Hypertension treatment and the prevention of coronary heart disease in the elderly

Both isolated systolic hypertension (>140 mm Hg/<90 mm Hg) and systolic/diastolic hypertension (>140 mm Hg/>90 mm Hg) are major risk factors for cardiovascular disease in the elderly. Specific antihypertensive drug therapy is available if lifestyle interventions fail to reduce blood pressure to a normal level. Diuretics and beta blockers both reduce the occurrence of adverse events related to cerebrovascular disease; however, diuretics are more effective in reducing events related to coronary heart disease. Treated patients are less likely to develop severe hypertension or congestive heart failure. In most instances, low-dose diuretic therapy should be used as initial antihypertensive therapy in the elderly. A long-acting dihydropyridine calcium channel blocker may be used as alternative therapy in elderly patients with isolated systolic hypertension. Trials are being conducted to evaluate the long-term effects of angiotensin converting enzyme inhibitors and angiotensin-II receptor blockers in elderly patients with uncomplicated hypertension.     

Unique dual mechanism of action of eprosartan: effects on systolic blood pressure, pulse pressure, risk of stroke and cognitive decline

Hypertension is a common condition associated with considerable morbidity and mortality. Antihypertensive drugs reduce the risk of cardiovascular and cerebrovascular events, and may also be associated with reductions in cognitive decline. Eprosartan is an angiotensin II type 1 receptor antagonist with a unique dual mechanism of action that is approved for the treatment of essential hypertension. In clinical trials, eprosartan has been shown to significantly reduce systolic blood pressure and to be associated with significant reductions in pulse pressure in elderly patients with isolated systolic hypertension. Data suggest that blood pressure reductions achieved with eprosartan in elderly hypertensive patients are also associated with improvements in cognitive function. Eprosartan compares favorably with other classes of antihypertensive agents in terms of reductions in mortality, cardiovascular and cerebrovascular events, and stroke recurrence. Evidence suggests that eprosartan may represent a useful addition to combination drug strategies for the management of hypertensive patients with elevated cardiovascular and cerebrovascular risk.     

Hypertension in elderly patients. The special concerns in this growing population.

Hypertension is quite common in the elderly population. Isolated systolic hypertension and diastolic hypertension are associated with cardiovascular complications. Like younger patients, the elderly may have labile hypertension. On the other hand, pseudohypertension, auscultatory gap, and postural hypotension are peculiar to the elderly. Obesity, atherosclerosis, arteriosclerosis, baroreceptor insensitivity, decline in renal function, physical inactivity, and insomnia are factors that can lead to or aggravate hypertension in older patients. Secondary hypertension should be suspected if elevated blood pressure first appears late in life or becomes resistant to previously adequate treatment. Spontaneous hypokalemia can indicate primary aldosteronism. Elevation in the serum creatinine level of a patient taking an angiotensin-converting enzyme (ACE) inhibitor suggests bilateral renovascular hypertension. The goal of antihypertensive therapy is to prevent morbidity, disability, and death from complications and to maintain quality of life. Psychosocial factors may play an important role in controlling hypertension. Nonpharmacologic treatment, such as weight loss, salt restriction, and exercise, should always be tried prior to and in conjunction with medical therapy. Antihypertensive drugs often cause side effects and should be prescribed with caution. Always start with a low dose and gradually increase it if necessary. All drugs that reduce blood pressure in the younger individual also work in the elderly. ACE inhibitors and calcium blockers are particularly useful because of their low incidence of adverse effects.     

Antihypertensive therapy in the elderly

Control of hypertension in the elderly has been shown to reduce cardiovascular morbidity. Although it is not known if this is also true for isolated systolic hypertension, drug treatment should be considered for systolic pressures over 170 mm Hg that cannot be controlled with nondrug therapy. The diuretics, calcium channel blockers, and the ACE inhibitors are very effective and generally well-tolerated therapy for the elderly. It may be necessary to combine two of these agents for some patients. Beta blockers are particularly useful for patients with ischemic heart disease or prior myocardial infarction. Beta blockers are the only agents which have been shown to be cardioprotective. For all antihypertensive agents, the elderly should be started on low doses. The drugs should then be titrated slowly if necessary. It is common for the elderly to respond to lower dosages than younger patients, and they should be monitored carefully for adverse reactions to medications. Antihypertensives should be administered once or twice daily whenever possible. If these principles are considered, most patients can be effectively controlled with a minimum of side effects.     

