Grades are shown as the source states them. WHO grades each recommendation as strong or conditional, with the certainty of evidence. The Chinese guideline uses classes (I recommended, IIa should be considered, IIb may be considered, III not recommended) with evidence levels A to C.
Key recommendations
Start drug treatment once hypertension is confirmed and systolic pressure is 140 mmHg or more or diastolic 90 mmHg or more. With established cardiovascular disease, treat from a systolic pressure of 130–139 mmHg.
Strong; moderate- to high-certainty evidenceRecommendation 1World Health Organization (WHO) 2021
Aged 65 or over: start drugs at 140/90 mmHg or above, alongside lifestyle change, and aim below 140/90 (Class I, level A). For those aged 80 or over: consider starting at 150/90 or above, first aim below 150/90, then below 140/90 if tolerated (Class IIa, level B). Frail and very old: start at 160/90 or above and aim for a systolic of 150 or lower, but not below 130 where possible (Class IIa, level C).
Choose a first drug from one of three classes: a thiazide or thiazide-like diuretic, an ACE inhibitor or angiotensin receptor blocker, or a long-acting dihydropyridine calcium channel blocker.
Strong; high-certainty evidenceRecommendation 4World Health Organization (WHO) 2021
In people aged 80 or over and in frail older people, start with a single drug at low dose; do not start with a combination (Class I, level A). For other older people whose blood pressure is more than 20 mmHg above target, start with two drugs (Class I, level A).
Table 12; basic principles of pharmacological therapyHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Measure blood pressure lying and standing, and encourage home and ambulatory monitoring, because older people often have large swings, night-time or morning hypertension and orthostatic hypotension.
BP measurement; orthostatic BP fluctuationHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Do not stop antihypertensive treatment that is well tolerated (Class III, level A).
Diagnosis
In people aged 65 or over who are not on treatment, hypertension means 140/90 mmHg or more on three readings taken on different days. Anyone already on treatment still has the diagnosis even if their blood pressure is now below 140/90.
Definition and categories of hypertension in the elderlyHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Out-of-office thresholds: home readings of 135/85 or more; ambulatory averages of 130/80 or more over 24 hours, 135/85 or more by day, or 120/70 or more at night. Use a validated upper-arm automatic monitor rather than a wrist or finger device.
Out-of-office BP measurementHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Isolated systolic hypertension is the commonest pattern in older people. A very wide pulse pressure with diastolic below 50 mmHg should raise suspicion of aortic regurgitation, and with severe aortic stenosis blood pressure should not be lowered too far.
The characteristics of hypertension in the elderlyHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Suspect pseudo-hypertension (stiff arteries over-reading on the cuff) when systolic pressure is very high without organ damage, or when treatment causes symptoms of low blood pressure; it can lead to over-treatment.
The characteristics of hypertension in the elderlyHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
White-coat hypertension affects up to 40% of older people. It is not completely benign, so review cardiovascular risk, advise on lifestyle and follow up.
White coat hypertensionHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Orthostatic hypotension is a fall of at least 20 mmHg systolic and/or 10 mmHg diastolic on standing from lying; it may appear within 15 seconds, within 3 minutes, or later.
Elderly hypertension with orthostatic BP fluctuationHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Investigations
When starting treatment, check electrolytes and creatinine, lipids, HbA1c or fasting glucose, a urine dipstick and an ECG — but do not delay treatment to get them. A long-acting calcium channel blocker is the most suitable choice if treatment must start before tests.
Conditional; low-certainty evidenceRecommendation 2World Health Organization (WHO) 2021
Assess overall cardiovascular risk at or after the start of treatment, where this is feasible and does not delay it.
Conditional; low-certainty evidenceRecommendation 3World Health Organization (WHO) 2021
Assess frailty before starting treatment (for example the FRAIL scale, gait speed or the Fried criteria), particularly after unintended weight loss of more than 5% in a year or when there is a risk of falls (Class I, level B).
Assess cognition early: both high and low blood pressure may increase the risk of cognitive impairment.
Hypertension in the elderly and cognitive dysfunctionHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Look for medicines that raise blood pressure: NSAIDs, corticosteroids, oestrogens, erythropoietin, some antidepressants (MAO inhibitors, tricyclics), ciclosporin and liquorice. Stop them where possible.
Drug-related hypertensionHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Treatment
WHO suggests starting with a combination, preferably a single pill, drawn from the three first-line classes, to improve adherence.
Conditional; moderate-certainty evidenceRecommendation 5World Health Organization (WHO) 2021
Targets: below 140/90 mmHg for people without comorbidities; systolic below 130 with known cardiovascular disease; and systolic below 130 suggested for those at high cardiovascular risk or with diabetes or chronic kidney disease.
Strong (first two) and conditional (third); moderate-certainty evidenceRecommendation 6World Health Organization (WHO) 2021
Review monthly after starting or changing treatment until the target is reached, then every 3–6 months once controlled.
