Journal of the American College of Cardiology Vol. 57, No. 20, 2011 © 2011 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/$36.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2011.01.008 EXPERT CONSENSUS DOCUMENT ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents Developed in Collaboration With the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension Writing Wilbert S. Aronow, MD, FACC, Co-Chair* Eduardo Ortiz, MD, MPH† Committee Jerome L. Fleg, MD, FACC, Co-Chair† Efrain Reisin, MD, FASN** Members Carl J. Pepine, MD, MACC, Co-Chair* Michael W. Rich, MD, FACC†† Douglas D. Schocken, MD, FACC, FAHA‡‡ Nancy T. Artinian, PHD, RN, FAHA‡ Michael A. Weber, MD, FACC§§ ʈʈ George Bakris, MD, FASN Deborah J. Wesley, RN, BSN Alan S. Brown, MD, FACC, FAHA‡ *American College of Cardiology Foundation Representative; †Na- Keith C. Ferdinand, MD, FACC§ tional Heart, Lung, and Blood Institute; ‡American Heart Association ʈ Representative; §Association of Black Cardiologists Representative; Mary Ann Forciea, MD, FACP ʈAmerican College of Physicians Representative; ¶American Academy William H. Frishman, MD, FACC* of Neurology Representative; #European Society of Hypertension Representative; **American Society of Nephrology Representative; Cheryl Jaigobin, MD¶ ††American Geriatrics Society Representative; ‡‡American Society for Preventive Cardiology Representative; §§American Society of Hyper- John B. Kostis, MD, FACC tension Representative; ʈʈACCF Task Force on Clinical Expert Con- Giuseppi Mancia, MD# sensus Documents Representative. Authors with no symbol by their name were included to provide additional content expertise apart from Suzanne Oparil, MD, FACC organizational representation. ACCF Task Robert A. Harrington, MD, FACC, Chair Michael F. Gilson, MD, FACC Force Members Mark A. Hlatky, MD, FACC, FAHA Eric R. Bates, MD, FACC Alice K. Jacobs, MD, FACC, FAHA Deepak L. Bhatt, MD, MPH, FACC, FAHA Sanjay Kaul, MBBS, FACC Charles R. Bridges, MD, MPH, FACC¶¶ David J. Moliterno, MD, FACC Mark J. Eisenberg, MD, MPH, FACC, Debabrata Mukherjee, MD, FACC¶¶ FAHA¶¶ Robert S. Rosenson, MD, FACC, FAHA¶¶ Victor A. Ferrari, MD, FACC, FAHA James H. Stein, MD, FACC¶¶ John D. Fisher, MD, FACC Howard H. Weitz, MD, FACC Timothy J. Gardner, MD, FACC, FAHA Deborah J. Wesley, RN, BSN Federico Gentile, MD, FACC ¶¶Former Task Force member during this writing effort. This document was approved by the American College of Cardiology Foundation Board Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ. of Trustees and the American Heart Association Science Advisory and Coordinating ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a Committee in October 2010 and the governing bodies of the American Academy of report of the American College of Cardiology Foundation Task Force on Clinical Neurology, American Geriatrics Society, American Society for Preventive Cardiology, Expert Consensus Documents. J Am Coll Cardiol 2011;57:2037–114. American Society of Hypertension, American Society of Nephrology, Association of This article has been copublished in Circulation, the Journal of the American Society Black Cardiologists, and European Society of Hypertension in March 2011. For the of Hypertension, the Journal of Clinical Hypertension, and the Journal of Geriatric purpose of complete transparency, disclosure information for the ACCF Board of Cardiology. Trustees, the board of the convening organization of this document, is available at: http:// Copies: This document is available on the World Wide Web sites of the American www.cardiosource.org/ACC/About-ACC/Leadership/Officers-and-Trustees.aspx. College of Cardiology (www.cardiosource.org), the American Heart Association ACCF board members with relevant relationships with industry to the document may (my.americanheart.org). For copies of this document, please contact Elsevier Inc. review and comment on the document but may not vote on approval. Reprint Department, fax 212-633-3820, e-mail [email protected]. The American College of Cardiology Foundation requests that this document be Permissions: Modification, alteration, enhancement, and/or distribution of this cited as follows: Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, document are not permitted without the express permission of the American College Ferdinand KC, Forciea MA, Frishman WH, Jaigobin C, Kostis JB, Mancia G, of Cardiology Foundation. 