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CLINICAL GUIDELINE
PharmacologicTreatmentofHypertensioninAdultsAged60Yearsor
OldertoHigherVersusLowerBloodPressureTargets:AClinical
PracticeGuidelineFromtheAmericanCollegeofPhysiciansandthe
AmericanAcademyofFamilyPhysicians
AmirQaseem,MD,PhD,MHA;TimothyJ.Wilt,MD,MPH;RobertRich,MD;LindaL.Humphrey,MD,MPH;JenniferFrost,MD;dan
MaryAnnForciea,MD;fortheClinicalGuidelinesCommitteeoftheAmericanCollegeofPhysiciansandtheCommissionon
HealthofthePublicandScienceoftheAmericanAcademyofFamilyPhysicians*

Keterangan: TheAmericanCollegeofPhysicians (ACP) dan rekomendasi,tinggi-qualityevidence).ACPandAAFPrecom-

American Academy of dokter keluarga (AAFP) bersama-sama pemmendthatcliniciansselectthetreatmentgoalsforadultsaged60
rekomendasi
opedthisguidelinetopresenttheevidenceandprovideclinical
berdasarkan benets dan merugikan
versuslowerbloodpressuretargetsforthetreatmentofhyper-tensio Recommendation2: ACPandAAFPrecommendthatclinicians
ninadultsaged60yearsorolder lebih tinggi.
Metode: Thisguidelineisbasedonasystematicreviewofpub-
lished acak, dikendalikan uji untuk hasil-hasil utama dan
pengamatan studi untuk merugikan hanya (identied
EMBASE, theCochraneDatabaseofSystematicReviews,
MED-LINE dan ClinicalTrials.gov), dari awal database
melalui
January2015.TheMEDLINEsearchwasupdatedthroughSep-te
mber2016. Evaluatedoutcomesincludedall-causemortality,
morbidityandmortalityrelatedtostroke, majorcardiacevents
(infark miokard fatal dan mematikan dan kematian
jantung mendadak), andharms. Metode
Thisguidelinegradestheevidenceandrec-ommendationsusin
gtheGRADE (penilaian GradingofRecommendations,
pengembangan, andEvaluation).
TargetAudienceandPatientPopulation: Target audi- bloodpressureoflessthan140mmHgtoreducetheriskfor
enceforthisguidelineincludesallclinicians, andthetargetpa-
tientpopulationincludesalladultsaged60yearsorolderwith
hipertensi.
Recommendation1: ACPandAAFPrecommendthatclinicians
initiatetreatmentinadultsaged60yearsorolderwithsystolic
bloodpressurepersistentlyatorabove150mmHgtoachievea
targetsystolicbloodpressureoflessthan150mmHgtoreduce
theriskformortality,stroke,andcardiacevents.(Kelas:kuat
-
yearsorolderbasedonaperiodicdiscussionofthebenetsand
harmsofspecicbloodpressuretargetswiththepatient.
considerinitiatingorintensifyingpharmacologictreatmentin
adultsaged60yearsorolderwithahistoryofstrokeortransient
ischemicattacktoachieveatargetsystolicbloodpressureofless
than140mmHgtoreducetheriskforrecurrentstroke. (Kelas:
weakrecommendation, moderat-qualityevidence). ACPand
AAFPrecommendthatcliniciansselectthetreatmentgoalsfor
adultsaged60yearsorolderbasedonaperiodicdiscussionof
thebenetsandharmsofspecicbloodpressuretargetswiththe
pasien.
Recommendation3: ACPandAAFPrecommendthatclinicians
considerinitiatingorintensifyingpharmacologictreatmentin
someadultsaged60yearsorolderathighcardiovascularrisk,
basedonindividualizedassessment, toachieveatargetsystolic
strokeorcardiacevents. (Kelas: weakrecommendation,
rendah-qualityevidence).
ACPandAAFPrecommendthatcliniciansse-lectthetreatmentgoalsf
oradultsaged60yearsorolderbased
onaperiodicdiscussionofthebenetsandharmsofspecic
bloodpressuretargetswiththepatient.
AnnInternMed. Doi:10.7326 / M16-1785 www.Annals.org
Forauthorafliations, seeendoftext.
http://www.Annals.org
Thisarticlewaspublishedat www.annals.orgon17January2017.

H ypertension, anelevationofsystemicarterialblood
tekanan (BP), isaverycommonchronicdiseasein
theUnitedStates.Theoverallprevalenceofhyperten-
Seealso:
Relatedarticle... 1
Sion di antara orang dewasa AS adalah 29.0%, dan itu meningkat
menjadi 64.9%inadults aged60yearsor older(1). Editorialcomment... 2
Hyperten-sionwasassociatedwithatotalof$ 46billioninhealth
SummaryforPatients... 3

