Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older

IN RESPONSE: We thank Dr. Rabi and colleagues for their comments and careful review of the guideline (1) and accompanying systematic review (2). Clinical guidelines from the American College of Physicians and the American Academy of Family Physicians are based on the best available evidence (2) and meet the Guidelines International Network's and Institute of Medicine's standards for guidelines (3, 4). We wholeheartedly agree that there are important differences among the studies addressing hypertension treatment goals. Dr. Rabi and colleagues point out that blood pressure measurement techniques are 1 source of clinical heterogeneity among the studies, but many other differences also need to be considered. We have reviewed the 2 meta-analyses that Dr. Rabi and colleagues mention, both of which are acknowledged and discussed in our evidence review (2). There are important differences between these meta-analyses and our evidence review, and there are tradeoffs in any meta-analytic approach. Large meta-analyses have the power to reveal important findings but can also obscure differences across studies and hamper application of the evidence to clinical practice. For example, most studies suggesting benefit from antihypertensive treatment in patients with a baseline SBP less than 140 mm Hg in Ettehad and coworkers' review (5) included those with heart failure or acute myocardial infarction. The benefit of antihypertensive medications in these patients is not in dispute and is not necessarily derived from lowering blood pressure. Because the clinical questions addressed by the evidence review (2) and the guideline (1) centered on blood pressure treatment targets rather than clinical management of distinct clinical conditions (such as acute myocardial infarction or congestive heart failure), we excluded studies of these patient populations. We disagree with Dr. Rabi and colleagues that the data support a broad-based systolic treatment target of less than 130 mm Hg. However, we do agree with Dr. Rabi and Dr. Cushman and their respective colleagues that a lower blood pressure target may be appropriate for older patients at high cardiovascular risk. We also agree with Dr. Cushman and associates that SPRINT is an important trial that should inform practice; in our guideline, it was the main rationale for including a recommendation for lower treatment targets in patients at high cardiovascular risk. The strength of recommendation and quality of evidence ratings reflect in part the inconsistency in findings, most notably between SPRINT and the ACCORD trial. A weak recommendation in support of a lower treatment target in specific patient populations is not a recommendation against more aggressive treatment in these populations. Rather, it emphasizes the need for individual decision making and accounts for the inconsistency among studies as well as the magnitude of benefits, harms, and treatment burden; it still supports more aggressive treatment in some patients.