2023 Guideline for the management of hypertension in the elderly population in China

Qi HUA; Li FAN; Zeng-Wu WANG; Jing LI

doi:10.26599/1671-5411.2024.06.001

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Guideline | Open Access

2023 Guideline for the management of hypertension in the elderly population in China

Qi HUA^¹(), Li FAN^²(), Zeng-Wu WANG^³(), Jing LI^¹()

Xuanwu Hospital, Capital Medical University, Beijing, China

Chinese PLA General Hospital, Beijing, China

Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

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References

[1]

Writing Group of 2018 Chinese Guidelines for the Management of Hypertension. [2018 Chinese guidelines for the management of hypertension]. Chin J Cardiovasc Med 2019; 24: 24−56. [In Chinese].

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Li SN, Chen Z, Wang ZW, et al. [The hypertension status of the elder population in China]. Chin J Hypertens 2019; 27: 140−148. [In Chinese].

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Zhang M, Wu J, Zhang X, et al. [Prevalence and control of hypertension in adults in China, 2018]. Chin J Epidem iol 2021; 42: 1780−1789. [In Chinese].

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Zhang M, Shi Y, Zhou B, et al. Prevalence, awareness, treatment, and control of hypertension in China, 2004–2018: findings from six rounds of a national survey. BMJ 2023; 380: e071952.

Recommended category	Definition	Suggested expressions
Class I	Evidence and/or general consensus that the treatment or method is beneficial, useful or effective	Recommended/Indicated
Class II	Inconsistent evidence and/or disagreement about the use/efficacy of the treatment or method
Class IIa	Evidence/opinion tends to be useful/valid	Should be considered
Class IIb	Insufficient evidence/opinion to establish useful/valid	Can be considered
Class III	Evidence and/or expert consensus that the treatment or method is not useful/ineffective and may be harmful in some cases	Not recommended

Evidence grading	Definition
Level A	Data from multiple randomized controlled clinical trials or a meta-analysis consisting of randomized controlled clinical trials
Level B	Data from a single randomized clinical trial or multiple large nonrandomized controlled studies
Level C	Data from expert consensus and/or small studies, retrospective studies or registries

Definition and classification	Systolic blood pressure, mmHg	Diastolic blood pressure, mmHg
Normal blood pressure	< 120	< 80
Normal high value	120–139	80–89
Hypertension	≥ 140	≥ 90
Grade 1	140–159	90–99
Grade 2	160–179	100–109
Grade 3	≥ 180	≥ 110
Isolated systolic hypertension	≥ 140	< 90

Blood pressure measurement	Diagnostic criteria
Office blood pressure	≥ 140/90 mmHg
Home self-measured blood pressure	≥ 135/85 mmHg
24-hour ambulatory blood pressure, mean	≥ 130/80 mmHg
Daytime, mean	≥ 135/85 mmHg
Nighttime, mean	≥ 120/70 mmHg

Year	Age, yrs	Prevalence	Awareness rate	Treatment rate	Control rate
2002	≥ 60	49.1%	37.6%	32.2%	7.6%
2012–2015	≥ 60	53.2%	57.1%	51.4%	18.2%
2018	60–70	54.4%	51.6%	45.0%	14.6%
	70–80	65.2%	55.7%	50.0%	14.8%
	≥ 80	66.7%	53.9%	48.2%	13.4%

Other risk factors and medical history	Blood pressure level
Other risk factors and medical history	SBP 130–139 mmHg and/or DBP 85–89 mmHg	SBP 140–159 mmHg and/or DBP 90–99 mmHg	SBP 160–179 mmHg and/or DBP 100–109 mmHg	SBP ≥ 180 mmHg and/or DBP ≥ 110 mmHg
CKD: chronic kidney disease; DBP: diastolic blood pressure; SBP: systolic blood pressure.
1–2 risk factors	moderate risk	moderate risk	high risk	very high risk
≥ 3 risk factors or target organ damage or CKD stage 3 or diabetes mellitus	high risk	high risk	very high risk	very high risk
Concomitant clinical conditions, CKD stage 4 to 5	very high risk	very high risk	very high risk	very high risk