Intervention trials for elderly hypertension in Western countries

Many large-scale intervention trials performed in Western countries have proven the necessity of treatment of hypertension in the elderly, including isolated systolic hypertension. However, it is still unclear the benefit of antihypertensive treatment in mild hypertensive patients and that in very elderly patients with hypertension. An ongoing clinical trial, the Hypertension in the Very Elderly Trial (HYVET), may clarify whether or not antihypertensive treatment is beneficial in the very elderly. Regarding target blood pressure, there is no clinical study in which average of systolic blood pressure at the end of study decreased lower than 140 mmHg. Regarding the first-line drugs for elderly hypertension, usefulness of diuretics and calcium channel blockers has been demonstrated in studies with placebo control group. Usefulness of inhibitors of the rennin-angiotensin system has been also reported in LIFE substudy and ANBP2. It is still required to perform large scale trials in the elderly hypertension to answer these undissolved problems.     

Hypertension in aging patients

Hypertension, especially isolated systolic hypertension, is commonly found in older (60-79 years of age) and elderly (≥80 years of age) people. Antihypertensive drug therapy should be considered in all aging hypertensive patients, as treatment greatly reduces cardiovascular events. Most classes of antihypertensive medications may be used as first-line treatment with the possible exception of α- and β-blockers. An initial blood pressure treatment goal is less than 140/90 mmHg in all older patients and less than 150/80 mmHg in the nonfrail elderly. The current paradigm of delaying therapeutic interventions until people are at moderate or high cardiovascular risk, a universal feature of hypertensive patients over 60 years of age, leads to vascular injury or disease that is only partially reversible with treatment. Future management will likely focus on intervening earlier to prevent accelerated vascular aging and irreversible arterial damage.     

Treatment of isolated systolic hypertension in the elderly

Systolic hypertension is a major health economy problem within our aging society. Increased arterial stiffness is the vascular phenotype of systolic hypertension, especially of the large arteries. Elevated systolic blood pressure is even more associated with cardiovascular morbidity and mortality than diastolic blood pressure. Treatment of systolic hypertension in the elderly should be based on nonpharmacological measures and medical therapy if the systolic hypertension cannot be controlled by conservative therapy alone. The HYVET study provided evidence-based medicine data showing that, in the very elderly, lowering blood pressure to a level of 150/80 mmHg is still very beneficial. Antihypertensive therapy needs to be tailored in the elderly because of comorbid conditions, such as ischemic heart disease, heart failure, atrial fibrillation, renal insufficiency and diabetes. Angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers should be considered in combination with diuretics or with a dihydropyridine calcium antagonist. β-blockers seem to be less effective for cardiovascular disease protection in comparison with other antihypertensive drug classes, such as diuretics, dihydropyridines, angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers. Major effort is required to reduce the therapeutic inertia and increase therapeutic adherence for better blood pressure control in the elderly with systolic hypertension.     

Myths about hypertension in the elderly

Many of the traditional concepts concerning hypertension in the elderly have turned out to be myths. Large randomized clinical trials have shown that antihypertensive therapy reduces the risk of cardiovascular mortality for elderly patients with diastolic hypertension. Elderly patients adhere well to prescribed regimens and they tolerate antihypertensive drugs as well as younger patients do. An oral diuretic is the agent of choice to initiate treatment for elderly patients with either diastolic or isolated systolic hypertension.     

