Treating hypertension in the elderly: protagonist viewpoint

Cardiovascular disease is the main cause of serious illness and death in the United States. Increasing age is a strong predictor of cardiovascular events, driven largely by such major conditions as hypertension and diabetes mellitus. Systolic hypertension probably reflects progressive stiffening of large and small arteries; close to 90% of all Americans will have this diagnosis by their 80s. Regardless of age, systolic hypertension is a powerful risk factor for stroke, heart failure, and other cardiovascular outcomes. Treating hypertension in the elderly sharply decreases the probability of these events. Clinical trial evidence does not include patients with stage 1 systolic hypertension (140–159 mm Hg), although the results in stage 2 are so convincing that it is very reasonable (as concluded by national guidelines committees) to extrapolate benefits and recommend treatment to patients in the less-severe group. Whereas evidence of treatment benefits in patients aged 80 years and older is limited, sufficient octogenarians have been studied to confidently assert that strokes, at least, can be prevented. Another potentially important benefit that is yet to be fully confirmed is that treating hypertension in older people may also reduce the incidence of dementia.     

老年难治性高血压

老年高血压的诊断也以收缩压(SBP)≥140mmHg和／或舒张压(DBP)≥90mmHg作为标准，单纯收缩期高血压(ISH)多见。随着增龄，老年人心脏收缩力下降，心排血量降低；主动脉及其主要分支的弹性降低，顺应性下降外周血管阻力逐渐升高；主动脉壁的可膨胀性在心脏收缩时也下降，脉压增大，收缩压较舒张压增高更明显。     

老年收缩期高血压研究(SHEP)

标　　题　抗高血压药物对老年收缩期高血压患者脑卒中的预防作用,老年收缩期高血压研究最终结果作　　者　该项目协作研究组。　　参考文献　ＪＡＭＡ,1991,265,3255～3264研究的疾病　高血压病。目　　的　评估抗高血压药物对老年收缩期高血压患者脑卒中的预防作用。设　　计　随机、双盲、安慰剂对照、多中心研究。病人资料　4736例年龄≥60岁的患者,入选时收缩压160～219ｍｍＨｇ,舒张压<90ｍｍＨｇ,无心血管疾病及其他严重疾病史。入选患者随机分为治疗组(2365例)及对照组(2371例)。随　　访　平均4.5年。治疗方案　目标血压是原收缩压…     

Isolated systolic hypertension in the elderly

Opinion statement Isolated systolic hypertension (ISH) is the predominant form of hypertension in persons older than 50 years, who represent the majority of individuals with hypertension. Systolic blood pressure (SBP) determines Joint National Committee blood pressure stage, and therefore the need for therapy, far more often than diastolic blood pressure (DBP). SBP consistently is associated with greater risk for overall mortality, coronary heart disease, stroke, congestive heart failure, renal failure, and other end points. In addition, clinicians are far less aggressive and less successful at controlling SBP compared with DBP. Thus, SBP should be acknowledged as the major criterion that determines diagnosis, staging, and therapeutic management in older individuals. Several recent large, randomized, placebo-controlled trials of drug therapy targeting ISH in the elderly have shown dramatic reductions in cardiovascular end points and mortality. The treatment of patients with ISH must occur within the framework of the larger goals associated with treatment of hypertension generally. Lifestyle modification, including salt restriction and increasing physical activity, may contribute to improvements in arterial compliance and control of ISH in particular. In clinical trials, most antihypertensive agents decrease SBP more than DBP. However, certain drug classes, such as angiotensin-converting enzyme inhibitors and nitrates, have advantageous properties that may make them particularly useful for the treatment of ISH.     

