Absolute Risk-Based Treatment Using Adaptive Blood Pressure Thresholds and Targets Is Crucial to Older Multimorbid Patients With High Fall Risk

Abstract

See related article, pp e13–e115 In essence, the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults1 advises physicians to consider, in eligible adults, starting blood pressure (BP) lowering treatment at threshold BP ≥120/80 mm Hg and targeting a BP <130/80 mm Hg. In the clinical practice guidelines for hypertension of the Ministry of Health, Singapore,2 the systolic BP (SBP) treatment thresholds, and the associated targets, are 10 mm Hg higher. The different approach stems from concerns about (1) aggressive treatment causing net harm to vulnerable patients and (2) applying BP targets achieved in highly-selected, mostly white, populations within randomized controlled trials to the older, multimorbid, falls-prone persons in a community comprising 76% Chinese, 15% Malay, 7.5% Indian, and 1.5% diverse races. In Singapore, approved digital oscillometric monitors have largely, but not totally, superseded analog mercury-column or aneroid manometers; but oscillometric home BP-monitoring is not universal. Disregarding the measurement technique, what factors promote falsely high BP readings? First, activation of the adrenergic nervous system by any combination of anxiety, exertion, ambient noise, smoking, caffeine, or a full bladder, raises the BP significantly. Crucially too, the alerting presence of other persons often increases the BP, further enhancing the risk of overtreatment.3,4 SPRINT (Systolic Blood Pressure Intervention Trial) used …