Hypertension in the elderly

As many as forty percent of Canadians over age sixty-five have blood pressure readings of 160/90 or higher. They are at greater risk for stroke, congestive heart failure, myocardial infarction and sudden death. Hypertension appears to be an exaggeration of the normal circulatory changes of aging--increased systemic vascular resistance and a slight decrease in cardiac output at rest and during exercise. The major trials of treatment for hypertension have included subsets of elderly hypertensives who have enjoyed about the same overall benefit from treatment as younger subjects. Two treatment trials specifically for elderly hypertensives also show that treating systolic-diastolic hypertension does more good than harm. Isolated systolic hypertension appears to be a risk factor of equal magnitude to systolic/diastolic hypertension. Although it is possible to treat isolated systolic hypertension, the definitive clinical trial comparing mortality and morbidity in treated and untreated groups is not yet published. Thiazides, while inexpensive and effective antihypertensives for the elderly, are relatively contraindicated in as many as half. Other classes of drugs, particularly calcium channel blockers, can be effective alternatives. Many, if not most, elderly hypertensives will be prescribed more than one type of antihypertensive in addition to other types of drugs. The possibility of drug interactions as well as the danger of overly rapid blood pressure reduction must be kept in mind.     

Osmo-adalat in the treatment of isolated systolic and systolic-diastolic arterial hypertension in aged patients

AIM: To examine efficiency and tolerance of osmo-adalat in monotherapy of mild and moderate arterial hypertension (AH) in the elderly. MATERIAL AND METHODS: 60 AH patients were randomized into two groups. Group 1 received osmo-adalat monotherapy in daily dose 30 mg for 3 weeks. These were 14 patients with isolated systolic AH (ISAH) and 16 patients with essential hypertension (EH). Of group 2 patients, 15 with ISAH and 15 with EH received cordipin in a dose 10 mg three times a day. All the patients underwent 24-h monitoring of arterial pressure, in 18 patients arterial pressure and ECG were registered in parallel for 24 hours. RESULTS: AH treatment with osmo-adalat is rather effective. This is proved by its positive effect on shifted profile of arterial pressure in patients with ISAH and EH. A fall of arterial pressure on the peak of osmo-adalat antihypertensive action is not associated with hypotonic overloading of target organs, myocardial ischemia and increased heart rate. A single intake of osmo-adalat provides a smooth circadian control of arterial pressure in elderly hypertensive patients, the end effect being 50% of the peak one. The drug is well tolerated. Side effects do not require osmo-adalat discontinuation. CONCLUSION: Osmo-adalat in a single daily dose 30 mg is effective and safe in the treatment of mild and moderate AH in elderly patients.     

Treatment of hypertension in the elderly

We have evaluated the effectiveness of antihypertensive therapy for predominant systolic hypertension in 55 patients, aged 61 to 76 years, with untreated systolic blood pressures of at least 160 mm Hg and diastolic blood pressures less than 100 mm Hg. In this retrospective analysis, 41 of the patients had been treated with the centrally acting agent guanabenz (average dose 24 +/- 14 [SD] mg daily) given alone, and 14 had received a combination of guanabenz (17 +/- 10 mg daily) and hydrochlorothiazide (60 +/- 30 mg daily). After six months of therapy, each regimen significantly decreased both systolic and diastolic blood pressures. Moreover, there were no differences between the two treatment regimens in their antihypertensive efficacy, and there was no evidence of orthostatic effects. In both treatment groups, approximately 50% of the patients had excellent therapeutic responses (decrease in supine systolic blood pressure of at least 20 mm Hg). The main side effects of treatment were drowsiness and dry mouth, though these tended to be mild and of short duration. Thus, in predominant systolic hypertension in elderly patients, guanabenz, either alone or in combination with a diuretic, appears to be an effective and well tolerated form of treatment.     

Current approaches to the treatment of hypertension in older persons

Hypertension is a major risk factor for cardiovascular disease and is present in 69% of patients with a first myocardial infarction, in 77% of patients with a first stroke, in 74% of patients with chronic heart failure, and in 60% of patients with peripheral arterial disease. Double-blind, randomized, placebo-controlled trials have demonstrated that antihypertensive drug therapy reduces cardiovascular events in patients aged 65 to 79 years. In the Hypertension in the Very Elderly Trial, patients aged ≥ 80 years who were treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30% reduction in fatal or nonfatal stroke (P = 0.06), a 39% reduction in fatal stroke (P = 0.05), a 21% reduction in all-cause mortality (P = 0.02), a 23% reduction in cardiovascular death (P = 0.06), and a 64% reduction in heart failure (P < 0.001). Although the optimal blood pressure (BP) treatment goal in the elderly has not been determined, existing epidemiologic and clinical trial data suggest that a reasonable therapeutic BP goal should be < 140/90 mm Hg in persons aged < 80 years and a systolic BP of 140 to 145 mm Hg if tolerated in persons aged ≥ 80 years. Nonpharmacologic lifestyle measures should be encouraged both to prevent development of hypertension and as adjunctive therapy in persons with hypertension. Diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and calcium channel blockers have all shown benefit in reducing cardiovascular events in randomized trials. The choice of specific drugs depends on efficacy, tolerability, presence of specific comorbidities, and cost. Adverse effects from treatment, such as electrolyte disturbances, renal dysfunction, and excessive orthostatic BP reduction, should be avoided.     

