Shimbo D, Tanner RM, Muntner P. Prevalence and Characteristics of Systolic Blood Pressure Thresholds in Individuals 60 Years or Older. JAMA Intern Med. 2014;174(8):1397-1400. doi:10.1001/jamainternmed.2014.2492
For more than 20 years, US Joint National Committee (JNC) hypertension guidelines, including JNC 7, have recommended systolic and diastolic blood pressure (BP) thresholds of 140/90 mm Hg for the initiation of antihypertensive medication and a goal during treatment for individuals without diabetes or chronic kidney disease.1,2 The 2014 report from the panel members appointed to JNC 8 recently recommended a higher systolic BP (SBP) threshold (150 mm Hg) for treatment initiation and a treatment goal in adults 60 years or older.3 We estimated the percentage and characteristics of older US adults potentially affected by the new SBP threshold.
We used data from the National Health and Nutrition Examination Surveys (NHANES) 2005-2010.4 The NHANES data represent cross-sectional, multistage, stratified probability samples of the US civilian noninstitutionalized population. Data were collected through interviews, a medical evaluation, and a medication review. We included 5797 participants 60 years or older who completed a medical evaluation in the mobile examination center. The response rate for this age group was 65.0%.4 The BP was measured 3 times by trained physicians using sphygmomanometers and appropriately sized cuffs. Analyses were limited to 5157 participants with data on BP and antihypertensive medication. The NHANES protocols were approved by the Centers for Disease Control and Prevention Institutional Review Board. Participants provided written informed consent.
Analyses were stratified by antihypertensive medication use. The distribution of SBP (<140, 140-149, or ≥150 mm Hg) was calculated for the entire sample and separately in men and women. Characteristics of the sample were calculated by SBP category. Logistic and linear regression analyses were used to evaluate differences in characteristics between participants with SBPs less than 140 or at least 150 mm Hg vs 140 to 149 mm Hg. Differences were considered statistically significant at P < .05. Analyses were performed using SUDAAN software (version 10.1; Research Triangle Institute), taking into account the sampling design of NHANES.
Of untreated older adults, 29.4% (95% CI, 26.8%-32.2%) had SBP at or above the JNC 7 threshold of 140 mm Hg. This percentage decreased to 16.3% (95% CI, 14.5%-18.3%) with SBP that exceeded the JNC 8 threshold of 150 mm Hg (Table 1). Among treated older adults, 36.3% (95% CI, 34.1%-38.7%) had SBP at or above the 140-mm Hg threshold. This percentage decreased to 20.5% (95% CI, 18.5%-22.6%) with SBP that exceeded the 150-mm Hg threshold. Overall, 13.1% (95% CI, 11.1%-15.5%) and 15.8% (14.3%-17.5%) of untreated and treated participants, respectively, had an SBP of 140 to 149 mm Hg. The percentages were similar in men and women and among participants without diabetes or chronic kidney disease.
Untreated participants with an SBP of 140 to 149 mm Hg vs less than 140 mm Hg were more likely to be at least 80 years old, more likely to have an estimated glomerular filtration rate less than 60 mL/min/1.73 m2 and a diastolic BP of at least 90 mm Hg, and less likely to have a history of myocardial infarction (Table 2). Treated participants with an SBP of 140 to 149 mm Hg were more likely than those with an SBP less than 140 mm Hg to have albuminuria, a history of stroke, or a diastolic BP of at least 90 mm Hg and less likely to be taking only one class of antihypertensive medication.
According to JNC 8 guidelines, many older US adults are no longer eligible for antihypertensive medication initiation or intensification.5 However, achieving the goal BP remains a substantial challenge under the new guidelines. As highlighted in our study, more older adults have an SBP of at least 150 mm Hg than have an SBP of 140 to 149 mm Hg. Study limitations included reliance on BP measurements from a single visit, absence of ambulatory BP monitoring, small sample sizes in some BP categories, and lack of data on antihypertensive medication indications, adherence, and dosing. Until data on the benefits of a lower SBP threshold become available, therapy in older adults should focus on patients with an SBP of 150 mm Hg or higher.
Corresponding Author: Daichi Shimbo, MD, Department of Medicine, Columbia University Medical Center, 622 W 168th St, Presbyterian Hospital 9-310, New York, NY 10032 (firstname.lastname@example.org).
Published Online: June 16, 2014. doi:10.1001/jamainternmed.2014.2492.
Author Contributions: Dr Shimbo and Ms Tanner had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Shimbo, Muntner.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Shimbo.
Critical revision of the manuscript for important intellectual content: Tanner, Muntner.
Statistical analysis: Tanner, Muntner.
Obtained funding: Shimbo.
Administrative, technical, or material support: Shimbo, Muntner.
Study supervision: Muntner.
Conflict of Interest Disclosures: Dr Muntner reported having received an institutional grant from and serving on an advisory board for Amgen Inc. No other disclosures were reported.
Funding/Support: This work was supported by grant P01-HL047540 from the National Heart, Lung, and Blood Institute (Dr Shimbo).
Role of the Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: The NHANES examination data were gathered by the National Center for Health Statistics, Centers for Disease Control and Prevention, with additional support for cardiovascular examination components from the National Heart, Lung, and Blood Institute, National Institutes of Health, through an interagency agreement (Y1-HC-8039).