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European guidelines (ESH-ESC2013) for the elderly have discussed well about treatment blood pressure (BP) levels and targeting BP levels. In general, elderly patients with systolic BP (SBP) ≥160 mmHg including individuals older than 80 years in good physical and mental conditions are recommended reducing SBP to between 150 and 140 mmHg. Furthermore, fit elderly patients <80 years old are recommended to consider antihypertensive treatment at SBP values ≥140 mmHg with a target SBP <140 mmHg. On the other hand, frail elderly patients are recommended to leave decisions on antihypertensive therapy to the treating physician, and based on monitoring of the clinical effects of treatment. NICE guidelines at 2011 and guidelines by the American Society of Hypertension and the International Society of Hypertension at 2013 indicate similar target BP with ESH-ESC2013 on principle, although patients aged less than 80 years old are recommended <140/90 mmHg regardless of physical condition. Guideline by the eighth Joint National Committee (JNC8) recommends moderate target BP, <150/90 mmHg, in patients aged less than 80 years old regardless of physical condition. Japanese guidelines (JSH2014) recommend starting drug therapy for patients with BP≥140/90 mmHg on principle. JSH2014 additionally indicate that, however, treatment indication must be individually assessed in persons, aged over 75 years old, with a systolic blood pressure of 140–149 mmHg or frail/disabled elderly, such as subjects who are unable to accomplish 6 m walking. Regarding target BP, patients aged 65–74 years old are recommended reducing BP<140/90 mmHg and those aged over 75 years old are recommended BP<150/90mmHg with more aggressive BP target <140/90 mmHg if treatment is well tolerated. All of these recommendations are based on comparison of achieved BP between the placebo and active-treated groups in the randomized placebo-controlled trials such as SHEP, Syst-Eur, and HYVET and studies directly compared target BP such as JATOS and VALISH. Differences in initiation levels and targeting levels of BP among guidelines may be partly due to how strictly applied evidences to guidelines and differences in the healthcare system among countries. In contrast with these guidelines, AHA/ACC/CDC Science Advisory published recommendations that target BP for most people including the elderly is <140/90 mmHg. This advisory further mentioned that lower target may be appropriate for some populations such as African-American, the elderly, or patients with LV hypertrophy, systolic or diastolic LV dysfunction, diabetes mellitus or chronic kidney disease depending on the results of randomized clinical trials (eg, Systolic Blood Pressure Intervention Trial [SPRINT]). SPRINT showed significant evidence that targeting SBP <120 mmHg (BP measured with an automated measurement protocol in separate room of the office) provides stronger protection from cardiovascular events and death than the traditional target BP of <140 mmHg. Recently, a subanalysis of SPRINT in patients aged 75 years or older showed the same results of primary endpoints with the main trial regardless of frailty status. SPRINT showed, however, significantly higher rates of some adverse events in the intensive-treatment group compared with standard-treatment group. The SPRINT did not enroll older adults residing in nursing homes, persons with type 2 diabetes or prevalent stroke. Individualized treatment of hypertension should be considered from the point of preventive effects of cardiovascular diseases, harmful risk of adverse events and effects on QOL based on not only evidence-based medicine but also individual physiology-based medicine in the very elderly and frail hypertensive patients.

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