Serial number	Items	Query
Frail: ≥ 3 items; Pre-frail: 1–3 items; Robust: 0 item.
1	Fatigue	You fell tired all or most of the time during the past 4 week
2	Resistance	By yourself and not using aids, you have difficulty walking up one stair without resting
3	Ambulation	By yourself and not using aids, you have difficulty walking one block or 100 m
4	Illness	A doctor has told you that you have more than five illnesses. The illnesses include hypertension,diabetes mellitus, cancer (other than a micro-dermal carcinoma), chronic lung disease, heart attack,congestive heart failure, angina, asthma, arthritis, stroke, and kidney disease
5	Loss of weight	Weight loss ≥ 5% occurs in one year or less

Serial number	Test item	Male	Female
Patients with 3–5, 1–2, and 0 factors are classified as frail, pre-frail, and robust, respectively. BMI: body mass index; CES-D: Center for Epidemiologic Studies-Depression questionnaire; MLTA: Minnesota Leisure Time Physical Activity.
1	Loss of weight	Unintentional weight loss [10 pounds (4.5 kg) or > 5%] in past year
2	Walking time, 4.57 m	Height ≤ 173 cm: ≥ 7 sHeight > 173 cm: ≥ 6 s	Height ≤ 159 cm: ≥ 7 sHeight > 159 cm: ≥ 6 s
3	Grip strength, kg	BMI ≤ 24.0 kg/m²: ≤ 29 kgBMI 24.1–26.0 kg/m²: ≤ 30 kgBMI 26.1–28.0 kg/m²: ≤ 30 kgBMI > 28.0 kg/m²: ≤ 32 kg	BMI ≤ 23.0 kg/m²: ≤ 17 kgBMI 23.1–26.0 kg/m²: ≤ 17.3 kgBMI 26.1–29.0 kg/m²: ≤ 18 kgBMI > 29.0 kg/m²: ≤ 21 kg
4	Physical activity, MLTA	< 383 kcal/week (Approx. 2.5 h of walking)	< 270 kcal/week (Approx. 2 h of walking)
5	Exhaustion	Any item in CES-D scored 2–3How many days have you experienced in the past week?(1) I felt that doing all the things need efforts (2) I could not get goingScored 0: < 1 d; Scored 1: 1–2 d; Scored 2: ≥ 3–4 d; Scored 3: > 4 d

Serial number	Items
1	Judgment problems (cannot make up their minds, make wrong decisions, buy gifts that are not suitable for the other party’s identity, or adjust their activities according to current conditions and environmental changes)
2	Loss of interest, disengagement from one’s hobbies and favorite activities
3	Asking the same thing repetitively
4	Difficulty learning to use common tools, household appliances, or equipment (e.g., basic functions of washing machines, computers, microwave ovens, cameras or mobile phones)
5	Cannot remember what year and month it is
6	Difficulty dealing with complex personal financial affairs (forgetting how to reconcile accounts or purchase water, electricity, or gas; unable to manage income reasonably)
7	Cannot remember appointments with other people (such as an appointment to travel together)
8	Frequent problems with memory or thinking skills

Recommendation	Recommended category	Evidence grading
BP: blood pressure.
Initiation of BP-lowering drug treatment is recommended for patients aged 65–79 years and BP ≥ 140/90 mmHg, simultaneous with the initiation of lifestyle changes, the target is < 140/90 mmHg and BP target can be < 130/80 mmHg if tolerated	Class I	Level A
Initiation of BP-lowering drug treatment is recommended for patients aged ≥ 80 years and BP ≥ 150/90 mmHg	Class I	Level A
The first goal should be lowering BP to < 150/90 mmHg	Class I	Level A
BP target can be lower if well tolerated	Class IIa	Level B
Initiation of BP-lowering drug treatment is recommended for frail patients aged ≥ 80 years and BP ≥ 150/90 mmHg. The systolic BP target is 130–150 mmHg, or the BP control target should be determined individually according to the actual situation of the patient	Class IIa	Level C
If the patient tolerates antihypertensive therapy well, antihypertensive therapy should continue	Class I	Level A