Conditional; low-certainty evidenceRecommendation 7World Health Organization (WHO) 2021
In older people use a low starting dose, long-acting once-daily drugs that cover the night and early morning, and single-pill combinations to help adherence.
Basic principles of pharmacological therapyHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
If two drugs are not enough, combine a calcium channel blocker, an ACE inhibitor or ARB and a thiazide-type diuretic, ideally as a single pill (Class I, level A). Never combine two renin–angiotensin blockers (Class III, level A).
Table 12; drug combinationsHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
For resistant hypertension, first exclude pseudo-resistance (poor measurement, non-adherence, white-coat effect, pseudo-hypertension) and correct salt, alcohol and interfering drugs. Then consider an aldosterone antagonist (Class IIa, level B), or an alpha-blocker in men with prostatic enlargement (Class IIa, level B).
The management of resistant hypertension; Table 20Hypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Lifestyle: salt below 6 g a day with moderate restriction, a diet rich in potassium, at least 30 minutes of aerobic activity on 5 or more days a week (not vigorous exercise), limited alcohol, avoiding rapid weight loss, good sleep and keeping warm in cold weather.
Non-pharmacological therapyHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Beta-blockers are not preferred for isolated systolic hypertension or after stroke unless there is a strong indication such as coronary disease, heart failure or a tachyarrhythmia.
Types and characteristics of antihypertensive drugs: beta blockerHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Trained nurses and pharmacists can start and manage treatment where they have prescribing authority, protocols and physician oversight.
Conditional; low-certainty evidenceRecommendation 8World Health Organization (WHO) 2021
Important geriatric considerations
The evidence for lower targets in people aged 65 and over comes mainly from high-risk trial populations; dizziness and myocardial ischaemia with intensive treatment can shift the balance of benefit and harm in older people.
Recommendation 6: evidence and rationaleWorld Health Organization (WHO) 2021
With orthostatic hypotension, lower blood pressure slowly; prefer an ACE inhibitor or ARB started low and increased every 1–2 weeks; avoid alpha-blockers, diuretics and tricyclic antidepressants, which worsen it; stand up slowly; and use counter-manoeuvres, compression stockings or an abdominal binder.
Elderly hypertension with orthostatic BP fluctuationHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Orthostatic hypotension with high lying blood pressure: raise the head of the bed 10–15° at night, avoid lying down by day, and if needed use a small dose of a short-acting drug (such as captopril or losartan) at bedtime rather than long-acting drugs or diuretics.
Elderly hypertension with orthostatic BP fluctuationHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Postprandial hypotension (systolic fall of 20 mmHg or more within 2 hours of eating) responds to drinking 350–480 mL of water before meals, smaller meals with less carbohydrate, and gentle walking after eating; acarbose 50 mg can help people with diabetes.
Postprandial hypotensionHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Blood pressure is higher in winter than summer in older people, so adjust treatment with the seasons.
Long-term BP variabilityHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
For people aged 80 or over, the aims are preserving organ function and quality of life. Monitor standing blood pressure and reduce treatment if symptoms of poor perfusion appear; low systolic pressure is linked with falls and frailty.
Hypertension in very old patient; characteristicsHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Drug doses
If orthostatic hypotension persists despite non-drug measures: midodrine 2.5–10 mg three times a day (not within 4–5 hours of bedtime); fludrocortisone from 0.1 mg daily, below 0.3 mg a day (avoid in heart or kidney failure); or droxidopa 100 mg three times a day, increased gradually.
When to refer
A hypertensive emergency (acute organ damage) needs hospital treatment with intravenous drugs. An urgency without new organ damage can be managed with oral drugs, lowering blood pressure to about 160/100 mmHg over 24–48 hours and reviewing within 2–3 days.
Hypertension urgencies and emergenciesHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Red flags
Hypertensive emergency: a sudden large rise (usually above 180/120 mmHg) with acute organ damage — encephalopathy, intracranial haemorrhage, stroke, acute heart failure, acute coronary syndrome, aortic dissection or kidney injury. New organ damage, not the number, separates an emergency from an urgency.
Hypertension urgencies and emergenciesHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
In an emergency (except stroke and aortic dissection), lower mean arterial pressure by no more than 25% in the first 1–2 hours, to about 160/100–110 over the next 2–6 hours, and towards normal over 24–48 hours.
Hypertension urgencies and emergenciesHypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Acute stroke: in ischaemic stroke do not lower blood pressure tightly unless it is 200/110 or more (treat from 185/110 if thrombolysis is planned); in intracerebral haemorrhage aim for systolic below 180.
Tables 13 and 21Hypertension Branch of the Chinese Geriatrics Society, with the Chinese Alliance of Geriatric Cardiovascular Disease 2019
Recent updates
WHO's 2021 guideline was its first on raised blood pressure since 1999, adding recommendations on treatment thresholds, targets, single-pill combinations and treatment by trained non-physician health workers.
Introduction; executive summaryWorld Health Organization (WHO) 2021