* Thispaper, writtenbyAmirQaseem, MD, PhD, MHA; TimothyJ.Wilt,MD,MPH; RobertRich, MD; LindaL.Humphrey,MD,MPH; JenniferFrost, MD; dan
MaryAnnForciea, MD, wasdevelopedfortheClinicalGuidelinesCommitteeoftheAmericanCollegeofPhysicians (ACP) andtheCommissiononHealthof
thePublicandScienceoftheAmericanAcademyofFamilyPhysicians(AAFP). IndividualswhoservedontheACPClinicalGuidelinesCommitteefrominitiation
oftheprojectuntilitsapprovalwereMaryAnnForciea, MD ) Kursi ); (NickFitterman, MDViceChair) ; MichaelJ.Barry,MD ; CynthiaBoyd, MD, MPH!; Carrie
A.Horwitch,MD,MPH ; LindaL.Humphrey,MD,MPH ; AlfonsoIorio, MD, PhD ; DevanKansagara, MD, MCR!; ScottManaker, MD, PhD!; RobertM.McLean,
MD ; SandeepVijan,MD,MS!;andTimothyJ.Wilt,MD,MPH . MembersoftheAAFP'sCommissiononHealthofthePublicandSciencewerePatriciaCzapp,
MD) Kursi )!; AdaDeniseStewart,MD!;DavidT.O'Gurek,MD!; JosephL.Perez,MD,MBA!; MargotL.Savoy,MD,MPH!; KennethW.Lin,MD,MPH!; Jason
M.Matuszak,MD!; RanitMishori,MD,MHS!;DaronW.Gersch,MD!; ClareA.Hawkins,MD,MSc!; BeuletteY.Hooks,MD!; RobynLiu, MD, MPH!; Shannon
Dowler, MD!; Shani Muhammad, MD!; Tobie-Lynn Smith, MD, MPH!; James Stevermer, MD!; Carolyn Gaughan!; Vivian Jiang, MD!; dan
Harris! Aisyah. ApprovedbytheACPBoardofRegentson16July2016.ApprovedbytheAAFPBoardofDirectorson20July2016. Author(participatedindiscussionandvoting).

!Nonauthorcontributor(participatedindiscussionbutnotvoting).

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CLINICAL GUIDELINE PharmacologicTreatmentofHypertensioninAdults

Tabel. TheAmericanCollegeofPhysicians'Guideline companying latar belakang bukti review (8) dan

GradingSystem*
fullevidencereport(9).

Qualityof StrengthofRecommendation
GradingtheEvidenceandDeveloping
Bukti Rekomendasi
BenetsClearlyOutweighRisks BenetsFinelyBalanced ThisguidelinewasjointlydevelopedbyACP'sClin -
andBurdenorRisksandBurden WithRisksandBurden
ClearlyOutweighBenets ical pedoman Komite dan perwakilan dari
AAFPaccordingtoACP'sguidelinedevelopmentpro-cess,
Tinggi Kuat Lemah detailsofwhichcanbefoundinthemethodspa-per (10).
Moderat Kuat Lemah Komite digunakan tabel bukti dalam andfullreport
Rendah Kuat Lemah theaccompanyingsystematicreview (8) (9) ketika
Insufcientevidencetodeterminenetbenetsorrisks
melaporkan bukti dan dinilai rec-ommendations
yang menggunakan kelas (penilaian dari Recom -
* AdoptedfromtheclassicationdevelopedbytheGRADE(Grading of mendations penilaian, pengembangan dan
Recommendations Assessment, Development, and Evaluation) Evalua-tion) metode (
workgroup. Meja ).
PeerReview
careservices, obat-obatan, andmisseddaysofworkin Tinjauan bukti VA adalah meninjau rekan dan
postedontheVAWebsiteforpubliccomments, dan
theUnitedStatesin2011(2). thepublishedreviewarticlewaspeerreviewedthrough jurnal.
Appropriatemanagementofhypertensionreduces Pedoman memiliki proses peer-review melalui jurnal dan
theriskforcardiovasculardisease, renaldisease, diposting online untuk com yang nyata dari ACP Bupati dan
cere-brovasculardisease,anddeath(3 6). Namun, Bupati, yang tersembunyi mewakili - dikirim anggota dokter
mencegah-miningthemostappropriateBPtargets, particularlyfor di tingkat nasional dan internasional-mem. Pedoman ini juga
adultsaged60yearsorolder, hasbeencontroversial. Perdebatan telah ditinjau oleh
tentang tujuan untuk sistolik BP (SBP) antara orang dewasa membersofAAFP'sCommissiononHealthofthePub-licandScience.
yang diperlakukan untuk hipertensi memiliki intensied, '
ESPE '-manusia menjadi sangat dalam terang hari
rekomendasi (7). Di PA-tion,
whenselectingBPtargetsforadultsaged60years atau lebih, klinisi
perlu mempertimbangkan komorbiditas condi -

tionsthatcouldaffecttreatmentchoice. Treatmentsfor BENEFITSOF TREATING HIGHER VERSUS

