130/80 is the new 140/90: Do we need a tailored approach for older patients?

Hypertension accounts for a substantial amount of preventable health loss attributable to modifiable risk factors, and its prevalence increases with age. With the aging of the population, it has become a global priority to control blood pressure (BP) levels according to the best available evidence. However, inconsistent results from clinical trials and observational studies have led to discrepant hypertension definitions among scientific societies, including the American Heart Association (AHA), the American College of Physicians (ACP) and the European Society of Cardiology (ESC). Particularly for older patients, the cut-off values for hypertension in the ACP and ESC guidelines are 150/90mmHg and 140/ 90mmHg, respectively. Meanwhile, the latest AHA hypertension guideline lowered the threshold of stage 1 hypertension to 130/80mmHg. This decision was based on a systematic appraisal of randomised clinical trials, indicating that hypertension treated to the new goal can reduce the risk of major cardiovascular events such as myocardial infarction, stroke and heart failure. Since its inception in 2017, the rigorous modification of BP thresholds in theAHAguideline has stimulated intense debate. Most of the criticism regarding the lowering of the BP threshold is based on the potential risks of overdiagnosis and overtreatment. With 130/80mmHg as a new cut-off value for stage 1 hypertension, more individuals would be identified as prevalent cases, and consequently more would require antihypertensive therapy. This could be particularly challenging when implementing the new AHA guidelines in the elderly, given the potential increase in the healthcare costs and the putative side effects of antihypertensive treatments related to older age. Against the overtreatment arguments, the AHA guideline indicates that based on the cardiovascular risk score calculation, only a small proportion of newly diagnosed patients would require medical treatment. The majority would control BP values through lifestyle modifications, which would imply the development of comprehensive preventive strategies targeting cardiovascular risk factors. Still, the implications of the current AHA guideline remain to be further explored in real life settings, beyond the clinical trials that originated the existing recommendations. In this issue of the European Journal of Preventive Cardiology, Na Liu et al. investigated the association of the new BP criteria with all-cause and cardiovascular disease (CVD) mortality, based on the pooled data from three prospective Chinese cohorts. In a total population of 154,000 participants, the prevalence of stage 1 hypertension was 45.6%. Stage 1 hypertension was associated with an increased risk of mortality due to CVD, ischaemic heart disease and cerebrovascular disease. Importantly, 27.4% and 9.8% of CVD deaths could be prevented if stage 1 hypertension was eliminated among adults younger and older than 65 years, respectively. However, as the authors acknowledge, the proportion of patients that would require antihypertensive medications according to the new AHA guideline could not be calculated in this setting due to the lack of available data on the baseline cardiovascular risk score. Of note, Na Liu et al. found that the association of stage 1 hypertension with mortality was stronger among participants younger than 65 years of age and was attenuated with increasing age. In line with the current AHA recommendations, it was concluded that for individuals younger than 65 years of age and without pre-existing CVD, a comprehensive management of BP to less than 130/80 mmHg (by way of lifestyle modifications and home BP monitoring) could contribute to the prevention of CVD mortality. This is also supported by other prospective studies performed in multi-ethnic populations, reporting that the risk of CVD for younger adults diagnosed with stage 1 hypertension is higher compared to those with normal BP values. On the other hand, the evidence for older patients is not as consistent as it is for younger patients, and this may be attributable to the large clinical heterogeneity within