Implantable cardioverter-defibrillators should be used routinely in the elderly

Implantable cardioverter-defibrillators (ICDs) reduce mortality in selected high-risk populations by reducing the risk of sudden death. No clinical trial examining ICD efficacy has focused specifically on benefits and risks in the elderly, but all trials have included substantial numbers of older patients. The author addresses several issues: Is the risk of sudden death different for the elderly than in younger patients? Is ICD implantation feasible in the elderly? Is there evidence that ICD use in the elderly improves survival? The author's research indicates that while total mortality is higher for the elderly, there does not appear to be a specific predilection for arrhythmic death. Recent reports indicate that while ICDs can be implanted in a Medicare population, ICD implantation is associated with significant mortality (0.9%), as well as periprocedural complications (10.8%). In spite of the risks, both secondary and primary prevention trials demonstrate that the survival benefit associated with ICD use in the study populations was at least as great for elderly patients as for younger persons. Thus, published data support judicious ICD use in elderly patients at high risk for sudden death.     

Oxprenolol in the treatment of hypertension in the elderly

Controversy continues to surround the value of drug treatment of hypertension in the elderly. Epidemiologic evidence implicates hypertension as a major risk factor in the precocious development of stroke and coronary heart disease in the elderly subject as clearly as it is implicated in the younger person. The hemodynamic and neuroendocrine profiles of the older patient with essential hypertension are similar to those of younger patients in the stable phase of the disease. However, the arterial ravages induced by many years of sustained hypertension render the circulation of the elderly subject more sensitive to pharmacologic intervention. The benefit-risk ratio of most antihypertensive drugs appears to be inversely related to age. Diuretics reduce the blood pressure at rest but have no influence on the increases in systolic pressure during normal activity; in addition, they carry potentially serious metabolic hazards in the elderly hypertensive patient. Centrally acting drugs likewise lower the blood pressure at rest without influencing the high systolic pressures induced by exercise. They also enhance the tendency to endogenous depression. Adrenergic-neurone blocking drugs and alpha-adrenoceptor antagonists are contraindicated because of the frequency of impaired cardiovascular reflexes in the elderly. The beta-blocking drugs can reduce the risk of coronary and cerebrovascular disease in the older patient with hypertension. They appear to be well tolerated, but because of their impaired metabolic handling in many elderly patients they should probably be used in smaller doses than those prescribed in younger patients. The influence of antihypertensive treatment on cardiovascular morbidity and mortality in the elderly hypertensive patient is not known.     

Review of blood pressure control rates and outcomes

Despite the high prevalence of hypertension and documented benefits of blood pressure (BP) control, >40% of patients with hypertension are not controlled. A majority of uncontrolled hypertensive patients receive two or more antihypertensive drugs. The current review examined the relationship between antihypertensive combination drug therapy, achievement of goal BP, and cardiovascular (CV) outcomes. Articles were selected from a PubMed search using a prespecified search strategy. Randomized, controlled clinical trials of adult human subjects published in English between January 1991 and January 2013 were included. From 2319 identified articles, 28 met inclusion criteria and contained a total of 226,877 subjects. There were seven placebo-controlled studies and 21 treatment comparator and combination therapy studies. The studies included in this review reported a positive association between the degree of BP lowering, number of medications, and CV outcomes. As combination therapy became available, it was increasingly utilized in clinical trials and enabled an increased proportion of patients to achieve a prespecified BP target. Adverse events with monotherapy and combination therapy were as anticipated for the specific classes of antihypertensive therapy. Although many patients reach BP goal, combination antihypertensive therapy is often needed to reach BP goal. Effective BP lowering has been shown to result in improvements in CV outcomes.     

Pharmacological interventions for hypertensive emergencies: a Cochrane systematic review

Hypertensive emergencies occur when high blood pressure is associated with the presence of acute end-organ damage, such as hypertensive encephalopathy. There is controversy as to when and which antihypertensive drugs to use in these situations. Using a comprehensive search strategy in electronic sources, MEDLINE, EMBASE and Cochrane clinical trial register, we conducted a systematic review to look all randomized control trials (RCTs) that compare an antihypertensive drug versus placebo, no treatment or another antihypertensive drug. Fifteen RCTs (representing 869 patients) met the inclusion criteria. Two trials included a placebo arm. All studies (except one) were open-label trials. Seven drug classes were evaluated in those trials: nitrates (nine trials), angiotensin-converting enzyme inhibitors (seven), diuretics (three), calcium channel blockers (six), alpha-1 adrenergic antagonists (four), direct vasodilators (two) and dopamine agonists (one). Mortality event data were reported in seven trials. Due to insufficient data, no meta-analysis was performed for clinical outcomes. Differences in blood pressure changes between antihypertensives were minor. There is no RCT evidence demonstrating that antihypertensive drugs reduce mortality or morbidity in patients with hypertensive emergencies. Furthermore, there is insufficient RCT evidence to determine which drug or drug class is most effective in reducing mortality and morbidity. There were some minor differences in the degree of blood pressure lowering when one class of antihypertensive drug is compared to another. However, the clinical significance is unknown. RCTs are needed to assess different drug classes to determine initial and longer-term mortality and morbidity outcomes.Journal of Human Hypertension (2008) 22, 596-607; doi:10.1038/jhh.2008.25; published online 17 April 2008.     