hipertensi meliputi modications gaya hidup, seperti
weightloss, dietarymodication, andincreasedphysi-
Cal kegiatan, dan obat anti hipertensi, yang
commonlyincludethiazide-typediuretics, angiotensin -
mengubah inhibitor enzim (ACEIs), reseptor
angiotensin blocker (ARB), blocker saluran kalsium, dan
GUIDELINE FOCUSAND TARGET POPULATION
ThepurposeofthisAmericanCollegeofPhysicians
(ACP) dan American Academy of pedoman bersama dokter
keluarga (AAFP) adalah untuk menyajikan
recommendationsonthebenetsandharmsofhigher berbasis
bukti (< 150mmHg) versuslower SBPtargets (d140mmHg)
untuk pengobatan tekanan darah tinggi dalam orang dewasa
berusia 60 tahun atau lebih tua. Target audiens untuk
includesallclinicians pedoman ini,
andthetargetpatientpopulation
includesadultsaged60yearsorolderwithhyperten-sion.
Rekomendasi ini didasarkan pada sebuah ulasan
punggungnya-tanah bukti (8) dan review sistematis
sponsoredbytheU.S.DepartmentofVeteransAffairs (VA)(9).
LOWER BPT ARGETSIN OLDER ADULTS
Acrossalltrials, treatinghighBPinolderadultswas benecial.
Namun, sebagian besar bukti yang datang dari
studiesofpatientswithmoderateorseverehyperten -
sion(SBP>160mmHg) atbaselineand, withtreatment,
achievedSBPtargetsgreaterthan140mmHg.
- blocker.
DifferingBPTargets
Bukti kualitas tinggi menunjukkan pengurangan dalam
semua-causemortality (relativerisk [RR], 0,90 [95%CI,0.83to
0,98]; pengurangan risiko mutlak [ARR], 1,64), stroke (RR,
0,74 [CI, 0.65to0.84]; ARR, 1.13), andcardiacevents (RR, 0.77
[CI, 0.68to0.89]; ARR, 1,25)
fortreatingpa-tientswithabaselineSBPof160mmHgorgreaterwho
achievedatargetSBPoflessthan150mmHg(11 21). Dalam studi
dengan SBP target yang lebih rendah (< 140 mm Hg),
pengurangan
rendah-qualityevidenceshowednostatisticallysignicant
kematian (RR, 0.86 [CI, 0,69 untuk 1,06]; ARR, 0.80)
orcardiacevents (RR, 0.82 [CI, 0.64to 1,00]; ARR 0.94)
(11-13, 20, 22, 23). Untuk studi dengan lowerBPtargets,
moderat-qualityevidenceshoweda reducedriskforstroke (RR,
0.79 [CI, 0.59to0.99]; ARR, 0.49)
comparedwithhigherBPtargets (11 13,20,22, 23). Banyak
studi ini, namun, tidak mencapai BP ditargetkan, dan ada
sedikit perbedaan menjadi-tween kelompok intensif
perawatan dan kontrol. Oleh karena itu, studi ini mungkin
belum mampu detectdifferencesinclinicaloutcomes.

METHODS
SystematicReviewoftheEvidence
Tinjauan bukti dilakukan oleh Program
Port-landVAHealthCareSystemEvidence-basedSynthesis Sebuah analisis subkelompok dibandingkan studi yang
. Ringkasan dari metode untuk bukti achievedlowerSBPtargets(<140mmHg) withthose
reviewcanbefoundinthe thatachievedhigherSBPtargets(e140mmHg) (11-13, 20,22-25).
http://www.Annals.orgLampiran (availableatwww
. annals.org). Rincian tambahan termasuk dalam ac-
Forthesesubgroups, tinggi-qualityevidence

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PharmacologicTreatmentofHypertensioninAdults CLINICAL UIDELINE
G
showedasimilarriskreductionformortality(RRfortar- menurunkan theywereatleastaslikelytobenetfromBP
Gete140mmHg, 0.91 [CI, 0.84to0.99] vs. RRfortar- pengobatan. Hal ini mungkin terkait dengan tinggi
mendapatkan < 140mmHg, 0,84 [CI, 0.74to0.95]) andcardiac fre-quencyofcardiovasculareventsseeninthesepatients.
acara (RR target e140 mm Hg, 0.78 [CI, 0,68 untuk 0.93] vs
RRfor target < 140 mm Hg, 0.83 [CI, 0,70 untuk 0.94]).
Pengurangan relatif dalam peristiwa stroke adalah
TreatmentEffectsAccordingtoDiastolicBP
slightlylargerforstudiesthatachievedatargetSBPof Evidencewasinsufcienttodeterminethebenet
140mmHgorgreater (RR, 0.72 [CI, 0.62to0.82]) daripada Hg oftreatingdiastolichypertensionintheabsenceofsys-tolichypertensio
thosethatachievedatargetSBPoflessthan140mm (RR, 0,81 [CI, n. Mosttrialsassessedtreatmentout - datang didasarkan pada
0.66 untuk 0,96]). Studi ini telah ditandai perbedaan klinis SBP, dan ujian tidak termasuk pasien withameandiastolicBP
dan signicant Statistik heterogenitas, (DBP) greaterthan90mmHg andameanSBPlessthan140mmHg.
whichshouldtempercondenceinthe menggenang hasil.
Penggunaan agen anti hipertensi bervariasi lintas studi: 7
digunakan ACEIs atau ARB, blocker saluran kalsium digunakan
5 dan 6 digunakan seperti tiazid

