Hypertension targets in the elderly

Successful hypertension treatment decreases risk for adverse outcomes among lower-risk and younger patient groups; however, for the very old (>80 years), results have been conflicting. Additionally, for the very old with hypertension and coronary disease, information is very limited.

In the International Verapamil SR Trandolapril Study 22 576 patients with clinically stable hypertensive coronary artery disease were enrolled, and almost 10% were aged >80. The main result of the study was that β blocker and calcium antagonist-based treatments were similarly effective in lowering blood pressure and equivalent for reducing risk of adverse outcomes. For this reason the authors combined the two groups and in a prespecified subgroup analysis, examined the risk of a composite primary outcome of all-cause death, first incidence of non-fatal myocardial infarction, or non-fatal stroke, stratifying the cohort for age in 10-year increments (aged ≥80, n=2180; 70–<80, n=6126; 60–<70, n=7602; <60, n=6668). At baseline, increasing age was associated with higher systolic blood pressure, lower diastolic blood pressure and wider pulse pressure (p<0.001).

After 61 835 total patient-years of follow-up, treatment decreased systolic, diastolic and pulse pressure for each age group to an equivalent degree. However, the very old retained the widest pulse pressure and were the highest proportion (23.6%) with the primary outcome (p80 the HR nadir was 140 mm Hg, and as the curve was j-shaped, in this age group the hazard of the primary outcome was almost the same at a systolic pressure of 160 mm Hg as it was at 120 mm Hg (figure 1).

Conclusion
In this study examining hypertension treatment in the elderly, no difference in morbidity and mortality between antihypertensive drug treatment strategies was identified, but a strong suggestion of increased risk associated with lower pressures as age increased was confirmed. Until more data become available it would seem that caution is in order when either systolic or diastolic blood pressure is lowered below 140 and 70 mm Hg respectively in the elderly figure 1.

Figure 1
Adjusted hazard ratio as a function of age, systolic and diastolic blood pressure. DBP, diastolic blood pressure; SNP, systolic blood pressure.

▶ Denardo SJ, Gong Y, Nichols WW, et al. Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. Am J Med 2010;123:719–26

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