A familiar dilemma in the day of a clinical pharmacist'

NICE recommends ACE inhibitors are used first-line to management of hypertension in those <55y, and calcium channel blockers (CCBs) in those ?55y (once diabetes and ethnicity are taken into account).

However, a UK cohort study showed that:

• In those who were not black, not diabetic and <55y there was no significant difference in BP control between ACE inhibitors or CCBs at 12 months.
• CCBs did seem to have greater BP-lowering effects in those over 75y.

What about BP targets in our frail patients?

A UK observational study showed that:

• In those over 85y, raised blood pressure was not associated with increased mortality (even if SBP >180!).
• In those aged 75'85y:
  • If moderately'severely frail, there was NO association between raised BP and mortality.
  • If mildly frail, raised blood pressure WAS associated with increased mortality.
  • Having too low a blood pressure was also harmful: in those ?75y, BP <130/80 was associated with an increased risk of all-cause mortality.

What does this mean in practice?

Guidelines are written for populations, and if there is a good reason to deviate from them then we are free to do that (remember to document your reasoning!).

• We can think more about comorbidities when choosing which drug to use; hypertension + proteinuria = consider ACE inhibitor, hypertension + CVA = consider CCB.
• Don't be afraid to adjust blood pressure targets people as become more frail.

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