HARMSOF HIGHER VERSUS LOWER BP

diuretik. TARGETSIN OLDER ADULTS
DifferingBPTargetsinPatientsWithTransient Studiesshowedmixedndingsforwithdrawaldue
untuk peristiwa-peristiwa buruk. Pengobatan untuk BP lebih
IschemicAttackorStroke rendah target creasedwithdrawalsduetoadverseeventsin4outof
Amongpatientswithahistoryofstrokeortransient iskemik 10 uji (RR, 44% sampai 100%); batuk dan hipotensi
attack (TIA), moderat berkualitas bukti werethemostfrequentlyreportedadverseevents (13,
showedthattreatingtoanSBPof130to140mmHg 15,17,18,20,24,27,29,31,32). Rendah-qualityevidence
reducedstrokerecurrence (RR, 0,76 [CI, 0.66to0.92]; ARR, 3,02) showedanincreased riskforsyncopeassociatedwith pengobatan
butnotcardiacevents (RR, 0.78 [CI, 0.61to untuk menurunkan BP target (mencapai SBP kisaran,
1.08])orall-causemortality(RR,0.98[CI,0.85to1.19]) (26,27). 121.5to143mmHg)(RR,1.52[CI,1.22to2.07]) (18, 23,28).
Heterogeneityforthisanalysiswaslow. Rendah-qualityevidenceshowednodifferencein
renaloutcomes(includingend-stagerenaldisease) untuk
treatmenttohigherversuslowerBPtargets (13,15,16, 18, 20,
22-25, 28, 29, 32-34). Kualitas sedang evi-mengumpulkan
DifferingBPTargetsBasedonAge bukti menunjukkan tidak ada perbedaan antara pengobatan
Rendah-qualityevidenceshowedsimilareffectsacross untuk
differentagegroups (12-14,16,18-20,22,24,26,28, 29). Analisis higherversuslowerBPtargetsinthedegreeofcogni-tivedeclineordem
subkelompok SPRINT (sistolik darah PressureInterventionTrial) entia (18,27,35-39), patah tulang (40,
thatwasnotincludedinthe 41),orqualityoflife(17,42 44). Rendah-qualityevidence
evidencereviewshowedthatpatientsaged75yearsor menunjukkan tidak ada perbedaan untuk perawatan untuk
olderhadlowerall-causemortalityandnonstatistically signicantly lebih tinggi dibandingkan lowerBPtargetsonfunctionalstatus
lebih rendah angka kematian kardiovaskuler, morbiditas, (42) ortheriskfor falls(23,40).
andincidence ofstrokewithtreatment untuk SBPtargets AsubgroupanalysisofSPRINTshoweda
lessthan120mmHgcomparedwithSBPtargetsless nonstatisticallysignicantincreaseintherateofserious efek
than140mmHg(30). samping, hipotensi, pingsan, elektrolit ab-normalities,
oracutekidneyinjuryinpatientsaged75 tahun atau lebih tua yang
dirawat untuk SBP target kurang Hg(28)
than120mmHgversusSBPtargetslessthan140mm.

DifferingBPTargetsBasedonMultipleChronic
Kondisi
Notrialsassessedtheeffectofcomorbidityonthe
benetsofmoreaggressiveBPtreatment.Low-kualitas
evidencefromsubgroupanalysesshowedgreaterab-solutebenetfr
ommoreintensiveBPtreatmentinpa-tients dengan risiko
kardiovaskular tinggi (22, 29-31). Bagaimana pernah, pasien Meskipun gangguan elektrolit efek samping yang umum
dengan beban tinggi penyerta yang mungkin tidak termasuk pengobatan tekanan darah tinggi dalam klinis praktek,
dalam grup keseluruhan studi (8). datawerenotpresentedontheseabnormali-tiesintheevidencereview
Ofthe21trialsincludedinthereview, 14excluded pasien dengan . Drugstotreathypertension memiliki efek samping yang
gagal jantung, 11 dikecualikan mereka dengan terkenal, termasuk hypokale-mia, hiperkalemia, hiponatremia,
re-centcardiovascularevents, hipotensi, dizzi-ness, sakit kepala, edema, disfungsi ereksi, dan batuk.
17excludedthosewithab-normalrenalfunction,
12excludedthosewithcanceror otherlife-limitingillness,
15hadcriteriathatwouldim-plicitlyorexplicitlyexcludethosewithdem
entiaordi-minished fungsional status, dan 7 dikecualikan
semua pasien diabetes atau mereka yang diperlukan insulin.
Al-thoughndingsfromACCORD
(ActiontoControlCar-diovascularRiskinDiabetes), EffectofAge
whichlimitedenrollment topatientswithtype2diabetes, Rendah-qualityevidenceshowednodifferenceinad-verseevents,
foundnoreductionin includingunsteadiness, pusing, andre-nalfailure, pada pasien
mortalityormajorcardiovasculareventswithmorein-tensivetreatment yang lebih muda atau lebih tua dari 75 tahun (13,23,28).
, asubgroupanalysisof7studies (12, 14,18-20,28,29) indiabetic
patientssuggestedthat

EffectofMultipleChronicConditions
Percobaan tidak dinilai efek komorbiditas
condi-tionsonharms.

