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To the Editor:—With great interest, we read the fine article by Knight et al. concerning evidence-based medicine (EBM) in the treatment of hypertension in older patients.1 The article is very important for decision making about therapeutic strategy in elderly hypertensive patients. However, most elderly patients have other diseases. Thus the effect of antihypertensive agents on other organs is also an important factor influencing the choice of the most suitable antihypertensive drug for elderly patients On this point, evidence alone may not be enough to decide the best treatment of hypertension in older patients. We and others have reported that angiotensin-converting enzyme (ACE) inhibitors are effective in preventing aspiration pneumonia in the elderly.2,3 The increased upper airway reflexes due to ACE inhibitors have some untoward effects on elderly hypertensive patients, but ultimately lead to good results in the patients. Furthermore ACE inhibitors may possess anti-inflammatory capacity. We have reported that ACE inhibitors inhibit the reactive oxygen species in bronchoalveolar lavage cells from chronic obstructive pulmonary disease (COPD) patients.4 Thus ACE inhibitors are a possible therapeutic agent for the treatment of oxidant-associated lung disorders in older hypertensive patients.

A beta-blocker would be the drug of choice for most hypertensive patients with a history of myocardial infarction; however, the drug could cause airway hyperresponsiveness in elderly patients with COPD and long standing asthma. Because COPD is increased with advancing age, beta-blockers may not be a good choice of antihypertensive drugs in elderly patients with airway diseases.

Calcium-channel blockers are good candidates for antihypertensive agents of choice for the elderly. Yet these agents have been reported to cause heart attacks,5 cancer,6 and gastrointestinal bleeding7 in older patients. However, many controlled trials have attested to the efficacy and safety of long-acting calcium-channel blockers. Thus the quality of the evidence should be carefully considered.

Based on the currently available evidence for the treatment of hypertension in older patients, a low-dose diuretic should be used more frequently for elderly hypertensive patients, as suggested by the editorial.8 Diuretics are also effective in the treatment of right heart failure in patients with COPD. However, the side effects of all drugs on volume status and electrolytes in relation to digoxin use are often concerns in elderly patients. In geriatric medicine, comprehensive strategies for treatment of hypertension are important for frail older patients with concomitant diseases. Further evidence is necessary to decide the best selection of antihypertensive drugs for elderly patients with other disorders. —Shinji Teramoto, MD,andHaruki Kume, MD,International University of Health and Welfare, Department of Internal Medicine, San-no Hospital, Tokyo, Japan and Takeshi Matsuse, MD,Department of Pulmonary Medicine, Yokohama City University Medical Center, Yokohama, Japan.

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