Geriatric hypertension

Hypertension in the elderly is a frequent occurrence and is associated with an increase in cardiovascular complications. Therapeutic drug intervention in diastolic-systolic hypertension is both safe and effective in decreasing cardiovascular morbidity and mortality. Convincing evidence supporting the value of therapeutic intervention in isolated systolic hypertension is not yet available. At present, selection of specific antihypertensive drugs remains empirical because of insufficient controlled trials in elderly hypertensives. Antihypertensive agents should be initiated in smaller dosages and titrated upward slowly with particular care in avoiding orthostatic hypotension. Above all, lifestyle modification should be kept to a minimum and special attention should be given to the patient's quality of life while on drug treatment.     

Antihypertensive Therapy for the Elderly: An Expert System to Assist Therapeutic Decisions

The prevalence of hypertension among the elderly is high. Recent multicenter studies have shown hypertension, especially isolated systolic hypertension, to be a risk factor and treatment to be elective, if individualized. In addition, the presence of multiple complicating conditions and the need for multiple medications in the elderly increases the required medical knowledge base necessary to appropriately determine antihypertensive therapy. To assist the primary provider, an expert system has been developed that provides advice on therapeutic decisions for elderly patients (greater than 65 years old and less than 85 years old). It takes into account such factors as age, sex, lifestyle, site of care, nutritional status, physiologic and pathophysiologic changes, co-existing diseases, multiple drug use, and prior antihypertensive drug exposure and response. The system user enters patient characteristics, disease states, risk factors, relevant laboratory values, and prior drug therapy. The system responds with a set of recommendations of appropriate therapy individualized for the specific patient. To further assist the process, relative costs of therapy are also included. The system, consisting of over 200 rules, is currently undergoing validation by a panel of cardiologists. It is implemented in IBM's Expert System Environment (ESE) on the IBM 4341. The authors wish to acknowledge the contribution of the ESE software by the IBM Corporation.     

Correction of sleep disorders and efficacy of antihypertensive monotherapy in elderly patients: use of ivadal]

AIM: To assess effects of ivadal (zolpidem) on arterial pressure (AP) in the cycle sleep-awake in aged patients with insomnia who have failed hypotensive monotherapy with different drugs, i.e. whose AP remained abnormal at night. MATERIALS AND METHODS: The trial included 25 aged patients (17 females, 8 males, mean age 66.4 +/- 3.7 years) with isolated systolic arterial hypertension (AH) of the first-second degree (WHO classification, 1999) and insomnia. AH duration averaged 8.7 +/- 3.7 years. All the patients have received antihypertensive monotherapy. As shown by the initial 24-h monitoring, patients with elevated night AP had significantly lower mean score by the questionnaire "Subjective Sleep Characteristics" and more frequently suffer from insomnia. These patients were given a hypnotic drug ivadal (zolpidem) in a single daily dose 5 mg in the evening for 10 days. On the treatment night 10 monitoring of AP was repeated. RESULTS: Ivadal treatment has significantly improved all the subjective parameters of sleep and 24-h AP profile, lowered sleep and awake AP. CONCLUSION: Ivadal treatment raises efficacy of a hypotensive monotherapy in aged patients with isolated systolic AH and insomnia.     

Hypertension in the elderly

Hypertension in the elderly may be of the classical or isolated systolic type. The former is amenable to therapy, and reduction in blood pressure clearly decreases morbidity and mortality. Isolated systolic hypertension is an undesirable risk factor, but the effectiveness of antihypertensive therapy for the problem is as yet unknown. Although various physiologic parameters change with age, diuretics, methyldopa, and beta-adrenergic blockers are generally safe in the elderly and are recommended.     