Classification	Drug	Daily dose, mg/d	Frequency, time/d	Notes
ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; CCB: calcium channel blocker.
CCB (dihydropyridine)	Amlodipine besylate	2.5–10	1	No absolute contraindicationDose-related ankle edema, flushing and constipation were more common in females than in malesThe side effects of levamlodipine like ankle edema were relatively few
	Levoamlodipine	1.25–5	1
	Felodipine extended release	2.5–10	1
	Cilnidipine	5–10	1
	Lercanidipine	10–20	1
	Nifedipine sustained release	10–80	2
	Nifedipine controlled release	30–60	1
	Lacidipine	4–8	1
	Benidipine	4–8	1
CCB (non-dihydropyridine)	Diltiazem zaozi001 extended release	90–360	1–2	Avoid routine combination with beta-blockers for the potential of bradycardia and conduction block
CCB (non-dihydropyridine)	Verapamil extended release	120–240	1	Not suitable for systolic heart failure
ACEI	Benazepril	5–40	1–2	The combination of ACEI and ARB is not recommended ARB is an altered choice for patients with dry cough who cannot tolerate ACEI Patients with chronic kidney disease or using potassium supplements or potassium-preserving drugs increase the risk of high potassium Risk of acute renal failure increased in patients with severe bilateral renal artery stenosis The ACEIs are contraindicated in patients with previous angioedema associated with ACE inhibitor therapy The ACEIs are contraindicated in patients with serum creatinine > 3 mg/dL (1 mg/dL = 88.4 μmol/L)
	Captopril	25–300	2–3
	Enalapril	2.5–40	1–2
	Fosinopril	10–40	1
	Lisinopril	2.5–40	1
	Imidapril	2.5–10	1
	Perindopril	4–8	1
	Ramipril	1.25–10	1
ARB	Candesartan	4–32	1	Precautions are the same as ACEI
	Irbesartan	150–300	1
	Losartan	25–100	1
	Olmesartan	20–40	1
	Telmisartan	20–80	1
	Valsartan	80–160	1
	Azilsartan	40–80	1
Thiazide diuretics	Hydrochlorothiazide	6.25–25	1	Sodium, potassium, uric acid and calcium concentrations should be monitored
Thiazide-like diuretics	Indapamide	0.625–2.5	1	Use cautiously if the patient has a history of gout, unless the patient has received uric acid lowering therapy
Loop diuretics	Bumetanide	0.5–4	2	For patients with symptomatic heart failure, loop diuretics are preferred For patients with moderate to severe chronic kidney disease, loop diuretics are preferred
	Furosemide	20–80	2
	Torasemide	5–10	1
Potassium-sparing diuretics	Amiloride	2.5–10	1–2	The antihypertensive effect of single use was not obvious Avoid these drugs in patients with severe chronic kidney disease
Potassium-sparing diuretics	Triamterene	25–100	1–2
Aldosterone receptor antagonist	Eplerenone	50–100	2	Spironolactone increases the risk of gynecomastia and erectile dysfunction Avoid combined use of potassium supplements and potassium-sparing drugs Avoid use in patients with severe chronic kidney disease
Aldosterone receptor antagonist	Spironolactone	20–80	Take in divided doses
Cardioselective beta-receptor antagonists	Metoprolol succinate	47.5–95	1	Beta-blockers are contraindicated in patients with disease of bronchospasm When beta-blockers must be used, highly beta1-selective beta blockers could be selected Avoid abrupt withdrawal
	Metoprolol tartrate	50–100	2
	Bisoprolol	2.5–10	1

Recommendation	Recommended category	Evidence grading
ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; ARNI: angiotensin receptor-neprilysin inhibitor; CCB: calcium channel blocker.
It is recommended to use thiazide/like diuretics, CCB, ACEI/ARB/ARNI for the initiation and maintenance of antihypertensive therapy, either single or in combination	Class I	Level A
For nonfrail hypertensive patients aged 65–79 years with grade 2 or higher hypertension or blood pressure higher than target blood pressure 20/10 mmHg, two-drug combination therapy can be used for initial and maintenance treatment, and single-pill combination agents are preferred to improve treatment compliance	Class I	Level B
ACEI, ARB and ARNI should not be used in combination	Class III	Level A

