Lower Blood Pressure May Offer Benefits Even for the Very Elderly

Adults aged 80 and older experience the highest prevalence of cardiovascular disease, yet the optimal blood pressure targets for this group have been unclear in clinical guidelines. Now, a new study from Yale School of Medicine (YSM) suggests that intensive blood pressure management may offer important benefits for very elderly patients.

As the American population rapidly ages, the proportion of adults aged 80 and above is expected to significantly increase over the next few decades. But despite their growing numbers, this population has been understudied and often excluded from clinical trials investigating blood pressure management. The American Heart Association’s current blood pressure guidelines for all adults call for blood pressure of 130/80 mmHg or below, but it’s unclear if this range is appropriate for the very elderly.

“The key challenge is the lack of strong evidence for this age group,” says Yuan Lu, ScD, assistant professor of medicine (cardiology) at YSM, and the senior author of the study published in the Journal of the American College of Cardiology. “Much of the scientific evidence in the hypertension guidelines is based on clinical trials, but these studies have often excluded adults aged 80 and older. When they are included, their numbers are usually too small to draw clear conclusions for this age group.”

To address this evidence gap, Lu and her team used data from the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey and National Death Index to investigate the association between blood pressure and death from cardiovascular disease in adults aged 80 and above who had been actively treated with hypertension medication. Despite previous conjecture that higher blood pressure might be acceptable in this age group due to concerns such as increased fall risk and other side effects when blood pressure is too low, Lu and her team found evidence suggesting that lower blood pressure and more intensive management may be associated with better outcomes for these patients.

With little evidence to guide hypertension treatment for this age group, physicians have often relied on experience, expert opinions, and observational studies. This has frequently led to the idea that higher blood pressure might be acceptable for very elderly patients.

“There’s concern that lowering blood pressure too much in very elderly patients could cause side effects like dizziness, falls, or other injuries,” Lu explains. "That’s why there’s still uncertainty among doctors about how aggressively to manage blood pressure in this age group. We simply don’t have enough data to say what the ideal target should be. Should we aim for 120 or 130? Or is 140 to 150 still acceptable for elderly patients?”

Lu and her team sorted data from over 1,500 patients aged 80 and above who had been treated for hypertension into three groups: those with systolic blood pressure lower than 130, those between 130 and 160, and those above 160. They found that those with systolic blood pressure below 130 had the lowest risk of dying from heart disease and stroke, even after accounting for factors such as frailty that could potentially moderate the benefits of aggressive blood pressure management. They also found that systolic blood pressure even in the range of 145 held significant cardiovascular disease mortality risk for these patients.

While these results challenge earlier suggestions that higher blood pressure might be acceptable in this age group, Lu emphasizes the importance of individualized care. “Blood pressure management in this age group should involve thoughtful conversations between patients and their physicians,” she explains. “It’s essential to consider each patient’s overall health, potential side effects, and personal preferences.”

Although the study found that lower blood pressure was associated with reduced cardiovascular mortality, Lu cautions that given the multiple comorbidities in very elderly patients, antihypertensive medications may increase the risk of additional complications—factors that need to be carefully weighed when making treatment decisions.

“Physicians need to engage in shared decision making and consider the full medical history of the patient. Starting medication slowly and closely monitoring their patient’s progress and symptoms as they reach blood pressure targets may help find the right balance,” says Lu, who is also an assistant professor of biomedical informatics and data science at YSM and of chronic disease epidemiology at Yale School of Public Health. “If there are no side effects, the benefits may outweigh the risks. If there are side effects, physicians may need to reassess and weigh the trade-offs.”

Ultimately, Lu believes that both this shared decision-making and follow-up research in the form of randomized control trials will be important moving forward.

“These findings provide evidence and support for more aggressive treatment among elderly patients, but at the same time, we also want to raise the point that the treatment decision would need to be personalized for frail patients and those with multiple comorbidities,” Lu says.

Other Yale co-authors include Huanhuan Yang, PhD; Chenxi Huang, PhD; Mitsuaki Sawano, MD, PhD; Jeph Herrin, PhD; Erica S. Spatz, MD; and Harlan M. Krumholz, MD.

The research reported in this news article was supported by the National Heart, Blood, and Lung Institute (award R01HL169954) and Yale University. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.