Effects of amlodipine, a long-acting dihydropyridine calcium antagonist in aging hypertension: pharmacodynamics in relation to disposition

Pharmacodynamics and disposition of amlodipine, a dihydropyridine calcium antagonist, were compared between elderly and young patients with hypertension. Elderly (mean +/- SD; age, 68 +/- 3 years) and young (35 +/- 5 years) patients received single intravenous amlodipine doses followed by oral administration once daily for a total of 12 weeks. After intravenous administration, elderly patients had prolonged elimination half-life values (58 +/- 11 versus 42 +/- 8 hours; p less than 0.01) caused by decreased clearance (19 +/- 5 versus 25 +/- 7 L/hr; p less than 0.01). After a 3-months oral treatment washout period, half-life tended to be prolonged in the elderly patients (69 +/- 20 hours for the elderly patients versus 53 +/- 14 hours for the young patients; difference not significant) and was not markedly different from the short-term intravenous measurement. Both systolic and diastolic blood pressure were significantly decreased from baseline throughout the treatment period, with greater decreases in elderly patients for both systolic and diastolic pressure. When amlodipine plasma concentration was correlated to change in mean blood pressure after short-term intravenous doses, elderly patients had a greater decrease than young patients at a given drug concentration. However, after long-term oral administration, elderly and young patients had comparable decreases in mean blood pressure at a given drug concentration, and the increased antihypertensive effect in the elderly was associated with somewhat higher amlodipine plasma concentration. Amlodipine administered once daily is an effective antihypertensive agent in elderly patients and young patients with essential hypertension.     

Maximizing antihypertensive management in the elderly

The management of hypertension in the elderly is safer and more effective if we consider diurnal fluctuations in blood pressure, preexisting postural and postprandial hypotension, and coronary risk when setting therapeutic goals and selecting or adjusting antihypertensive medications. Lifestyle modifications should coincide with drug therapy in the management of elderly hypertensive patients. The author suggests a checklist of specific considerations when treating hypertension in the elderly.     

降压药物联用治疗老年性单纯收缩期高血压效果

目的探讨联合应用降压药物治疗老年性单纯收缩期高血压的效果。方法对48例老年性单纯收缩期高血压、服用单一药物血压控制不良病人联合应用降压药物治疗，缬沙坦80mg每日1次早6：00时服用，伲福达10mg每日1次晚饭前服。分别于联合用药前和用药1个月后测血压值并进行比较。结果联合应用降压药物前后收缩压比较差异有显著性（t=5．217，P〈0．01）．而舒张压比较差异无显著性（t=1．354．P〉0．05）。结论缬沙坦、伲福达联合应用治疗老年性单纯收缩期高血压效果较好，尤其是对服用单一药物血压控制不良者。     

坎地沙坦对轻中度高血压患者颈动脉重构的影响

目的:观察以坎地沙坦为基础的降压治疗对原发性高血压患者颈动脉内中膜厚度、内中膜厚度/血管内径的影响,探讨坎地沙坦降血压以外的心血管保护作用。方法:63例1～2级原发性高血压患者,超声检测其颈动脉的内中膜厚度和内径,给予以坎地沙坦为基础的降压治疗,根据患者血压的反应加用小剂量的氢氯噻嗪,6个月后超声复查颈动脉情况。结果:63例原发性高血压患者,收缩压在治疗前为(155.08±7.926)mm Hg,治疗6个月后为(128.44±3.509)mm Hg;舒张压治疗前(96.06±4.586),治疗6个月后(81.24±4.257)mm Hg;心率治疗前为(77.21±7.565)次/min,治疗6个月后为(72.79±3.976)次/min,治疗前、后比较差异有统计学意义(P<0.05)。治疗6个月后,内中膜厚度较治疗前减少(0.088±0.046)mm,内径较治疗前增加(0.138±0.069)mm,内中膜厚度/血管内径较治疗前减少(0.032±0.020),差异均有统计学意义(P<0.01)。结论:以坎地沙坦为基础,加用小剂量利尿剂的降压方案具有良好的临床效果,具有确切的改善动脉粥样硬化作用。