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Abstract

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References

Hypertension in older adults is not well controlled in clinical practice. Isolated systolic hypertension is often more difficult to manage. A systematic PubMed search was conducted to look for evidence showing benefits of lowering blood pressure (BP) in older hypertensive adults. Lowering BP in these individuals significantly reduces the risk of coronary artery disease, stroke, and cardiovascular and all-cause mortality. Based on trial evidence, a low-dose diuretic should be considered the most appropriate first-step treatment for preventing cardiovascular morbidity and mortality. Therapy with >1 medication is often necessary to reduce BP in these patients. There is unequivocal evidence that cardiovascular events can be prevented in older adults, even those older than 80 years, by treating hypertension.

Hypertension (HTN) in older adults, defined as systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg,1 is present in >10 million men and at least 17 million women aged 65 years or older2 in the United States. Isolated systolic HTN (ISH) (SBP ≥140 mm Hg and DBP <90 mm Hg)1 is more common than systolic/diastolic HTN in older adults.3 An estimated $7 to $15.5 billion per year is spent on the treatment of this disease in the United States.4 By the year 2020, about 25% of the US population will be older than 65 years; the very old (older than 85 years) is the fastest-growing segment of the US population.5–10 Both systolic/diastolic HTN and ISH are independent risk factors for cardiovascular (CV) events.8 It is also well established that SBP is a better predictor of CV risk than DBP11,12; SBP and pulse pressure13,14 yield similar diagnostic and prognostic information.

Despite evidence that lowering high blood pressure (BP) with antihypertensive therapy in clinical trials significantly reduces CV events in adults, including patients 80 years and older,15–18 BP has only been adequately controlled (<140/90 mm Hg) in 36.8% of all hypertensive patients in the United States and in 36.7% of patients 60 years or older in 2003 and 2004.19 A recent survey in 2007 suggests, however, that hypertension in >50% of patients is controlled.20 Being older than 65 years and having ISH are 2 major determinants for poor HTN awareness and poor HTN control rates in the United States.21 Health care professionals who take care of older adults are often reluctant to provide adequate antihypertensive interventions, especially to the very old with HTN.22 In addition, the CV risks associated with so-called prehypertension (BP levels of 120–139/80–89 mm Hg) and the choice of therapy in older adults are not clear. This paper reviews evidence from randomized controlled trials (RCTs) and meta-analyses of the benefits of CV risk reduction by lowering high BP with antihypertensive interventions in older adults (65–79 years) and the very old (80 years and older). We also present evidence in an attempt to define the CV risk of prehypertension, the choice of initial interventions, and the benefits of antihypertensive medications in hypertensive older adults.

EVIDENCE SEARCH AND ACQUISITION

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References

Systematic PubMed searches of English-language literature were made using the search terms hypertension classification, drug therapy, diet therapy, economics, epidemiology, mortality, prevention and control, and therapy. This resulted in 26,029 citations. Limiting the search results to humans, age groups of 65 years and older and 80 years and older, and clinical trials reduced the search to 676 articles. The references of pertinent articles were also searched for identification of additional relevant papers. We reviewed all the relevant articles and included 8 RCTs and 2 meta-analyses that met inclusion criteria (Table I).

Table I.  Criteria for Inclusion of Studies for This Review
Randomized controlled trial or meta-analysis of randomized control trials
Patients with hypertension aged 60 years or older
Follow-up of at least 1 year
Interventions that included antihypertensive drugs
Outcome measures that included cardiovascular events and cardiovascular and/or total mortality

EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References

Both the CV risk from any given level of BP and the benefits of treating HTN increase substantially with age. In addition, more strokes, myocardial infarctions, episodes of heart failure, and deaths will be prevented by treating hypertensive individuals 65 years and older than by treating hypertensive individuals 50 years or younger with the same BP level.23 RCTs and meta-analyses of HTN24–27 or ISH16,28–30 strongly support the use of antihypertensive medications in the treatment of older patients (age range, 60–84 years) (Table II and Table III) to reduce the risk of HTN-related CV events. Results of a meta-analysis by He and Whelton31 of pooled data from RCTs indicated that an average reduction of 12 to 13 mm Hg in SBP over 4 years was associated with a 21% reduction in coronary artery disease (CAD), a 37% reduction in stroke, a 25% reduction in total CV mortality, and a 13% reduction in all-cause mortality. In addition to the CV benefits in the Systolic Hypertension in Europe (Syst-Eur) trial,16 the active treatment group had fewer cases of dementia compared with the placebo group (3.8 vs 7.7 cases per 1000 patient-years)32; this reduction in dementia persisted during extended follow-up after termination of the original trial.33 Other trials, however, have not reported similar benefits.

Table II.  Randomized Clinical Trials of Combined Systolic and Diastolic Hypertension
TrialNo. of Patients (Follow-Up Years) and Entry-Level BPAge, yIntervention vs ComparisonStroke Risk Reduction, %All Cardiovascular Disease Risk Reduction, %Reduction in Total Mortality, %
European Working Party on High Blood Pressure in the Elderly (EWPHE)24840 (4.6) 160–239/90–119 mm Hg≥60HCTZ + triamterene vs placebo. If BP remained raised, methyldopa was added to the active regimen or placebo.3629NS
Coope and Warrender25884 (4.4) >170/105–120 mm Hg60–79Atenolol and bendrofluazide.3058 
Swedish Trial in Old Patients With Hypertension (STOP-HTN)261627 (2) 180–230/105–120 mm Hg70–84One of 4 regimens: atenolol 50 mg, metoprolol 100 mg, pindolol 5 mg, or hydrochlorothiazide 25 mg + amiloride 2.5 mg. If SBP was ≥160 mm Hg or DBP was ≥95 mm Hg after ≥2 mo of treatment, a diuretic was added to β-blockers or vice versa. Patients were changed to open treatment if their mean BP exceeded 230/120 mm Hg.474043
Medical Research Council Working Party274396 (5.8) 160–209/>115 mm Hg65–74Atenolol 50 mg/d, HCTZ 25–50 mg/d + amiloride 2.5–5 mg/d, or placebo. Active treatments were modified to achieve target BP levels.2517 
Abbreviations: DBP, diastolic blood pressure (BP); HCTZ, hydrochlorothiazide; NS, not significant; SBP, systolic BP.
Table III.  Randomized Clinical Trials of Isolated Systolic Hypertension
TrialNo. of Patients (Follow-Up Years) and Entry-Level BPAge, yIntervention vs ComparisonStroke Risk Reduction Compared With Control, %All Cardiovascular Disease Risk Reduction Compared With Control, %Reduction in Total Mortality, %
Systolic Hypertension in the Elderly Program (SHEP)164736 (4.5) ≥160/<90 mm Hg≥60Chlorthalidone + atenolol or reserpine vs placebo. Any patient with sustained SBP >220 mm Hg or DBP >90 mm Hg was given active treatment.3332NS
Systolic Hypertension in Europe Trial (Sys-Eur)284695 (2) 160–219/ <95 mm Hg≥60Nitrendipine 10–40 mg/d + enalapril 5–20 mg/d and HCTZ 12.5–25 mg/d vs placebo.4226NS
Systolic Hypertension in China Trial (Sys-China)292394 (3) 160–219/ <95 mm Hg≥60Nitrendipine 10–40 mg/d + captopril 12.5–50 mg/d or HCTZ 12.5–50 mg/d vs placebo.383739
Staessen et al3015,693 (3.8)≥60 3026 
Abbreviations: DBP, diastolic blood pressure (BP); SBP, systolic BP; HCTZ, hydrochlorothiazide; NS, not significant.

EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References

Health care professionals involved in the care of elderly individuals are often reluctant to intervene with lifestyle or pharmacologic recommendations in very old hypertensive patients (80 years and older).22 Except in the Swedish Trial in Old Patients With Hypertension (STOP-HTN),26 very old hypertensive patients have rarely been enrolled in RCTs. Until the announcement of the preliminary results of the Hypertension in the Very Elderly Trial (HYVET),34 the benefits and risks of treating HTN in individuals older than 80 years were uncertain. Cross-sectional epidemiologic studies showed that a positive relationship between elevated BP and excess mortality between the ages of 60 and 69 years became an inverse relationship in men older than 75 years and in women older than 85 years, with older individuals with higher BP living longer.35 Moreover, a longitudinal study of changes in SBP and DBP between the ages of 70 and 90 years found that individuals alive at the age of 93 years had higher BP levels at age 90 years than those who had died.36 Some of this might be related to selection bias resulting from recruitment of older adults with low BP secondary to other causes with poor outcomes (eg, heart failure, malnutrition, and general poor health). A trend analysis suggested that antihypertensive treatment might be less effective or even harmful in very old (80 years and older) hypertensive patients.24,37 A meta-analysis of pooled data from the cohort of patients 80 years and older has reported that antihypertensive therapy reduces the risk of nonfatal CV events, especially stroke (36% reduction, P=.01) and heart failure (39% reduction, P=.01)18; however, a significant effect on total or CV mortality was not found. Due to lack of knowledge about the effect of antihypertensive treatment on mortality in very old hypertensive patients, an RCT was started in 1994.38,39 HYVET-Pilot40 data indicated that antihypertensive medications in the very old were associated with a reduction in stroke events (relative hazard rate, 0.47; 95% confidence interval [CI], 0.24–0.91; P=.02]). An estimate of total mortality, however, again indicated that there was no significant effect on mortality with active treatment (relative hazard rate, 1.23; 95% CI, 0.75–2.01; P=.42) (Table IV). The preliminary results, however, supported the need for the continuation of the main HYVET trial. The HYVET main study was terminated early in July 2007 at the recommendation of its data safety monitoring board, which stated that the trial should be stopped because the preliminary results suggested that lowering BP significantly reduced both stroke and mortality in hypertensive individuals 80 years and older.34

Table IV.  Risk Reduction for Total Mortality, Cardiovascular Mortality, and Stroke Events for Intervention vs Placebo
Outcome MeasuresRR From Meta-Analysis18RHR From HYVET-Pilot38a
Stroke events0.67 (.01)0.47 (.02)
Cardiovascular mortality1.01 (.93)1.13 (.66)
Total mortality1.06 (.30)1.23 (.42)
Values in parentheses are P values. aThe Hypertension in the Very Elderly Trial (HYVET) was stopped early in July 2007 because of significantly decreased mortality in the intervention group. Abbreviations: RHR, relative hazard rate; RR, risk reduction.

PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)1 introduced a new category of BP in adults considered prehypertensive (defined as having an SBP of 120–139 mm Hg and a DBP of 80–89 mm Hg). In a prospective cohort study, 53,163 apparently healthy men aged 39 to 84 years (stratified by ages 39–49, 50–59, 60–69, and 70–84 years) were followed for 5.7 years. Compared with men with normal BP levels, those with prehypertension had a multivariate-adjusted relative risk of 1.02 (95% CI, 0.73–1.42) for CV mortality. In this large cohort, prehypertension was not associated with a significantly increased risk of CV mortality in healthy men 50 years and older.41

Analyses were conducted on participants (n=2704; 65 years or older, 7.57%) in the National Health and Nutrition Examination Survey I (NHANES I) (1971–1975) observed for 18 years for major CV disease events.42 A total of 93% of prehypertensive individuals had at least 1 CV risk factor. Prehypertension remained a predictor of CV disease in unadjusted (2.13; 95% CI, 1.64–2.76) and adjusted (1.42; 95% CI, 1.09–1.84) analyses. Another analysis was conducted on a nationally representative cohort in the NHANES II (1976–1980) and the NHANES II Mortality Study (1992).43 In this cohort, which included 9087 patients aged 30 to 74 years at baseline and represented nearly 95 million Americans, prehypertension was not significantly associated with either all-cause (hazard ratio, 0.82, 95% CI, 0.64–1.04) or CV (hazard ratio, 1.00; 95% CI, 0.72–1.39) mortality.

INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References

Thiazide-type diuretics have been used for initial therapy in most RCTs.44 In a network meta-analysis of 42 clinical trials that included 192,478 patients (inclusion criteria: RCTs that evaluated major CV disease end points in hypertensive patients over the course of at least 1 year; exclusion criteria: trials that recruited patients who had congestive heart failure or myocardial infarction and trials of smoking cessation or lipid-lowering), diuretics were found to be the most effective first-step treatment for preventing the occurrence of CV morbidity and mortality.44 The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT),45 the largest randomized, blinded, controlled trial of antihypertensive medications in hypertensive individuals (n=33,357; 65 years or older, 57%; mean follow-up, 4.9 years), compared chlorthalidone (12.5–25 mg/d), amlodipine (2.5–10 mg/d), and lisinopril (10–40 mg/d) and found thiazide-type diuretics to be superior in preventing ≥1 major form of CV disease and that they were less expensive. The primary outcome (ie, CV disease events) did not differ among the thiazide-based treatment group compared with the calcium channel blocker (CCB)- or angiotensin-converting enzyme inhibitor (ACEI)–based treatment groups; however, secondary outcomes of heart failure were less with thiazides than CCBs, and the incidence of strokes and heart failure was less with the diuretic than the ACEI.45 Based on these data, JNC 7 recommended thiazide-type diuretics as initial therapy for most patients with HTN, either alone or in combination with one of the other classes of antihypertensive medications.1 In a meta-analysis of 13 RCTs (n=105,951) comparing β-blockers with other antihypertensive drugs and 7 studies (n=27,433) comparing β-blockers with placebo or no treatment, an increased risk of stroke was found.46 Hence, β-blockers should not be the first choice in the treatment of HTN, especially in older adults who may be at risk for cognitive impairment.46 Deviation from evidence-based guidelines in HTN treatment leads to higher costs of medications for older adults as well as difficulty in providing affordable prescription drug benefits for older Americans.47 Adherence to evidence-based prescribing guidelines for geriatric HTN could result in savings of about $1.2 billion per year nationally.47

BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References

Because many of the early placebo-controlled trials used diuretics and β-blockers, concerns were raised about whether the benefits of BP-lowering therapy in older adults extend to treatment with other antihypertensive agents. It is clear from the STOP-HTN 2 trial15 and the Syst-Eur28 and Systolic Hypertension in China (Syst-China)29 trials that newer antihypertensive medications (ie, ACEIs and CCBs) are just as beneficial in reducing CV events as diuretics and β-blockers. The primary combined end point (fatal stroke, fatal myocardial infarction, and other fatal CV disease) was identical in the diuretic/β-blocker group (19.8 events per 1000 patient-years) and the CCB/ACEI group (19.8 events per 1000 patient-years (relative risk, 0.99; 95% CI, 0.84–1.16; P=.89).15 Of interest is that BP was equally reduced in both groups. In the Syst-China trial, however, eligibility criteria were not completely fulfilled in 19.3% of participants and assignment to placebo or active treatment did not completely guarantee blinding of the clinicians. This may have introduced some bias in the recruitment and treatment assignment of the Syst-China patients and might have influenced the reported estimates of relative and absolute benefit.29 The recently performed Systolic Hypertension in the Elderly Lacidipine Long-Term (SHELL) study48 compared the effects of a dihydropyridine long-acting CCB (lacidipine) with chlorthalidone in 1882 patients with a mean age of 72 years and found no difference in the incidence of CV events or mortality between treatment groups, with similar BP reductions. Treatments were similarly effective in men and women and in age groups between 60 and 69 years (n=763), 70 and 79 years (n=744), and 80 years and older (n=375).48

DISCUSSION

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References

Lowering BP with antihypertensive interventions in 65- to 79-year-old hypertensive individuals significantly reduces the risk of CAD, stroke, and CV and all-cause mortality. Lowering BP with antihypertensive interventions in hypertensive individuals 80 years and older also significantly reduces the risk of fatal and nonfatal strokes, heart failure, and mortality. Low-dose diuretics have been shown to be an effective initial treatment for preventing CV morbidity and mortality: CCBs and other antihypertensive agents usually in combination with diuretics are also effective in hypertensive older adults.