Clinical conditions	Drugs
ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; ARNI: angiotensin receptor-neprilysin inhibitor; CCB: calcium channel blocker.
Asymptomatic target organ damage
Left ventricular wall hypertrophy	ACEI, ARB, CCB, ARNI
Asymptomatic atherosclerosis	ACEI, ARB, CCB
Microalbuminuria	ACEI, ARB
Mild renal insufficiency	ACEI, ARB, ARNI
Clinical cardiovascular events
Previous myocardial infarction	Beta-blocker, ACEI, ARB
Angina pectoris	Beta-blocker, CCB
Heart failure	Diuretics, beta-blockers, ACEI, ARB, aldosterone receptor blocker, ARNI
Aortic aneurysm	Beta-blockers, ARB
Atrial fibrillation, prevention	ACEI, ARB, beta-blockers, aldosterone antagonist
Atrial fibrillation, ventricular rate control	Beta-blockers, non-dihydropyridine CCB
Kidney damage, proteinuria	ACEI, ARB, ARNI
Peripheral arterial diseases	ACEI, ARB, CCB
Other
Isolated systolic hypertension (geriatric)	Diuretics, CCB
Metabolic syndrome	ACEI, ARB, CCB
Diabetes mellitus	ACEI, ARB
Benign prostatic hyperplasia	Alpha-blockers

Classification	Name	Ingredient dose	Dosage
A + C	Perindopril/Amlodipine	Arginine perindopril 10 mg/Amlodipine besylate 5 mg	0.5–1 capsule, once a day
	Amlodipine/Benazepril	Amlodipine 5 mg/Benazepril 10 mg	0.5–2 capsule, once a day
	Amlodipine/Benazepril	Amlodipine 2.5 mg/Benazepril 10 mg	0.5–4 capsule, once a day
	Amlodipine/Losartan	Amlodipine 5 mg/Losartan 100 mg	0.5–1 capsule, once a day
	Amlodipine/Losartan	Amlodipine 5 mg/Losartan 50 mg	0.5–2 capsule, once a day
	Olmesartan/Amlodipine	Olmesartan 20 mg/Amlodipine 5 mg	0.5–2 capsule, once a day
	Irbesartan/Amlodipine	Irbesartan 100 mg/Amlodipine 5 mg	0.5–2 capsule, once a day
	Irbesartan/Amlodipine	Irbesartan 100 mg/Amlodipine 10 mg	0.5–1 capsule, once a day
	Amlodipine/Valsartan	Amlodipine 5 mg/Valsartan 80 mg	0.5–2 capsule, once a day
	Amlodipine/Telmisartan	Amlodipine 5 mg/Telmisartan 80 mg	0.5–1 capsule, once a day
A + D	Perindopril/Indapamide	Perindopril 4 mg/Indapamide 1.25 mg	0.5–2 capsule, once a day
	Lisinopril/Hydrochlorothiazide	Lisinopril 10 mg/Hydrochlorothiazide 12.5 mg	0.5–2 capsule, once a day
	Benazepril/Hydrochlorothiazide	Benazepril 10 mg/Hydrochlorothiazide 12.5 mg	0.5–2 capsule, once a day
	Losartan Potassium/Hydrochlorothiazide	Losartan Potassium 50 mg/Hydrochlorothiazide 12.5 mg	0.5–2 capsule, once a day
		Losartan Potassium 100 mg/Hydrochlorothiazide 12.5 mg	0.5–1 capsule, once a day
		Losartan Potassium 100 mg/Hydrochlorothiazide 25 mg	0.5–1 capsule, once a day
	Valsartan/Hydrochlorothiazide	Valsartan 80 mg/Hydrochlorothiazide 12.5 mg	0.5–2 capsule, once a day
	Irbesartan/Hydrochlorothiazide	Irbesartan 150 mg/Hydrochlorothiazide 12.5 mg	0.5–2 capsule, once a day
	Telmisartan/Hydrochlorothiazide	Telmisartan 40 mg/Hydrochlorothiazide 12.5 mg	0.5–2 capsule, once a day
	Telmisartan/Hydrochlorothiazide	Telmisartan 80 mg/Hydrochlorothiazide 12.5 mg	0.5–1 capsule, once a day
	Olmesartan/Hydrochlorothiazide	Olmesartan 20 mg/Hydrochlorothiazide 12.5 mg	0.5–2 capsule, once a day
	Candesartan/Hydrochlorothiazide	Candesartan ester 16 mg/Hydrochlorothiazide 12.5 mg	0.5–1 capsule, once a day
B + C	Bisoprolol/Amlodipine	Bisoprolol 5 mg/Amlodipine 5 mg	0.5–2 capsule, once a day
B + C	Nitrendipine and Atenolol Tablets	Nitrendipine 10 mg/Atenolol 20 mg	1 capsule, once or twice a day
Compound diuretics	Compound/Amiloride	Amiloride 2.5 mg/Hydrochlorothiazide 25 mg	0.5–1 capsule, once a day
Low-dose multicomponent combination agents	Compound Reserpine/Triamteridine Tablets	Reserpine 0.1 mg/Triamterene 12.5 mg/Hydrochlorothiazide 12.5 mg/Dihydralazine 12.5 mg	0.5–1 capsule, once a day