Treating systolic hypertension in the very elderly with valsartan-hydrochlorothiazide vs. either monotherapy: ValVET primary results

J Clin Hypertens (Greenwich). 2011;13:722–730. ©2011 Wiley Periodicals, Inc.This 16‐week trial investigated the efficacy and safety of single‐pill valsartan/hydrochlorothiazide (HCTZ) vs the individual components in patients 70 years and older with systolic hypertension. Patients were randomized to valsartan/HCTZ 160/12.5 mg (n=128), HCTZ 12.5 mg (n=128), or valsartan 160 mg (n=128) for 4 weeks. Patients whose blood pressure (BP) was ≥140/90 mm Hg at weeks 4, 8, or 12 were up‐titrated to a maximum of valsartan/HCTZ 320/25 mg. Week 4 systolic BP reduction (primary efficacy outcome) was greater with valsartan/HCTZ than valsartan (−17.3 mm Hg vs −8.6 mm Hg, P <.0001) but only marginally greater than HCTZ (−13.6 mm Hg, P =.096). Median time to BP control was shorter with valsartan/HCTZ (4 weeks) vs HCTZ (8 weeks, P<.05) or valsartan (12 weeks, P<.0001). Thiazide monotherapy was more effective than angiotensin receptor blocker monotherapy (by about 5 mm Hg), but greater antihypertensive efficacy was achieved by initiating treatment with combination valsartan/HCTZ in the elderly.

The prevalence of hypertension increases with advancing age, from about 7% in individuals aged 18 to 39 years to 66% in those 60 years or older, largely as a result of the steady increase in systolic blood pressure (SBP) with age. ¹ , ² Blood pressure (BP) control rates in older individuals remain low, in part because of the difficulty in controlling SBP: only one third of individuals with hypertension older than 60 years have BP values <140/90 mm Hg (or <130/80 mm Hg in diabetics). ² The value of antihypertensive therapy in older individuals is clearly established. The Systolic Hypertension in the Elderly Program (SHEP) ³ and the Medical Research Council studies ⁴ proved that diuretic‐based therapy reduces rates of stroke and myocardial infarction in older hypertensive patients. More recently, the Hypertension in the Very Elderly Trial (HYVET) proved that mortality and cardiovascular disease rates could be reduced in persons 80 years or older. ⁵ In general, ≥2 antihypertensive agents are needed to achieve BP goals, ⁶ , ⁷ but there is a general reluctance by clinicians to initiate combination therapy in older patients, often because of perceived safety concerns such as orthostatic hypotension. ⁸ Reasons to choose different drug classes may differ with age. For example, older people with hypertension usually have lower plasma renin activity (PRA) compared with younger people with hypertension. ⁹ Although largely unproven by clinical trial data, recent European and British Hypertension Society guidelines suggest that blockers of the renin‐angiotensin system (RAS), including angiotensin‐converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), are less effective in individuals older than 55 years. ⁶ , ¹⁰ An ARB/diuretic combination was somewhat better than ARB monotherapy in a secondary analysis of individuals younger than 65 years, ¹¹ , ¹² but no study to date has directly compared a RAS blocker with a diuretic in an elderly cohort.The Valsartan Very Elderly Trial (ValVET) is the first prospective trial in individuals 70 years or older that compares: (1) efficacy and safety of initial combination therapy with valsartan and hydrochlorothiazide (HCTZ) with either component as monotherapy; and, (2) HCTZ with ARB monotherapy.     

Treatment of hypertension in the elderly

Investigation of preventive measures for hypertension and atherosclerosis is a geriatric medicine priority. While the causes of both isolated systolic hypertension and conventional systolic and diastolic hypertension in the elderly are well defined, the benefits of lowering blood pressure are not. Evidence to support the treatment of symptomatic hypertension is convincing for men 60 years of age; it is not for women in this age group. The need to treat hypertension, particularly isolated systolic hypertension in patients above 75 years old, is still not resolved. Isolated systolic hypertension in older patients is at least as strong a risk factor for cardiovascular disease as is diastolic hypertension. Ongoing trials may answer these questions; in the meantime, drug therapy in this group will vary widely. The elderly hypertensive is more likely than the younger hypertensive to have other diseases; diagnosis of these disorders is crucial. Hypertension arising de novo late in life warrants a search for underlying and possibly remedial causes. Antihypertensive drug therapy to relieve symptoms is difficult to justify, because most elderly hypertensive patients are asymptomatic; however, it has been shown to delay morbid and fatal complications of hypertension. Appropriate therapy for the elderly hypertensive must be individualized and should be associated with few or no side effects. The thiazides are the preferred diuretics for long-term treatment of hypertension in the elderly. Beta blockers are attractive because they are cardioprotective, counter the end organ effect of catecholamines and reduce angina; however, some decrease cardiac output, increase peripheral resistance, decrease renal blood flow and cause fatigue.(ABSTRACT TRUNCATED AT 250 WORDS)     