Current evidence for the pharmacotherapy of HTN in patients aged 65 to 79 years and the very old (aged 80 years and older) suggests that there is no absolute age threshold above which BP should not be lowered in hypertensive older adults.18,34,40 Physicians should routinely offer lifestyle and pharmacologic antihypertensive interventions to old and very old hypertensive patients, explaining clear benefits and adverse effects of medications.

In the real world of clinical practice, there are missed opportunities for improving the control rates of HTN. A survey of opinions and self-reported practices of a national random sample of health care professionals (n=1060) involved in the care of older individuals regarding the management of HTN in older adults found that 35% of those surveyed considered the increase in BP with age a normal process of aging and 25% considered treating HTN in an 85-year-old patient to have more risks than benefits.22 In this survey, respondents were more likely to recommend lifestyle modifications and to start antihypertensive therapy at a lower BP level and target a lower BP in 65-year-old patients compared with 85-year-old patients; diuretics and β-blockers were less likely to be used as first-line drugs by respondents in the very old in 2002.22 Evidence indicates that older patients tolerate medications well and do not experience more adverse effects than the young.49 Some older adults, however, initially experience symptoms of orthostatic hypotension as their BP is lowered. A “start low and go slow” approach helps up-titration of antihypertensive medications to achieve a goal BP of <140/90 mm Hg.49 Allowing 4 to 8 weeks of scheduled up-titration when BP is still higher than the goal helps baroreceptors to readjust as the BP stabilizes and symptoms clear.49

The goal of Healthy People 2000 to have BP controlled in 50% of Americans with HTN by the year 2000 was not achieved, and this goal has been reaffirmed to be attained by the year 2010.50 The American Heart Association has established the ambitious goal to reduce coronary heart disease, stroke, and risk by 25% over current levels by 2010.51 According to the JNC 7,1“treatment recommendations for older individuals with hypertension, including those who have isolated systolic hypertension, should follow the same principles outlined for the general care of hypertension.” It is apparent that at the current rate of BP control of 36.8% in US adults with HTN and with the attitude of physician practices about treating HTN in the elderly,22 it is anticipated that the goal of Healthy People 2010 of achieving a BP control rate of 50% may again be unsuccessful. A recent national survey, however, suggests that control rates may be higher than reported in the 2003–2004 surveys.20 To make progress toward attaining successes in these national goals it is imperative that health care professionals, especially primary care physicians who are at the forefront of CV risk reduction, apply evidence-based interventions to treat HTN in older individuals. Diuretics should remain the initial drug of choice for most hypertensive older adults unless compelling indications exist that would dictate the choice of other antihypertensive agents. CCBs are also effective agents in older adults, and ACEIs or angiotensin receptor blockers, when used with a diuretic, will lower BP in this age group.

CONCLUSIONS

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References

Current evidence strongly supports lowering high BP with antihypertensive drugs in older adults with HTN for the prevention of CV events and mortality. Thiazide-type diuretics should be considered as initial therapy for most hypertensive older adults.