2038 Aronow et al. JACC Vol. 57, No. 20, 2011 Hypertension in the Elderly May 17, 2011:2037–114 1.6.2. Coronary Artery Disease ......................2062 TABLE OF CONTENTS 1.6.3. Disorders of Left Ventricular Function........2064 1.6.3.1. HEART FAILURE ...........................2064 Preamble ....................................................2039 1.6.3.2. LEFT VENTRICULAR HYPERTROPHY ............2064 1.6.4. Atrial Fibrillation .............................2065 Executive Summary .......................................2040 1.6.5. Abdominal Aortic Aneurysm and Peripheral Arterial Disease ....................2065 1.6.5.1. ABDOMINAL AORTIC ANEURYSM ..............2065 1. Introduction .............................................2045 1.6.5.2. THORACIC AORTIC DISEASE..................2065 1.6.5.3. PERIPHERAL ARTERIAL DISEASE ..............2065 1.1. Document Development Process and 1.6.6. Chronic Kidney Disease.......................2066 Methodology .......................................2045 1.6.7. Ophthalmologic Impairment ..................2066 1.1.1. Writing Committee Organization .............2045 1.6.7.1. AGE-ASSOCIATED RETINAL CHANGES ..........2066 1.1.2. Relationships With Industry and Other Entities ...2046 1.6.7.2. PATHOPHYSIOLOGY ........................2066 1.1.3. Consensus Development ......................2046 1.6.8. Quality of Life Issues .........................2067 1.1.4. External Peer Review .........................2046 1.1.5. Final Writing Committee and Task Force 2. Interactions Between Aging and Other CV Risk Approval of the Document....................2046 Conditions Associated With Hypertension .........2067 1.1.6. Document Approval...........................2046 1.1.7. Document Methodology ......................2046 2.1. Family History of Premature Coronary Artery Disease 1.2. Purpose of This Expert Consensus Document ....2047 .............................................2067 2.2. Dyslipidemia 1.3. General Considerations ...........................2047 ........................................2068 1.4. Nomenclature, Definitions, and 2.3. Diabetes Mellitus ..................................2068 Clinical Diagnosis..................................2047 2.4. Obesity and Weight Issues .......................2068 1.5. Magnitude and Scope of the Problem ...........2049 2.4.1. Structural and Hemodynamic Changes........2068 1.5.1. Epidemiology of Hypertension Related 2.4.2. Vascular Changes .............................2069 to Aging ......................................2049 2.4.3. Role of the Sympathetic Nervous System .....2069 1.5.1.1. ISOLATED SYSTOLIC HYPERTENSION ...........2050 2.4.4. Role of the Renin-Angiotensin-Aldosterone 1.5.1.2. SYSTOLIC AND DIASTOLIC HYPERTENSION AND System ........................................2069 PULSE PRESSURE .........................2050 2.5. Microalbuminuria ..................................2069 1.5.1.3. SPECIAL POPULATIONS .....................2050 2.6. Hyperhomocysteinemia ...........................2069 1.5.1.3.1. ELDERLY WOMEN................2051 1.5.1.3.2. ELDERLY BLACKS................2052 2.7. Gout .................................................2070 1.5.1.3.3. ELDERLY HISPANICS .............2053 2.8. Osteoarthritis and Rheumatoid Arthritis ........2070 1.5.1.3.4. ELDERLY ASIANS ................2054 1.5.2. Pathophysiology of Hypertension in the 3. Clinical Assessment and Diagnosis .................2070 Elderly ........................................2054 1.5.2.1. AORTA AND LARGE ARTERIES ................2054 3.1. Measurement of Blood Pressure.................2070 1.5.2.2. AUTONOMIC DYSREGULATION ................2056 3.1.1. Pseudohypertension ...........................2070 1.5.2.3. RENAL FUNCTION AND CATION BALANCE .......2056 3.1.2. White-Coat Effect and 1.5.2.3.1. SODIUM .......................2057 White-Coat Hypertension ....................2070 1.5.2.3.2. POTASSIUM ....................2057 3.1.3. Ankle Blood Pressure .........................2071 1.5.3. Secondary Causes of Hypertension Important 3.2. Ambulatory Blood Pressure Monitoring .........2071 in the Elderly .................................2057 1.5.3.1. RENAL ARTERY STENOSIS ...................2057 3.3. Out-of-Office Blood Pressure Recordings .......2071 1.5.3.2. OBSTRUCTIVE SLEEP APNEA .................2058 3.4. Clinical Evaluation .................................2072 1.5.3.3. PRIMARY ALDOSTERONISM..................2058 1.5.3.4. THYROID STATUS AND HYPERTENSION .........2059 4. Recommendations for Management ................2072 1.5.3.4.1. HYPERTHYROIDISM AND BLOOD PRESSURE ...............2059 4.1. General Considerations ...........................2072 1.5.3.4.2. HYPOTHYROIDISM AND 4.1.1. Blood Pressure Measurement and Goal .......2072 BLOOD PRESSURE ...............2059 4.1.2.