The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have issued an evidence-based clinical practice guideline on the appropriate systoilc blood pressure target for adults aged ≥60 years with hypertension. The joint guideline has been published in Annals of Internal Medicine.

The ACP and AAFP recommend the following for clinicians: 

Recommendation 1: Start treatment in adults aged ≥60 years with persistent systolic blood pressure (SBP) ≥150mmHg to achieve a target of <150mmHg to reduce the risk of mortality, stroke, and cardiac events. (Grade: strong recommendation, high-quality evidence).

Recommendation 2: Consider initiating or intensifying pharmacologic treatment in adults aged ≥60 years with a history of stroke or transient ischemic attack to achieve a target SBP of <140mmHg to reduce the risk of recurrent stroke. (Grade: weak recommendation, moderate-quality evidence). 

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Recommendation 3: Consider initiating or intensifying pharmacologic treatment in some adults aged ≥60 years at high cardiovascular risk, based on individualized assessment, to achieve a target SBP of <140mmHg to reduce the risk of stroke or cardiac events. (Grade: weak recommendation, low-quality evidence). Increased cardiovascular risk includes patients with known vascular disease, diabetes, chronic kidney disease with eGFR <45mL/min/1.73m2, metabolic syndrome (eg, abdominal obesity, hypertension, diabetes, dyslipidemia), and older age. 

Some patients may have falsely high readings in clinical settings, also known as “white coat hypertension,” so ambulatory measurement may be appropriate. Also, clinicians should consider nonpharmacologic therapy such as weight loss, dietary changes, and an increase in physical activity, as initial or concurrent treatment with pharmacologic treatment. 

For older patients taking multiple medications, clinicians should consider treatment burden and drug interactions when selecting treatment options.  Moreover, physicians are advised to prescribe generic formulations over brand name drugs when available, as they have similar efficacy, lower cost, and thus improved adherence. 

Evidence for adults who are frail or who have multiple comorbidities was limited. No recommendations about diastolic blood pressure targets were made due to insufficient evidence. 

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