Continued clinical observation is appropriate for this older patient with elevated blood pressure measurements. The eighth report of the Joint National Committee (JNC 8) recommends that pharmacologic treatment be initiated to lower blood pressure in patients aged ≥60 years who have systolic blood pressure persistently ≥150 mm Hg or diastolic blood pressure ≥90 mm Hg, and treat to a goal of systolic <150 mm Hg and diastolic <90 mm Hg. This recommendation is based on good-quality evidence that a blood pressure goal of <150/90 mm Hg reduces the risk of cardiovascular events, but there appears to be no added benefit with lower targets (140-149 mm Hg). Therefore, in this 70-year-old patient in whom multiple readings have not shown blood pressure above this threshold for treatment, continued clinical observation with periodic blood pressure determinations and evaluation for potential end-organ damage associated with hypertension is recommended.

In a 2017 guideline, the American College of Physicians and American Academy of Family Physicians addressed the treatment of hypertension in patients ≥60 years of age (Qaseem et al, 2017). The guideline includes three recommendations:

• Initiate treatment in patients ≥60 years of age with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk for mortality, stroke, and cardiac events.
• Consider initiating or intensifying pharmacologic treatment in patients ≥60 years of age with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for recurrent stroke.
• Consider initiating or intensifying pharmacologic treatment in some patients ≥60 years of age at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for stroke or cardiac events.

Pharmacologic treatment, such as a thiazide diuretic or an ACE inhibitor, is not indicated at this time.

Although echocardiography is more sensitive for detecting left ventricular hypertrophy than electrocardiography, it is not indicated for evaluation of possible hypertension or as an initial study in patients with documented hypertension in the absence of another indication (such as clinical evidence of heart failure).