High renin hypertension in the elderly

This paper describes clinical features of high renin hypertension in the elderly. Peripheral plasma renin activity ranged from 0 to 20.1 ng/ml/hr in 59 hypertensive in-patients aged 70 to 86. The patients were divided into 2 groups: 9 cases with plasma renin activity greater than or equal to 3.0 ng/ml/hr (high renin group) and the remaining 50 with plasma renin activity less than 3.0 ng/ml/hr (control group). The development of hypertension differed between the 2 groups. Six of the high renin group (66.7%) had a history of acceleration of previously mild hypertension, while only 3 of the control group (6.0%) had this history (p less than 0.01). The frequencies of high diastolic blood pressure (greater than or equal to 120 mmHg), massive proteinuria (at least 3.0 g/day), hypokalemia (serum potassium less than or equal to 3.0 mEq/L) and high serum cholesterol (greater than or equal to 250 mg/100 ml) were significantly greater in the high renin group than in the control group (p less than 0.01, respectively). Renovascular hypertension was suspected in 6 patients from the high renin group (66.7%), as compared with 1 of the control group (2.0%) (p less than 0.001). There was massive proteinuria in 3 of 6 patients with renovascular hypertension in the high renin group and 2 showed nephrotic syndrome. Thus, two-thirds of the elderly patients with high renin hypertension had probable renovascular hypertension with a history of rapid progression of hypertension.     

Treatment of hypertension in the elderly

Summary Treatment of hypertension in the elderly is beneficial, and benefit exceeds risk, but in some individuals it may be difficult to decrease blood pressure to goal or normotensive levels. Recent data suggest that the use of diuretics and, in some instances, beta-adrenergic inhibitors will reduce morbidity and mortality in elderly hypertensives and will probably not alter metabolic parameters to a clinically significant degree in most individuals.     

Treatment of hypertension in the elderly

Numerous double-blind, randomized, placebo-controlled studies have shown that antihypertensive drug therapy reduces cardiovascular events in elderly persons. In the Hypertension in the Very Elderly Trial, patients aged 80 years and older treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30 percent reduction in fatal or nonfatal stroke, a 39 percent reduction in fatal stroke, a 21 percent reduction in all-cause mortality, a 23 percent reduction in death from cardiovascular causes, and a 64 percent reduction in heart failure. The goal of treatment of hypertension in elderly persons is to lower the blood pressure to less than 140/90 mmHg and to less than 130/80 mmHg in older persons with diabetes or chronic renal insufficiency. All antihypertensive drugs may predispose the elderly person to develop symptomatic orthostatic hypotension and postprandial hypotension and syncope or falls. Adverse effects depend upon the antihypertensive drugs used, the doses of these drugs, the comorbidities in the elderly patients taking these drugs, and drug-drug interactions.     

Pathophysiology of hypertension in the elderly

Combined systolic and diastolic arterial hypertension and isolated systolic hypertension in the elderly are proven risk factors for stroke, sudden death, coronary artery disease, and congestive heart failure. Because hemodynamics, vascular and cardiac adaptations, fluid volume, and endocrine functions are distinctly altered in the elderly hypertensive patient compared with a younger patient, antihypertensive treatment should be individualized, and an unsophisticated regimen, such as a stepped-care approach, is too rigid to be as beneficial for elderly hypertensive patients as for young hypertensive patients.