Recommendations	Recommended category	Evidence grading
For patients aged < 80 years, it is recommended to target blood pressure to < 140/90 mmHg^{[1,44,155,156]}	Class I	Level A
If the general condition is good and the antihypertensive therapy can be tolerated, the blood pressure can be lowered to < 130/80 mmHg^[44,66,157]	Class IIa	Level C
For patients aged ≥ 80 years, the blood pressure target is < 150/90 mmHg and the diastolic blood pressure should not be lower than 60 mmHg^[156]	Class IIb	Level C

Clinical situation	Specification	Initial blood pressure target	Drug choice
Hypertensive encephalopathy	Cerebral perfusion needs to be ensured while lowering blood pressure, and the systolic blood pressure should be reduced by 20% to 25% within 1 h after administration, but not by more than 50%	160–180/100–110 mmHg, gradually decrease to the normal level after stabilization	Urapidil, labetalol, nicardipine
Cerebral hemorrhage	When systolic blood pressure is more than 220 mmHg in patients with acute cerebral hemorrhage, active intravenous antihypertensive treatment is needed while the blood pressure should be closely monitored. When systolic blood pressure is more than 180 mmHg, intravenous antihypertensive treatment should be adjusted and guided by clinical manifestations	Systolic blood pressure 130–180 mmHg.^{[151,222,223]} Actively reducing the blood pressure early and controlling the systolic blood pressure at 130–150 mmHg is probably safe and reasonable (Class IIb, Level C)^{[151,222,223]}	Urapidil, labetalol, nicardipine
Subarachnoid hemorrhage	Prevent exacerbation of hemorrhage and excessive decrease of blood pressure, which may cause transient neurological deficits and delayed diffuse lethal cerebral vasospasm	Systolic blood pressure < 150–160 mmHg	Nicardipine, nimodipine, labetalol, or esmolol
Cerebral infarction	Generally no need for tight control of blood pressure, slightly higher blood pressure is beneficial to perfusion of ischemic area, unless blood pressure ≥ 200/120 mmHg or with heart failure, aortic dissection, hypertensive encephaloathy, etc	Initiate antihypertensive therapy when blood pressure ≥ 220/120 mmHg (Class IIb, Level C);^[140-142] patients who are intended to receive intravenous thrombolysis or mechanical thrombectomy should control the blood pressure to ≤ 185/110 mmHg before treatment (Class IIb, Level C);^[143-145] for patients who undergo mechanical thrombectomy, it is avoid to control systolic blood pressure below 120 mmHg (Class IIa, Level B)^[146]	Urapidil, labetalol, nicardipine, or sodium nitroprusside
Malignant hypertension with or without kidney damage	Avoid violent fluctuations in blood pressure, steadily reduce blood pressure, and ensure renal perfusion	< 140/90 mmHg	Urapidil, nicardipine or labetalol, diuretics, pay attention to renal function and electrolytes
Acute heart failure	It is often manifested as acute pulmonary edema. In order to relieve symptoms and reduce congestion, vasodilators combined with diuretics are recommended	< 140/90 mmHg, not lower than 120/70 mmHg^[224]	Combined diuretics with vasodilators, urapidil, sodium nitroprusside, or nitrates
Acute coronary syndrome	Reduce blood pressure and myocardial oxygen consumption, but do not affect the coronary perfusion pressure and coronary blood flow, and prevent reflex tachycardia	< 130/80 mmHg, diastolic blood pressure > 60 mmHg^[224]	Nitroglycerin, esmolol, urapidil, or diltiazem
Aortic dissection	Under the premise of ensuring organ perfusion, the blood pressure is rapidly lowered and maintained as low as possible	Systolic blood pressure < 120 mmHg, heart rate 50–60 beats/min	Esmolol, labetalol, diltiazem, urapidil, sodium nitroprusside, or nicardipine
Pheochromocytoma crisis	Due to the short half-life of periodically released catecholamines, the blood pressure fluctuates greatly in patients, and blood pressure must be closely monitored to avoid the occurrence of hypotension	Blood pressure < 160/90 mmHg in 24 h before operation^[224]	Alpha-blockers such as phentolamine and urapidil are the first choice. Sodium nitroprusside and nicardipine can also be used. If tachycardia and arrhythmia exist, beta blockers can be added to alpha-blockers

