 65 years or older now comprise 15.3%
of the Canadian population and, if projections prove
accurate, will constitute one-quarter of the populace or 13
million individuals by 2056.1 In other countries, similar
aging population demographic trends are occurring.2
For clinicians who manage patients with high blood pres-
sure (BP), advanced age substantially complicates the
management of hypertension. This is primarily because
existing evidence gaps lead to genuine uncertainty as to
the threshold for initiating antihypertensive drug
therapy and the target BP that should be achieved in older
patients.
Cardiovascular risk increases with advancing age, inde-
pendent of other traditional risk factors.3 Thus, older age,
especially in the presence of
1 additional cardiovascular
risk factors, often places an individual in the moderate- to
high-risk category (10-year risk of a cardiovascular event of

10%). Consequently, older patients frequently qualify
for aggressive risk factor management on the basis of cur-
rent Hypertension Canada clinical practice guidelines, also
known as the Canadian Hypertension Education Program.
An additional consequence of aging is that progressive
vascular stiffness occurs. In the large vessels, this manifests
as arteriosclerosis, early rebound of pressure waves,
augmented systolic BP levels, and reduced diastolic BP.4,5
In other words, older individuals phenotypically manifest
with isolated systolic hypertension, and thus it is the sys-
tolic BP target that is most often examined when initiating
and titrating antihypertensive drug therapy.
Received for publication October 17, 2016. Accepted November 10, 2016.
Corresponding author: Dr Ross D. Feldman, Health Sciences Centre,
Room 5306, 300 Prince Philip Dr, St John’s, Newfoundland and Labrador
A1B 3V6, Canada. Tel.: þ1-709-777-6079; fax: þ1-709-777-8031.
E-mail: ross.feldman@med.mun.ca
See page 593 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2016.11.010
0828-282X/Ó 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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How to treat these patients has continued to be an
important and controversial issue. In a commentary published
in the Canadian Journal of Cardiology 1 year ago, we suggested
that, in deciding whether or not to treat the elderly patient to
the then-target of 150 mm Hg, “practitioners are advised to
continue to adhere to foundational therapeutic principles
when considering whether or not to initiate antihypertensive
drug therapy.”6 We especially focused on the frail elderly
population, questioning whether the current Hypertension
Canada clinical practice guidelines (or any atherosclerotic risk
prevention recommendations) should apply to them.
Over the past year, significant changes in our hypertension
guidelines have made this issue even more important. The
Canadian Hypertension Education Program has made a major
change in their recommendations for hypertension manage-
ment in the elderly populationdperhaps the most substantive
change in the almost 40-year history of this guidelines process.
Up to 2016, 2 major treatment recommendations were
directly influenced by age.7 First, use of b-blockers were not
recommended in patients aged 60 or older, because published
data indicate that this drug class is less effective in reducing
cardiovascular end points compared with other drug classes.8
We expect that this recommendation will continue un-
changed into the 2017 recommendations. Second, in very
elderly patients (aged 80 years or older), the systolic BP
threshold for initiating drug therapy was recommended
as
160 mm Hg, with a target of < 150 mm Hg. This
recommendation was primarily derived from the Hyperten-
sion in the Very Elderly Trial (HYVET) and additional meta-
analytic data.9 HYVET was a placebo-controlled trial that
enrolled 3845 subjects (mean age, 83.6 years). This trial was
stopped early (median follow-up, 1.8 years) and had some
important limitations that are discussed elsewhere; the major
finding was that the relative hazard for fatal or nonfatal stroke
was reduced by 0.70 with active therapy (12.4% vs 17.7% for
placebo; 95% confidence interval, 0.49-1.01). Although this
result was of borderline statistical significance, stroke mortality
and all-cause mortality were conclusively reduced by clinically
important amounts.9
However, in 2016, the targets and thresholds for many
older individuals were dramatically altered, primarily on the
592
basis of the findings from the Systolic Blood Pressure Inter-
vention (SPRINT) study. For elderly patients (older than 75
years) who meet the criteria for enrollment in the SPRINT
study, Hypertension Canada now recommends that an anti-
hypertensive drug treatment initiation threshold of > 130
mm Hg and a target of  120 mm Hg be considered. These
individuals mostly comprise patients for whom a year
earlier their thresholds/target BP were 30 mm Hg higher!
SPRINT was a treat to target study in 9361 high-risk subjects,
with participants randomized to a BP threshold of < 140 mm
Hg (standard therapy) vs < 120 mm Hg (intensive therapy).10
After 3.3 years, the hazard ratio for composite cardiovascular
events was 0.75 (5.2% event rate with intensive therapy
vs 6.8% with standard therapy; 95% confidence interval,
0.64-0.89). Age alone, specifically being 75 years of age or
older, qualified participants as high-risk and entry into
SPRINT and the trial findings were robust in this subgroup.11
Importantly, in SPRINT BP was measured using an
automated office device and this should be the method
used when applying SPRINT in clinical practice.
