Hypertension in the Older Adult: An Update on Canadian Hypertension Education Program Recommendations

Norm R.C. Campbell, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
J. George Fodor, MD, FRCPS, PhD, Ottawa Heart Institute, Ottawa, ON.
Robert Herman, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
Pavel Hamet, MD, FRCPC, PhD, Research Center, CHUM, Montréal, QC (for the Canadian Hypertension Education Program).

Hypertension is a leading risk for morbidity and mortality in Canada. The older population is at greater risk from hypertension and has a greater reduction in cardiovascular risk with treatment than young patients. Frequent screening for hypertension is prudent as the estimated risk of developing hypertension is about 90%, even in normotensive 65-year-olds. Systolic blood pressure is a more relevant risk factor than diastolic blood pressure in older patients and is more difficult to treat to target. Most hypertensive patients will have multiple cardiovascular risks that require screening and management to reduce cardiovascular risk optimally. Lifestyle therapy is efficacious. Effective first-line drug therapies that reduce hypertension complications include thiazide-type diuretics, ACE inhibitors, long-acting calcium-channel blockers, and angiotensin-receptor blockers. Most patients require two or more drugs to achieve current blood pressure targets.
Key words: high blood pressure, hypertension, guidelines, recommendations, evidence-based medicine.

Over half of older Canadians have hypertension.1,2 Even for those with normal blood pressure (BP) at age 65, the Framingham study estimates that over 90% will develop hypertension.3 Hypertension is the strongest risk factor for stroke and congestive heart failure, and overall approximately 50% of cardiovascular events are attributed to suboptimal blood pressure.4 Therefore, physicians who assess older patients need to be aware of recommendations for screening and management of hypertension. This brief review outlines some important aspects of hypertension in the older adult and some of the new Canadian Hypertension Education Program (CHEP) recommendations.5 The hypertension recommendations, a slide kit, and various implementation tools are available online at

Systolic Blood Pressure vs. Diastolic Blood Pressure
Systolic blood pressure increases linearly with age while diastolic blood pressure increases to about age 60 and then begins to decline.2 It is therefore not surprising that systolic hypertension accounts for 60% of hypertension in those over age 65, and diastolic hypertension becomes less common after age 60.6 Thus, isolated systolic hypertension is more common as people age. Current evidence suggests that the greatest cardiovascular risk is from isolated systolic hypertension and that risk is more closely associated with systolic blood pressure than diastolic blood pressure in older patients.7,8

Risk of Hypertension and the Benefits of Therapy
The absolute risk associated with hypertension also increases with age, and the absolute benefits associated with therapy are greater in older than younger patients.8,9 The number of patients required to be treated to prevent a cardiovascular event becomes lower as patients age, making therapy more cost effective in older patients.

Cardiovascular Risks and Global Risk Reduction
In general, the number and magnitude of cardiovascular risks increase as patients get older. There are age-related increases in dyslipidemia, abnormalities of glucose metabolism (glucose intolerance and diabetes), sedentary behaviour, and obesity.1,10 Moreover, age itself is the most substantive risk for cardiovascular disease. Once atherosclerotic cardiovascular disease becomes overt, the risk of another event dramatically increases. Over 90% of hypertensive Canadians have other cardiovascular risks. Hypertension should be viewed as not only a cardiovascular risk but also as a marker for the presence of other cardiovascular risks. Patients with clinically overt atherosclerosis or three or more cardiovascular risks, or those who meet the criteria in the dyslipidemia management recommendations, are recommended for treatment with a statin-type medication to lower cholesterol.