The effects of calcium channel blockers on cardiovascular outcomes: a review of randomised controlled trials

The choice of antihypertensive treatment should be guided by evidence of a reduction in the risk of cardiovascular (CV) events and therefore improved long-term outcome. Using pre-determined criteria, ten randomised, controlled trials that assessed the effects of calcium channel blockers (CCBs) on CV events in patients with hypertension were identified. Six of them enrolled a relatively small number (< 1500) of hypertensive patients, whereas four of the studies were much larger (> 4500 patients). The smaller studies produced mixed findings, especially those trials where CCBs were compared with diuretics; this may reflect methodological limitations and the impact of random error. The results from the four larger studies produced a consistent message: long-acting CCBs such as nifedipine, administered in a gastro-intestinal-transport-system (GITS) formulation, nitrendipine and diltiazem, reduce CV morbidity and mortality in hypertensive patients. In the one study that specifically enrolled high-risk hypertensive patients, nifedipine GITS was as effective as diuretic therapy in reducing CV events, and in all four larger studies sub-group analyses showed that the benefits of these CCBs extend to hypertensive patients with diabetes. The available evidence supports the use of these long-acting CCBs as a first-line treatment option in hypertensive patients.     

Systematic review: antihypertensive drug therapy in patients of African and South Asian ethnicity

Despite the large differences in the epidemiology of hypertension across Europe, treatment strategies are similar for national populations of white European descent. However, hypertensive patients of African or South Asian ethnicity may require ethnic-specific approaches, as these population subgroups tend to have higher blood pressure at an earlier age that is more difficult to control, a higher occurrence of diabetes, and more target organ damage with earlier cardiovascular mortality. Therefore, we systematically reviewed the evidence on antihypertensive drug treatment in South Asian and African ethnicity patients. We used the Cochrane systematic review methodology to retrieve trials in electronic databases including CENTRAL, PubMed, and Embase from their inception through November 2015; and with handsearch. We retrieved 4596 reports that yielded 35 trials with 7 classes of antihypertensive drugs in 25,540 African ethnicity patients. Aside from the well-known blood pressure efficacy of calcium channel blockers and diuretics, with lesser effect of ACE inhibitors and beta-blockers, nebivolol was not more effective than placebo in reducing systolic blood pressure levels. Trials with morbidity and mortality outcomes indicated that lisinopril and losartan-based therapy were associated with a greater incidence of stroke and sudden death. Furthermore, 1581 reports yielded 16 randomized controlled trials with blood pressure outcomes in 1719 South Asian hypertensive patients. In contrast with the studies in African ethnicity patients, there were no significant differences in blood pressure lowering efficacy between drugs, and no trials available with mortality outcomes. In conclusion, in patients of African ethnicity, treatment initiated with ACE inhibitor or angiotensin II receptor blocker monotherapy was associated with adverse cardiovascular outcomes. We found no evidence of different efficacy of antihypertensive drugs in South Asians, but there is a need for trials with morbidity and mortality outcomes. Screening for cardiovascular risk at a younger age, treating hypertension at lower thresholds, and new delivery models to find, treat and follow hypertensives in the community may help reduce the excess cardiovascular mortality in these high-risk groups.     

Hypertension in the elderly: Are we all on the same wavelength?

Hypertension is of frequent occurrence in the elderly population.Isolated systolic hypertension(ISH) accounts for the majority of cases of hypertension in the elderly.ISH is associated with a 2-4-fold increase in the risk of myocardial infarction,left ventricular hypertrophy,renal dysfunction,stroke,and cardiovascular mortality.There have been many studies to determine the optimal treatment for hypertension in the elderly. Why,when and how to treat hypertension in the elderly was the scope of the majority of these trials.Despite countless efforts many aspects remain obscure.While a number of novel drugs are being developed,the issue of whether all antihypertensive drugs bestow parallel benefits or whether some agents offer a therapeutic advantage beyond blood pressure control remains of crucial importance.Furthermore,the response of theelderly to different antihypertensive agents also differs from that of younger patients and may explain some of the disparities in outcomes of trials conducted in elderly patients with hypertension.     

