Risks associated with intensive blood pressure control in older patients

: Hypertension management forms a cornerstone of cardiovascular prevention. Strong evidence is available supporting the benefits of blood pressure (BP) lowering in older adults and recent studies indicate that intensive BP control may provide additional advantages on cardiovascular and mortality risk, also at older ages. Yet, in older adults the cardiovascular benefit of intensive treatment may come at the expense of increase in adverse events. Indeed, advanced age and frailty may modify the risk/benefit ratio of BP lowering due to a greater predisposition to hypotension and more severe consequences deriving from treatment-related adverse effects. This mostly applies to individuals with poor health status and limited life expectancy, in whom aggressive BP lowering may not lead to cardiovascular benefits, but rather increase the risk of short-term treatment-related complications. Furthermore, the potential harms of intensive BP control might be underestimated in clinical trials due to exclusion criteria which preclude patients with frailty and multimorbidity from being eligible. Syncope and falls are the most frequently mentioned antihypertensive-related safety concern, but aggressive BP lowering may negatively affect also renal function, cognitive performance, quality of life and survival. With the growing emphasis on intensive treatment strategies, raising awareness on potential harms associated with aggressive BP lowering might help improve hypertension management in older adults and encourage implementation of clinical research on safety issues. Given these premises, we present a narrative review illustrating the most relevant risk potentially associated with intensive BP control in older patients.