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 CLINICAL GUIDELINE
RECOMMENDATIONS
The Figure summarizestherecommendationsand
clinicalconsiderations.
Recommendation1:ACPandAAFPrecommend
thatcliniciansinitiatetreatmentinadultsaged60years
orolderwithsystolicbloodpressurepersistentlyator
above150mmHgtoachieveatargetsystolicblood
pressureoflessthan150mmHgtoreducetheriskfor
mortality,stroke,andcardiacevents.(Grade:strongrec-
ommendation,high-qualityevidence).ACPandAAFP
recommendthatcliniciansselectthetreatmentgoalsfor
adultsaged60yearsorolderbasedonaperiodicdis-
cussionofthebenetsandharmsofspecicblood
pressuretargetswiththepatient.
High-qualityevidenceshowedthattreatinghyper-
tension in older adults to moderate targets
(<150/90 mm Hg) reduces mortality (ARR, 1.64),
stroke (ARR,
1.13),andcardiacevents(ARR,1.25).Mostbenetsap-
plytosuchadultsregardlessofwhethertheyhavedia-
betes.Themostconsistentandgreatestabsoluteben- et
was shown in trials with a higher mean SBP at
baseline (>160 mm Hg). Any additional benet from
aggressiveBPcontrolissmall,withalowermagnitude
ofbenetandinconsistentresultsacrossoutcomes.
Althoughthisguidelinedidnotspecicallyaddress
pharmacologic versus nonpharmacologic treatments
forhypertension,severalnonpharmacologictreatment
strategiesareavailableforconsideration.Effectivenon-
pharmacologic options for reducing BP include such
lifestyle modications as weight loss, such dietary
changesastheDASH(DietaryApproachestoStopHy-
pertension) diet, and an increase in physical activity.
Nonpharmacologic options are typically associated
with fewer side effects than pharmacologic
therapies and have other positive effects; ideally,
they are in- cluded as the rst therapy or used
concurrently with drug therapy for most patients
with hypertension. Ef-
fectivepharmacologicoptionsincludeantihypertensive
medications, such as thiazide-type diuretics (adverse
effectsincludeelectrolytedisturbances,gastrointestinal
discomfort,rashesandotherallergicreactions,sexual
dysfunction in men, photosensitivity reactions, and
orthostatichypotension),ACEIs(adverseeffectsinclude
cough and hyperkalemia), ARBs (adverse effects in-
clude dizziness, cough, and hyperkalemia), calcium-
channel blockers (adverse effects include dizziness,
headache, edema, and constipation), and
-blockers
(adverse effects include fatigue and sexual
dysfunction).
MostoftheincludedstudiesmeasuredseatedBP
after5minutesofrestandusedmultiplereadings.Cli-
niciansshouldensurethattheyareaccuratelymeasur- ing
BP before beginning or changing treatment of
hypertension. Assessment may include multiple mea-
surementsinclinicalsettings(forexample,2to3read-
ingsseparatedby1minuteinaseatedpatientwhois resting
alone in a room) or ambulatory or home
monitoring(45).
Recommendation2:ACPandAAFPrecommend
thatcliniciansconsiderinitiatingorintensifyingpharma-
4 AnnalsofInternalMedicine
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PharmacologicTreatmentofHypertensioninAdults
cologictreatmentinadultsaged60yearsorolderwith
ahistoryofstrokeortransientischemicattacktoachieve
atargetsystolicbloodpressureoflessthan140mmHg
toreducetheriskforrecurrentstroke.(Grade:weak
recommendation,moderate-qualityevidence).ACPand
AAFPrecommendthatcliniciansselectthetreatment
goalsforadultsaged60yearsorolderbasedonape-
riodicdiscussionofthebenetsandharmsofspecic
bloodpressuretargetswiththepatient.
Moderate-quality evidence showed that treating
hypertensioninolderadultswithpreviousTIAorstroke
toanSBPtargetof130to140mmHgreducesstroke
recurrence (ARR, 3.02) compared with treatment to
highertargets,withnostatisticallysignicanteffecton
cardiaceventsorall-causemortality.
Recommendation3:ACPandAAFPrecommend
thatcliniciansconsiderinitiatingorintensifyingpharma-
cologictreatmentinsomeadultsaged60yearsorolder
athighcardiovascularrisk,basedonindividualizedas-
sessment,toachieveatargetsystolicbloodpressureof
lessthan140mmHgtoreducetheriskforstrokeor
cardiacevents.(Grade:weakrecommendation,low-
qualityevidence).ACPandAAFPrecommendthatclini-
ciansselectthetreatmentgoalsforadultsaged60years
orolderbasedonaperiodicdiscussionofthebenets
andharmsofspecicbloodpressuretargetswiththe
patient.
AnSBPtargetoflessthan140mmHgisareason- able
goal for some patients with increased cardiovas-
cularrisk.Thetargetdependsonmanyfactorsunique
toeachpatient,includingcomorbidity,medicationbur-
den,riskforadverseevents,andcost.Cliniciansshould
individuallyassesscardiovascularriskforpatients.Gen-
erally, increased cardiovascular risk includes persons
withknownvasculardisease,mostpatientswithdiabe- tes,
older persons with chronic kidney disease with
estimated glomerular ltration rate less than 45 mL/
min/per1.73m ,thosewithmetabolicsyndrome(ab-
2
dominalobesity,hypertension,diabetes,anddyslip
ide- mia), and older persons. For
example, among the in- cluded studies,
SPRINT (23) dened patients with
increasedcardiovascularriskasthosemeetingatlea
st
1ofthefollowingcriteria:clinicalorsubclinicalcardio
-
vasculardiseaseotherthanstroke;chronickidneydis
2
- ease,excludingpolycystickidneydisease,withanesti- m
cardiovasculardiseaseof15%orgreaterbased
onthe
Framinghamriskscore;orage75yearsorolder
.This
trialfoundthattargetingSBPtolessthan120m
mHg
comparedwithlessthan140mmHginadultswi
thout
diabetesorpriorstroke,athigh-riskforcardiov
ascular
disease,andwithabaselineSBPoflessthan140
mm
Hgsignicantlyreducedfatalandnonfatalcard
iovascu-
lareventsandall-causemortality.Incontrast,ACCORD (40)
www.annals.org
 PharmacologicTreatmentofHypertensioninAdults CLINICAL UIDELINE
G