Geriatric hypertension: chairman's comments on the NIH Working Group report

Of the more than 25,000,000 people in the United States older than 65 years, more than 60% have hypertension. Approximately 10% of the elderly people have isolated systolic hypertension (systolic blood pressure greater than or equal to 160 mm Hg, diastolic less than 90 mm Hg). Hypertension in the elderly, either systolic or diastolic, increases the risk of cardiovascular morbidity and mortality as much as it does for younger patients. Three large, controlled clinical trials have shown that diuretic-based stepped care therapy will reduce the risk of cardiovascular mortality for patients 60 years of age and older who have diastolic hypertension. In general, elderly patients tolerate antihypertensive drugs as well as younger patients do, and they are as compliant as younger patients. As yet, there is no evidence from controlled trials that drug treatment reduces the risk for patients with isolated systolic hypertension.     

Aggressive blood pressure control and stroke prevention: role of calcium channel blockers

Cerebrovascular disease is a major cause of morbidity and mortality worldwide and its prevalence is expected to increase as a result of projected demographic trends. Stroke is one of the leading causes of disability and death of over 30 million people each year worldwide. Hypertension is the most important modifiable risk factor for stroke. Recent data indicate that treatment with antihypertensive drugs reduces the incidence of all strokes in men (by 34%), women (by 38%), the elderly (by 36%), including those older than 80 years (by 34%), younger persons, those with systolic and diastolic hypertension, persons with isolated systolic hypertension, and those with a history of stroke or transient ischemic attack (by 28%). Furthermore, several large, prospective, randomized, clinical outcome trials have shown that calcium channel blockers (CCBs) are effective and safe antihypertensive drugs compared with placebo and reduce the cardiovascular morbidity and mortality of treated patients. Moreover, when CCBs were compared with conventional antihypertensive drugs they demonstrated similar blood pressure-lowering effects and similar reductions in cardiovascular morbidity and mortality, with the exception of a higher incidence of heart failure and fatal myocardial infarction in some studies. Considering all the evidence available today, however, these drugs should be considered safe for the treatment of the uncomplicated hypertensive patient in combination with other drugs. They can also be used as first-line therapy for older, stroke-prone hypertensive patients. The aim of this review is to summarize the role of CCBs in the prevention of stroke.     

Hypertension in the Elderly

Hypertension as a risk factor for cardiac and cerebrovascular morbidity and mortality poses a major health problem for our increasingly elderly population. Recent trials have shown large reductions in stroke, heart failure, and coronary artery disease when elderly hypertensive patients are treated. These benefits are also seen in elderly patients with isolated systolic hypertension. The elderly patient with hypertension should be investigated and managed in a similar manner to their younger counterpart. Nonpharmacological measures, such as dietary salt and calorie restriction, regular exercise, cessation of smoking, and reduction of excess alcohol intake, should be recommended. If these are insufficient, pharmacological treatment should be tailored to the individual patient. Diuretics have been shown to improve outcome measures in the elderly. Other antihypertensive drugs may be added or substituted depending on the patient's blood pressure response to therapy and their comorbid conditions. If all elderly hypertensive patients were treated, a major reduction in cardiovascular and cerebrovascular mortality and morbidity would result. Consideration also needs to be given to nonpharmacological treatment, particularly salt restriction in older subjects where blood pressure is at the upper limit of normal, as this would also result in a major reduction in cardiovascular morbidity and mortality.     

Should we prefer different drugs to treat hypertension in older and younger adults? Practical implications of clinical trials: European perspective

Guidelines for the management of hypertension almost invariably include sections where the evidence for or against treatment or for certain types of treatment in certain types of patients is inconclusive. This is especially the case of older patients with hypertension. As a consequence, although a large number of randomized trials including hypertensive patients aged > or = 60 years showed that antihypertensive drugs reduce cardiovascular morbidity and mortality, health care professionals who take care of older adults have been often reluctant to provide adequate antihypertensive therapy. In a recent meta-analysis, the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) compared the effects of different drugs for reducing blood pressure (BP) in older and younger adults; the reduction in BP levels and the relative risk reduction of a cardiovascular event with various antihypertensive drugs occurred independently of the patients' ages, and the benefits of antihypertensive regimens based on different drug classes were widely comparable across age groups. The BPLTTC analysis strongly suggests an early and aggressive management of hypertension irrespectively of age; more myocardial infarctions, strokes, heart failures and deaths will be prevented by treating hypertensive patients aged > or = 65 years than by treating patients < or = 50 years with the same BP levels. Antihypertensive treatment should be embedded within the management of global cardiovascular risk, with the use of charts for stratifying risk based on additional risk factors, target organ damage or additional clinical conditions.     