Notably, patients with diabetes were excluded from
SPRINT; the Hypertension Canada guidelines recommend
a BP threshold for initiation of pharmacotherapy of
130/80 mm Hg, with a BP target of < 130/80 mm Hg
regardless of age.7
Clinicians can be forgiven if they find the multiple afore-
mentioned targets and thresholds confusing, especially when a
given patient simultaneously qualifies for 2 different thresh-
olds and targets like patients with diabetes who are older than
75 years of age. In our commentary 1 year ago, we focused
specifically on the challenges encountered when applying
these recommendations to the frail elderly patient. As we
noted, frailty, which can be assessed using a number of clinical
models, is common in older individuals, affecting nearly 10%
of individuals older than 75 years of age and > 25% of in-
dividuals older than 85 years of age.12 Frailty is an indepen-
dent and robust risk factor for falls, adverse drug reactions,
institutionalization, and death.12 However, even for the frail
elderly patient, recommendations on the basis of the findings
of SPRINT and HYVET cannot be easily dismissed as irrel-
evant. Both studies included frail individuals. Further, the
benefits of antihypertensive drug therapy reported in SPRINT
and HYVET were present regardless of baseline frailty.11,13
Additionally, although the incidence of hypotension and
syncope were nonsignificantly higher in the elderly SPRINT
patients, overall, the risk of injurious falls tended to be lower
(although again not significantly) and the risk of serious
adverse events in the frail elderly population in SPRINT was
not increased in the intensively treated group. However, the
SPRINT trial excluded individuals with dementia, those with
a standing BP < 110 mm Hg, institutionalized patients, as
well as a range of other comorbidities. Thus, we might well be
entering an era in which for each of our elderly patients with
hypertension we will need to determine whether they are
“SPRINT-like” or “non-SPRINT-like” before determining
their thresholds/targets for treatment.
Nevertheless, because practitioners were often reticent to
reduce BP to even the older target of < 150 mm Hg for fear
of causing harm in frail patients, applying the new SPRINT
targets/thresholds might be even more challenging. Last year
we did note that, before implementation of aggressive BP
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Canadian Journal of Cardiology
Volume 33 2017
targets, there should be “careful characterization of the
benefit-risk profile; individualization of therapy according to
the values and wishes of each patient; and close follow-up and
monitoring after drug therapy is initiated.” We would reiterate
those caveats this year. Supporting a cautionary stance is the
increased risk of adverse effects, including syncope, hypoten-
sion, electrolyte disturbances, and acute kidney injury seen
with the intensive intervention used in SPRINT.10 Although
these adverse effects cannot be considered on par with expe-
riencing a cardiovascular event, they remain important con-
siderations. Additional support to exercise caution comes from
observational data showing higher rates of cardiovascular
events, cognitive decline, and mortality in older individuals
with frailty or dementia receiving antihypertensive drugs and
exhibiting low BP levels.14-16 However, and of critical
importance, these latter observational data are simply asso-
ciative in nature and how they balance with the clear
demonstration of the “hard outcome” benefits of achieving
lower targets on the basis of gold standard randomized
controlled trials is problematic.
In summary, when trying to determine how best to
manage older patients with hypertension, especially in those
who are frail and/or susceptible to adverse effects, we are
faced with a quandary created by the disconnect between the
results of clinical trials and meta-analyses (more methodo-
logically rigourous data but of limited generalizability) and
the principle of primum non nocere, with this latter concept
supported by nondefinitive observational data. Conse-
quently, our advice to clinicians is to individually tailor
therapy for each patient. Because older individuals, especially
those aged 75 years or older, comprise a higher risk sub-
group, aggressive therapy is justifiable. In a “less” frail patient
who is interested, willing, and has sufficient life expectancy,
attempts should be made to reach a target systolic BP of
 120 mm Hg because the potential benefit is
substantialdthe number needed to treat in the SPRINT
elderly subgroup analysis was 27 to prevent 1 cardiovascular
event and 41 to prevent 1 death.11 However, in the
institutionalized frailer patients, in those who experience
side effects or who are not in favour of intensive therapy, or
in patients in whom this low threshold is unlikely to
be achievable, a target BP of < 150 mm Hg (or < 130 mm
Hg if diabetes is present) is still reasonable. Further,
notwithstanding the lack of any signal of increased
injurious falls with intensive therapy, especially in the frail
patient, management should be predicated on careful
assessment of standing BPs (at 1 minute as done in SPRINT
and probably earlier to assess for the extent of the immediate
decrease in BP upon rising) and careful elicitation of
details on history of symptoms of orthostatic faintness at
times of greatest risk (eg, upon rising in the morning and
after meals).
We are reminded of the words of Sir William Osler,
who said “It is much more important to know what sort of a
patient has a disease than what sort of a disease a patient has.”
Current guidelines provide a framework for action, but the
art of implementation remains firmly in the jurisdiction of
clinicians, and even more importantly, that the ultimate
decision-making is made by the patient after a meaningful
dialogue that outlines the benefits as well as the risks of
therapy.
Feldman and Padwal
Hypertension Guidelines in the Elderly
Disclosures
Both authors have leadership roles in Hypertension Can-
ada and in Hypertension Canada’s clinical practice guidelines.
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