Figure. SummaryoftheAmericanCollegeofPhysiciansandAmericanAcademyofFamilyPhysiciansjointguidelineon
pharmacologictreatmentofhypertensioninadultsaged60yearsoroldertohigherversuslowerbloodpressuretargets.

Summary of the American College of Physicians and American Academy of Family Physicians Joint Guideline on
Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets

Disease/Condition Hypertension

Target Audience All clinicians

Target Patient Population Adults aged 60 y with hypertension
Treatments Evaluated Treatment to higher (<150 mm Hg) vs. lower (140 mm Hg) SBP targets
Outcomes Evaluated All-cause mortality, morbidity and mortality related to stroke, cardiac events, and harms
Benefits Mortality, incidence of stroke, and cardiac events were all reduced with treatment.

Treating to a lower BP target did not further reduce mortality, quality of life, or functional status, but it did reduce the incidence of
stroke and cardiac events.
Harms Increased withdrawals due to adverse events with lower vs. higher BP targets

Increased cough, hypotension, and risk for syncope with treating to lower vs. higher BP targets

No difference between higher and lower BP targets for renal outcomes, cognitive outcomes, or falls and fractures

Adverse Effects Some of the adverse effects associated with antihypertensive medications include (but are not limited to) the
following:

Thiazide-type diuretics: electrolyte disturbances, gastrointestinal discomfort, rashes and other allergic reactions,
sexual dysfunction in men, photosensitivity reactions, and orthostatic hypotension

ACEIs: cough and hyperkalemia

ARBs: dizziness, cough, and hyperkalemia

Calcium-channel blockers: dizziness, headache, edema, and constipation

-blockers: fatigue and sexual dysfunction

Recommendations Recommendation 1: ACP and AAFP recommend that clinicians initiate treatment in adults aged 60 years or older with systolic
blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg to
reduce the risk for mortality, stroke, and cardiac events. (Grade: strong recommendation, high-quality evidence). ACP and
AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of
the benefits and harms of specific blood pressure targets with the patient.

Recommendation 2: ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in
adults aged 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of
less than 140 mm Hg to reduce the risk for recurrent stroke. (Grade: weak recommendation, moderate-quality evidence). ACP
and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion
of the benefits and harms of specific blood pressure targets with the patient.

Recommendation 3: ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in
some adults aged 60 years or older at high cardiovascular risk, based on individualized assessment, to achieve a target systolic
blood pressure of less than 140 mm Hg to reduce the risk for stroke or cardiac events. (Grade: weak recommendation,
low-quality evidence). ACP and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older
based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

Clinical Considerations Accurate measurement of BP is important before initiating treatment for hypertension. Some patients may have elevated BP in clinical settings,
and ambulatory measurement may be appropriate.

Clinicians should consider treatment with nonpharmacologic options, including weight loss, dietary changes, and an increase in physical
activity, initially or concurrently with pharmacologic treatment.

Many older adults may be taking various medications. Clinicians should consider treatment burden and drug interactions when deciding on
treatment options.

When selecting pharmacologic therapy, clinicians should prescribe generic drugs where available.

Evidence for adults who are frail or those with multimorbidity is limited.

ACEI=angiotensin-convertingenzymeinhibitor;ARB=angiotensin-receptorblocker;BP=bloodpressure;SBP=systolicbloodpressure.

