Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: The minority view

The guideline panel was faced with a lack of definitive RCT evidence to determine the optimum SBP. In the United States, millions of treated older hypertensive patients have an average SBP closer to the range of 135 to 140 mm Hg than the range of 145 to 150 mm Hg. Which SBP goal is most likely to reduce cardiovascular events without overwhelming adverse events? Panel members agreed that available RCTs provide strong evidence that treatment of an SBP greater than 150 mm Hg will reduce cardiovascular events with little evidence of serious harm. On the basis of expert opinion, the panel also agreed to recommend an SBP target of less than 140 mm Hg for patients younger than 60 years, those older than 60 years with DM, and those younger than 70 years with CKD. However, the panel did not reach unanimous consensus on the recommendation for persons older than 60 years who do not have DM or CKD. The majority embraced the view that in the absence of definitive evidence, increasing the SBP goal was the optimum approach. We, the panel minority, believed that evidence was insufficient to increase the SBP goal from its current level of less than 140 mm Hg because of concern that increasing the goal may cause harm by increasing the risk for CVD and partially undoing the remarkable progress in reducing cardiovascular mortality in Americans older than 60 years. Because of the overall evidence, including the RCT data reviewed by the panel, and the decrease in CVD mortality, we concluded that the evidence for increasing a blood pressure target in high-risk populations should be at least as strong as the evidence required to decrease the recommended blood pressure target. In addition, one target would simplify implementation for clinicians. However, we did believe that an SBP goal of less than 150 mm Hg for frail persons aged 80 years or older was a reasonable alternate approach to addressing the concern that elderly patients are at higher risk for treatment-related serious events. A target SBP of less than 140 mm Hg for patients younger than 80 years would also be in line with guidelines from Europe (5), Canada (6), the United Kingdom (7), the American College of Cardiology Foundation and the American Heart Association (8), and the American Society of Hypertension and the International Society of Hypertension (9).