References

  1. Top of page
  2. Abstract
  3. EVIDENCE SEARCH AND ACQUISITION
  4. EVIDENCE FOR BENEFITS OF BP-LOWERING IN 65- TO 79-YEAR-OLD PATIENTS
  5. EVIDENCE FOR BENEFITS OF BP-LOWERING IN PATIENTS 80 YEARS AND OLDER
  6. PREHYPERTENSION IS A RISK FACTOR FOR CV DISEASE
  7. INITIAL DRUG THERAPY FOR THE TREATMENT OF HTN IN OLDER ADULTS
  8. BENEFITS OF NEWER ANTIHYPERTENSIVE MEDICATIONS
  9. DISCUSSION
  10. CONCLUSIONS
  11. References
  • 1
    The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:25602572.
  • 2
    Fields LE, Burt VL, Cutler JA, et al. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension. 2004;44:398404.
  • 3
    Borzecki AM, Wong AT. Hickey EC, et al. Hypertension control: how well are we doing? Arch Intern Med. 2003;163:27052711.
  • 4
    Giles TD. Pharmacoeconomic issues in antihypertensive therapy. Am J Cardiol. 1999;84:25K28K.
  • 5
    Hobbs FB, Damon BL. Sixty-five Plus in America. Current Population Reports, Special Studies. Washington, DC: US Department of Commerce, Economics, and Statistics Administration, Bureau of the Census; 1996.
  • 6
    Stamler J, Stamler R, Neaton JD. Blood pressure, systolic and diastolic, and cardiovascular risks. US population data. Arch Intern Med. 1993;153:598615.
  • 7
    Stokes J 3rd, Kannel WB, Wolf PA, et al. Blood pressure as a risk factor for cardiovascular disease. The Framingham Study—30 years of follow up. Hypertension. 1989;13:I13I18.
  • 8
    Van Den Hoogen PC, Feskens EJ, Nagelkerke NJ, et al. The relation between blood pressure and mortality due to coronary heart disease among men in different parts of the world. Seven Countries Study Research Group. N Engl J Med. 2000;342:18.
  • 9
    Martin MJ, Hulley SB, Kuller LH, et al. Serum cholesterol, blood pressure, and mortality: implications from a cohort of 361,662 men. Lancet. 1986;2:933936.
  • 10
    Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:19031913.
  • 11
    Kannel WB, Gordon T, Schwartz MJ. Systolic versus diastolic blood pressure and risk of coronary heart disease. Am J Cardiol. 1971;27:335345.
  • 12
    Dustan HP. 50th anniversary historical article. Hypertension. J Am Coll Cardiol. 1999;33:595597.
  • 13
    Franklin SS, Khan SA, Wong ND, et al. Is pulse pressure useful in predicting risk for coronary heart Disease? The Framingham heart study. Circulation. 1999;100:354360.
  • 14
    Madhavan S, Ooi WL, Cohen H, et al. Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infarction. Hypertension. 1994;23:395401.
  • 15
    Hansson L, Lindholm LH, Ekbom T, et al. Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension 2 study. Lancet. 1999;354:17511756.
  • 16
    SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA. 1991;265:32553264.
  • 17
    Neal B, MacMahon S, Chapman N; Blood Pressure Lowering Treatment Trialists' Collaboration. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs. Lancet. 2000;356:19551964.
  • 18
    Gueyffier F, Bulpitt C, Boissel JP, et al. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomized controlled trials. Lancet. 1999;353:793796.
  • 19
    Ong KL, Cheung BMY, Man YB, et al. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999–2004. Hypertension. 2007;49:6975.
  • 20
    Moser M, Franklin SS. Hypertension management: results of a new national survey for the hypertension education foundation: Harris interactive. J Clin Hypertens (Greenwich). 2007;9:316323.
  • 21
    Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med. 2001;345:479486.
  • 22
    Hajjar I, Miller K, Hirth V. Age-related bias in the management of hypertension: a national survey of physicians' opinions on hypertension in elderly adults. J Gerontol A Biol Sci Med Sci. 2002;57:M487M491.
  • 23
    Applegate WB. Hypertension in elderly patients. Ann Intern Med. 1989;110:901915.
  • 24
    Amery A, Birkenhager W, Brixko P, et al. Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet. 1985;1(8442):13491354.
  • 25
    Coope J, Warrender TS. Randomised trial of treatment of hypertension in elderly patients in primary care. BMJ. 1986;293:11451151.
  • 26
    Dahlöf B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-HTN). Lancet. 1991;338:12811285.
  • 27
    MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ. 1992;304:405412.
  • 28
    Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. Lancet. 1997;350:757764.
  • 29
    Liu L, Wang JG, Gong L, et al. Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Systolic hypertension in China (Sys-China) Collaborative Group. J Hypertens. 1998;16:18231829.
  • 30
    Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic HTN in the elderly: meta-analysis of outcome trials. Lancet. 2000;355(9207):865872.
  • 31
    He J, Whelton PK. Elevated systolic blood pressure as a risk factor for cardiovascular and renal disease. J Hypertens Suppl. 1999;17:S7S13.
  • 32
    Forette F, Seux ML, Staessen JA, et al. Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet. 1998;352(9137):13471351.
  • 33
    Forette F, Seux ML, Staessen JA, et al. Systolic Hypertension in Europe Investigators. The prevention of dementia with antihypertensive treatment: new evidence from the Systolic HTN in Europe (Syst-Eur) study. Arch Intern Med. 2002;162:20462052.
  • 34
    News and events. Imperial College London. Trial stops after stroke and mortality significantly reduced by blood pressure-lowering treatment for elderly patients. http://www1.ic.ac.uk/medicine/news/p70708/ Accessed September 20, 2007.
  • 35
    Bulpitt CJ, Fletcher AE. Prognostic significance of blood pressure in the very old. Implications for the treatment decision. Drugs Aging. 1994;5:184191.
  • 36
    Lernfelt B, Svanborg A. Change in blood pressure in the age interval 70–90. Late blood pressure peak related to longer survival. Blood Press. 2002;11:206212.
  • 37
    Amery A, Birkenhager W, Brixko P, et al. Influence of antihypertensive drug treatment on morbidity and mortality in patients over the age of 60 years. European Working Party on High blood pressure in the Elderly (EWPHE) results: sub-group analysis on entry stratification. J Hypertens Suppl. 1986;4(suppl 6):S642S647.
  • 38
    Bulpitt CJ, Fletcher AE, Amery A, et al. The Hypertension in the Very Elderly Trial (HYVET). J Hum Hypertens. 1994;8:631632.
  • 39
    Bulpitt CJ, Fletcher AE, Amery A, et al. The Hypertension in the Very Elderly Trial (HYVET). Drugs Aging. 1994;5:171183.
  • 40
    Bulpitt CJ, Beckett NS, Cooke J, et al. Hypertension in the Very Elderly Trial Working Group. Results of the pilot study for the Hypertension in the Very Elderly Trial. J Hypertens. 2003;21:24092417.
  • 41
    Bowman TS, Sesso HD, Glynn RJ, et al. JNC 7 category and risk of cardiovascular death in men: are there differences by age? Am J Geriatr Cardiol. 2005;14:126131.
  • 42
    Liszka HA, Mainous AG 3rd, King DE, et al. Prehypertension and cardiovascular morbidity. Ann Fam Med. 2005;3:294299.
  • 43
    Mainous AG 3rd, Everett CJ, Liszka H, et al. Prehypertention and mortality in a nationally representative cohort. Am J Cardiol. 2004;94:14961500.
  • 44
    Psaty BM, Smith NL, Siscovick DS, et al. Health outcomes associated with antihypertensive therapies used as first-line agents. A systematic review and meta-analysis. JAMA. 1997;277:739745.
  • 45
    ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:29812997.
  • 46
    Lindholm LH, Carlberg B, Samuelsson O. Should β-blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet. 2005;366:15451553.
  • 47
    Fischer MA, Avorn J. Economic Implications of Evidence-Based Prescribing for HTN Can Better Care Cost Less? JAMA. 2004;291:18501856.
  • 48
    Malacco E, Mancia G, Rappelli A, et al. SH ELL Investigators. Treatment of isolated systolic hypertension: the SHELL study results. Blood Press. 2003;12:160167.
  • 49
    Moser M, Alderman MH, Wright JT Jr. Roundtable discussion: Clinical problems in the management of hypertension 1) Prehypertension: should we treat? 2) The very elderly: how should we treat. J Clin Hypertens (Greenwich). 2004;6:262266.
  • 50
    Healthy People 2010: Understanding and improving Health. 2nd ed. US Department of Health and Human Services. Washington, DC: US Government Printing Office. November 2000.
  • 51
    Smaha LA. From bench to bedside: the future is now. Presented at the 72nd Scientific Sessions of the American Heart Association, Atlanta, Georgia. Circulation. 2000;101:942945.