www.annals.org AnnalsofInternalMedicine 5

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 CLINICAL GUIDELINE
butthereweremoreseriousadverseeventsassociated
withanSBPtargetoflessthan120mmHgversusless
than140mmHg.
AREASOF INCONCLUSIVE EVIDENCE
TreatmentofPatientsWithMultipleChronic
Conditions
Notrialsassessedtherelationshipbetweenmulti-
plecomorbidconditionsandthebenetsandharmsof
treatingBPtodifferenttargets.Patientswithahighco-
morbidity burden were probably not included in
the overall group of studies. Many studies excluded
pa- tientswithvariouscomorbidconditions,suchasdiabe-
tes,insulinuse,recentcoronaryevents,heartfailure,or
chronic kidney disease, and most studies had
criteria
thatwouldimplicitlyorexplicitlyexcludethosewithde-
mentiaordiminishedfunctionalstatus.
TreatingAccordingtoDBP
Evidence was insufcient for targeting treatment
accordingtoDBP.
MULTIPLE CHRONIC CONDITIONS: CLINICAL
CONSIDERATIONSFOR ADULTS AGED 60Y EARS
OR OLDER
Individualassessmentofbenetsandharmsispar-
ticularlyimportantinadultsaged60yearsorolderwith
multiple chronic conditions, several medications, or clinicalpracticeguidelinesareconsideredautomaticallywith-
frailty. These patients might theoretically benet
from more aggressive BP treatment because of
higher car- diovascular risks. However, they are
more likely to be susceptible to serious harm from
higher rates of syn-
copeandhypotension,whichwereseeninsometrials. Moreover,theabsolutebenetsofmoreaggressiveBP
treatmentinelderlypersons,thosewithmultimorbidity,
orthosewhoarefrailarenotwell-known,givenlimita-
tionsofthetrials.Thesepatientsoftenreceivemultiple
medicationsandareondrugregimensthataredifcult
tomanageandincreasethecostandriskfordrugin-
teractions. Indeed, most trials had exclusion criteria
that implicitly or explicitly excluded patients who
had dementia or diminished functional status. Few
trials were available to compare patients with and
without
diabetes,whichmadedrawingconclusionsaboutrela- tive
treatment effects in these populations difcult.
WhetherthedifferenceinresultsbetweenSPRINTand
ACCORDwasbecauseofdiabetesstatusisunclear,but
itisreasonabletorationalizethatthebenetsobserved
withthelowertargetsachievedinSPRINTmostclosely
applytopatientpopulationswithoutdiabetes.
HIGH-VALUE CARE
Mostpatientsaged60yearsorolderwithanSBPof
150 mm Hg or greater who receive antihypertensive
medications will have benet with acceptable harms
and costs from treatment to a BP target of less
than 150/90mmHg.Althoughsomebenetisachievedby
aiming for lower BP targets, most benet occurs with
6 AnnalsofInternalMedicine
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PharmacologicTreatmentofHypertensioninAdults
acceptableharmsandcostsinthepharmacologictreat-
ment of patients who have an SBP of 150 mm Hg
or greater. When prescribing drug therapy,
clinicians should select generic formulations over
brand-name drugs, which have similar efcacy,
reduced cost, and
thereforebetteradherence(46).Cliniciansshouldcon-
siderthepatient'streatmentburdenwhendecidingon
treatment options. Studies have correlated multiple
dosesofhypertensivemedicationswithpoorermedica-
tion adherence (47, 48). The balance of benets
and harmsidentiedinourevidencereportisbasedinpart
onrigorousandaccurateassessmentofBP.Somepa-
tientsmayhavefalselyelevatedreadingsinclinicalset-
tings(knownaswhite-coathypertension).Therefore,
itisimportanttoensureaccurateBPmeasurementbe- fore
initiating or changing treatment of hypertension.
Themostaccuratemeasurementscomefrommultiple
BPmeasurementsmadeovertime.
From the American College of Physicians and University
of PennsylvaniaHealthSystem,Philadelphia,Pennsylvania;Min-
neapolis Veterans Affairs Medical Center, Minneapolis,
Min- nesota; Community Care of the Lower Cape Fear,
Wilming- ton, North Carolina; Oregon Health & Science
University, Portland, Oregon; and American Academy of
Family Physi- cians,Leawood,Kansas.
Note: Clinicalpracticeguidelinesareguidesonlyandmay
notapplytoallpatientsandallclinicalsituations.Thus,they are
not intended to override clinicians' judgment. All ACP
drawnorinvalid5yearsafterpublicationoronceanupdate
hasbeenissued.
Disclaimer: The authors of this article are responsible for
its contents, including any clinical or treatment
recommendations.
FinancialSupport: Financial support for the development
of this guideline comes exclusively from the ACP operating
budget.
Disclosures: Authorsfollowedthepolicyregardingconictsof
interest described at www.annals.org/article.aspx?articleid
=745942. Disclosures can also be viewed at
www.acponline
.org/authors/icmje/ConictOfInterestForms.do?msNum=M16
-1785.Allnancialandintellectualdisclosuresofinterestwere
declared and potential conicts were discussed and man-
aged.Drs.Boyd,Kansagara,andVijanparticipatedinthedis-
cussionforthisguideline,buttheywererecusedfromvoting onthe
recommendations because of active indirect intellec- tual
conicts. Dr. Manaker participated in the discussion for
thisguidelinebutwasrecusedfromvotingontherecommen-