Drug	Dose	Onset time	Duration	Adverse reactions	Contraindications
Nitroglycerin	5–100 μg/min, i.v.	2–5 min	5–10 min	Headache, vomiting	Allergy to nitrates, severe anemia, increased intracranial pressure, angle-closure glaucoma
Sodium nitroprusside	0.25–10 μg/kg per min, i.v.	Immediately	2–10 min	Hypotension, tachycardia, headache, muscle spasm. If patients with renal insufficiency use persistently for more than 48 h, cyanide or thiocyanate in plasma must be measured every day, and thiocyanate should not exceed 100 μg/mL, cyanide does not exceed 3 μmol/mL to prevent cyanide poisoning	Compensated hypertension such as arteriovenous shunt or coarctation of the aorta
Labetalol	20–80 mg, i.v.; 0.5–2 mg/min, iv.gtt; not to exceed 300 mg in 24 h	5–10 min	3–6 h	Nausea, vomiting, headache, bronchospasm, conduction block, orthostatic hypotension	Bronchial asthma, cardiogenic shock, second- to third-degree atrioventricular block, sinus bradycardia, severe or acute heart failure
Esmolol	250–500 μg/kg, i.v.; then 50–300 μg/kg per min, iv.gtt	1–2 min	10–20 min	Hypotension, nausea	Severe sinus bradycardia, second- to third-degree atrioventricular block, sick sinus syndrome, cardiogenic shock, decompensated heart failure, bronchial asthma attack or exacerbation
Urapidil	10–50 mg, i.v.; 6–24 mg/h	5 min	2–8 h	Hypotension, dizziness, nausea, tiredness	Patients with aortic isthmus stenosis or arteriovenous shunt (except shunt during renal dialysis)
Nicardipine	0.5–10 μg/kg per min, i.v.	5–10 min	1–4 h	Tachycardia, headache, peripheral edema, nausea	Severe aortic stenosis, severe mitral stenosis, obstructive hypertrophic cardiomyopathy, hypotension, acute cardiac insufficiency with cardiogenic shock, severe acute myocardial infarction with unstable cardiac function
Diltiazem	5–10 mg, i.v.; 5–15 μg/kg per min, pump in	5 min	30 min	Bradycardia, atrioventricular block, heart failure, peripheral edema, headache, constipation, hepatotoxicity	Severe hypotension or cardiogenic shock, second- to third-degree atrioventricular block or sick sinus syndrome (persistent sinus bradycardia, sinus arrest and sinoatrial block, etc.), severe congestive heart failure, severe cardiomyopathy