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The table summarizes current and recent guidelines [ 6 ]. The definition of blood
pressure targets is a key issue since treatment-resistant hypertension is usually
defined as failure to reach those targets. The diversity of guidelines promotes a
nihilistic approach to therapy of hypertension in the elderly. In this regard, and
given the rapidly increasing segment of the population that is elderly (Fig. 12.1),
adequately powered clinical trials with hard endpoints are urgently needed in elderly
patients of different age ranges and categories of renal dysfunction. We must
remember that aging is a process, and, thus, what is adequate for the 60–70 years
age range may not be appropriate for the 80–90 years age range or for the growing
number of centenarians. Conversely, a patient with chronic kidney disease and glo-
merular filtration rate category G1 and albuminuria category A2 may not benefit
from the same approach as someone with glomerular filtration rate category G5.
Health authorities should actively promote such trials since blood pressure can be
adequately controlled with non-expensive medications, and pharma companies are
unlikely to commit funding for this purpose.
Definition of Resistant Hypertension in Elderly People
Resistant hypertension is defined as blood pressure above goal despite adherence to
a combination of at least three optimally dosed antihypertensive medications, one of
which is a diuretic [ 6 – 9 ]. As discussed before, this is a nonspecific definition, since
the precise goal is key to the definition. In this regard, the blood pressure goal for
elderly individuals with chronic kidney disease ranges from 130/80 mmHg recom-
mended by KDIGO for patients with chronic kidney disease and albuminuria, since
no specification is made for the elderly, to <150/90 mmHg for those aged 80 years
or older, without specification of exceptions for chronic kidney disease, as recom-
mended by NICE and ESH/ESC (Table 12.1). Specifically, Eighth Joint National
Committee (JNC 8) recommendations are as follows [ 10 ]:
Recommendation 1: In the general population aged ≥60 years, initiate pharma-
cologic treatment to lower blood pressure at systolic blood pressure (SBP) ≥ 150
mmHg or diastolic blood pressure (DBP) ≥90 mmHg, and treat to a goal SBP <150
mmHg and goal DBP <90 mmHg (strong recommendation – Grade A).
Recommendation 4: In the population aged ≥18 years with chronic kidney
disease, initiate pharmacologic treatment to lower BP at SBP ≥140 mmHg or DBP
≥90 mmHg, and treat to goal SBP <140 mmHg and goal DBP <90 mmHg (expert
opinion – Grade E).
Recommendation 5: In the population aged ≥18 years with diabetes, initiate
pharmacologic treatment to lower BP at SBP ≥140 mmHg or DBP ≥90 mmHg,
and treat to a goal SBP <140 mmHg and goal DBP <90 mmHg (expert opinion –
Grade E).
Notice that while the goal for the elderly (aged ≥60 years) in the general popu-
lation is <150/<90 mmHg and that this is a strong recommendation, no such age
limit is provided for chronic kidney disease and diabetics, in whom based on expert
R. Fernández-Prado et al.