dations because of an active indirect nancial conict. A
re- cordofdisclosuresofinterestandmanagementofconictsof
iskeptfor each ClinicalGuidelines Committee meeting and
conference call and can be viewed at www.acponline.org
/clinical_information/guidelines/guidelines/conicts_cgc.htm.
RequestsforSingleReprints: AmirQaseem,MD,PhD,MHA,
American College of Physicians, 190 N. Independence Mall
www.annals.org
 PharmacologicTreatmentofHypertensioninAdults
West, Philadelphia, PA 19106-1572; e-mail, aqaseem@
acponline.org.
Currentauthoraddressesandauthorcontributionsareavail-
ableatwww.annals.org.
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www.annals.org
 CurrentAuthorAddresses: Dr.Qaseem:AmericanCollegeof
Physicians,190N.IndependenceMallWest,Philadelphia,PA
19106-1572.
Dr. Wilt: Minneapolis Veterans Affairs Medical Center,
One VeteransDrive(111-0),Minneapolis,MN,55417.
Dr.Rich:BladenMedicalAssociates,300AEastMcKayStreet,
POBox517,Elizabethtown,NC28337.
Dr.Humphrey:VeteransAffairsPortlandHealthCareSystem,
3710SWU.S.VeteransHospitalRoad,Portland,OR97201.
Dr. Frost: American Academy of Family Physicians,
11400 TomahawkCreekParkway,Leawood,KS66211.
Dr. Forciea: University of Pennsylvania Health System,
3615 ChestnutStreet,Philadelphia,PA19104.
AuthorContributions: Conception and design: A. Qaseem,
L.L.Humphrey.
Analysisandinterpretationofthedata:A.Qaseem,T.J.Wilt
, L.L.Humphrey,J.Frost,M.A.Forciea.
Draftingofthearticle:A.Qaseem,T.J.Wilt,R.Rich,L.L.Hum
- phrey,J.Frost.
Critical revision of the article for important intellectual
con- tent: A. Qaseem, T.J. Wilt, R. Rich, L.L.
Humphrey, J. Frost, M.A.Forciea.
Finalapprovalofthearticle:A.Qaseem,T.J.Wilt,R.Rich,L.L.
Humphrey,J.Frost,M.A.Forciea.
Statisticalexpertise:A.Qaseem,T.J.Wilt.
Administrative,technical,orlogisticsupport:A.Qaseem.
APPENDIX: DETAILED METHODS
The evidence review was conducted by the Port-
landVAHealthCareSystemEvidence-basedSynthesis
Programtoaddressthefollowingkeyquestions(KQs):
KQ1:Inadultsaged60yearsorolder,whatarethe
healthoutcomeeffectsofdifferingBPtargets?
KQ 1b: In patients who have suffered a TIA or
stroke, does treatment of BP to specic targets
affect healthoutcomes?
KQ2:Howdoesagemodifythebenetsofdiffer-
ingBPtargets?
StudyDesign
KQ 3: How does the patient burden of
comorbid conditionsmodifythebenetsofdifferingBPtargets? controlled
KQ4:WhataretheharmsoftargetinglowerBPin
olderpatients?Dotheharmsvarywithage?
KQ5:DotheharmsoftargetinglowerBPvarywith
patientburdenofcomorbidconditions?
SearchStrategy
The reviewers searched EMBASE and the
Cochrane Database of Systematic Reviews from data-
base inception through January 2015, MEDLINE
through September 2016, and ClinicalTrials.gov to
identify studies that were in progress or
unpublished. Observational studies were excluded
from analysis of
suchhealthoutcomesasmortality,stroke,andcardio-
vascular events. For additional information, including
inclusionandexclusioncriteria,refertotheaccompa- nyingarticle(8)andfullreport(9).
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Meta-analysisandIndividual-PatientData
Meta-analysis
Thereviewersconductedameta-analysisonstudy-
level data using the random-effects model. They
also conductedindividual-patient
datameta-analysistoas- sesstreatmentaccordingtoagesubgroups.
QualityAssessment
ThequalityofstudieswasassessedusingtheCo-
chrane risk-of-bias tool (49). The evidence reviewers
graded the quality of evidence using the Agency
for HealthcareResearchandQualitysystem(50).
Population
Adultsaged60yearsorolderwithadiagnosisof
hypertensionwerestudied.
InterventionsEvaluated
Theinterventionsevaluatedincludedtreatmentto
higher(<150mmHg)versuslower(140mmHg)SBP
targets.
Comparators
ThecomparatorwaslessintensiveBPtreatment.
Outcomes
Evaluated outcomes included all-cause mortality;
cardiac events (myocardial infarction and sudden
car- diacdeath);morbidityandmortalityrelatedtostroke;
and harms, including cognitive impairment, quality
of life,falls,fractures,syncope,functionalstatus,hypoten-
sion, acute kidney injury (dened as the doubling
of serum creatinine or need for renal replacement
ther- apy), medication burden, and withdrawal due
to ad- verseevents.
Timing
Outcomes were assessed in the long-term (>6
months)forKQs1,2,and3andanytimeframeforKQs
4and5.
Controlled study designs (randomized,
trialsandnonrandomized,controlledtrials)(KQs1,2,3, 4
and 5) and cohort studies (KQs 4 and 5) were in-
cluded. Case reports; case series; randomized, con-
trolledtrialswithlessthan6-monthfollow-up;andcon- trolledbeforea
PeerReview
The VA evidence review was sent to invited
peer reviewers and posted on the VA Web site for
public comments, and the published review article
was peer reviewed through the journal. The
guideline had a peer-review process through the
journal and was posted online for comments from
ACP Regents and Governors, who represent
physician members at the national level. It was also
reviewed by members of AAFP's Commission on
Health of the Public and Science.
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