Benefits of antihypertensive drugs when blood pressure is below 140/90 mmHg

Antihypertensive medications are used to lower blood pressure (BP) but, ultimately, their true value lies in reductions in morbidity and mortality (cardiovascular, cerebrovascular, and renal diseases). Hypertension is defined discreetly (generally 140/90 mmHg) but the actual relationship between BP and adverse cardiac and cerebrovascular outcomes is continuous. Observational studies have demonstrated a powerful log-linear relationship between BP and mortality due to ischemic heart disease (IHD) or stroke over the range of 115/75 to 185/115 mmHg. Clinical trials and meta-analyses have clearly demonstrated benefits of antihypertensive drugs in nonhypertensive individuals: delay or prevention of the onset of hypertension and microalbuminuria and reduced morbidity and mortality from IHD, stroke, and chronic kidney disease. This is not surprising given that various antihypertensive drug classes have multiple potential beneficial effects. A persistent concern is that overtreatment of hypertension may increase risk in individuals with coronary artery disease, but a "J-curve" effect is not consistently found in clinical studies. The use of antihypertensive drugs in at-risk individuals who are below the traditional threshold (140/90 mmHg) is fully justifiable, but the decision requires adequate clinical experience and judgment and a full assessment of risks and benefits.     

Hypertension and the elderly: more than just blood pressure control

Hypertension is a major risk factor for cardiovascular disease in both young and elderly persons; therefore, good blood pressure control is at the center of improved cardiovascular health. The recently issued seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the European Society of Hypertension/European Society of Cardiology 2003 guidelines for hypertension management emphasize the importance of treatment efficacy rather than age in treating elderly persons with hypertension. Most hypertension clinical trials have been carried out with younger hypertensives, but this is changing with trials such as the Systolic Hypertension in the Elderly Program, the first Swedish Trial of Old Patients With Hypertension, and the Systolic Hypertension in Europe trial. These trials have clearly demonstrated the benefits of good blood pressure control in reducing the risk of stroke in elderly persons. With many safe and effective antihypertensive drugs on the market, the question becomes how elderly persons should be treated. Elderly patients often have isolated systolic hypertension, which is related to loss of arterial elasticity or compliance with aging and is more recalcitrant to treatment than essential hypertension. In addition, with advancing age there is the likelihood that other disease states are present in addition to hypertension. The newer antihypertensive drugs that interfere with the renin angiotensin system, such as angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, have the potential of improving cardiovascular outcomes in elderly persons in addition to offering effective blood pressure reduction. Their use should be considered within a comprehensive risk assessment that includes individualized risk-benefit considerations.     

Has the role of calcium channel blockers in treating hypertension finally been defined?

Several large, prospective, randomized, clinical outcome trials have shown that calcium channel blockers are effective and safe antihypertensive drugs compared with placebo and reduce the cardiovascular morbidity and mortality of treated patients. In other studies, when compared with conventional antihypertensive drugs, they demonstrated similar blood pressure-lowering effects and similar reductions in cardiovascular morbidity and mortality, with the exception of a higher incidence of heart failure and fatal myocardial infarction in some studies. However, considering all the evidence available today, these drugs should be considered safe for the treatment of the uncomplicated hypertensive patient in combination with other drugs. They can also be used as first-line therapy for older, strokeprone hypertensive patients. In addition, when a calcium channel blocker is indicated for better blood pressure control, its use should not be withheld for safety concerns.     

Hypertension and its Treatment in the Elderly

Controlled trials have demonstrated the protective effect of antihypertensive drug therapy in subjects over 60 years of age. Elderly patients are often peculiarly sensitive to the side-effects of some antihypertensive drugs, which must therefore be deployed with especial care in this age-group. The widely-supposed differential benefits and acceptability of various drug classes in the elderly have been shown to have been inferred often from inadequate evidence. These aspects require further study. The already large elderly hypertensive population will continue to expand, thus raising important, problematic, but rewarding, therapeutic and economic issues.     

Effects of Traditional Chinese Patent Medicine on Essential Hypertension: A Systematic Review

Traditional Chinese patent medicine (TCPM) is widely used for essential hypertension (EH) in China. However, there is no critically appraised evidence, such as systematic reviews or meta-analyses, regarding the potential benefits and disadvantages of TCPM to justify their clinical use and recommendation. The aim of this review was to systematically evaluate and meta-analyze the effects of TCPM for EH.Seven databases, the Cochrane Library, PubMed, EMBASE, the China National Knowledge Infrastructure, the Chinese Scientific Journal Database, the Chinese Biomedical Literature Database, and the Wanfang Database, were searched from their inception to August 2014 for relevant studies that compared one TCPM plus antihypertensive drugs versus antihypertensive drugs alone. The methodological quality of the included trials was assessed using the Cochrane risk-of-bias tool. The primary outcome measures were mortality or progression to severe complications and adverse events. The secondary outcome measures were blood pressure (BP) and quality of life (QOL).Seventy-three trials, which included 8138 patients, on 17 TCPMs were included. In general, the methodological quality was low. Two trials evaluated the effects of TCPMs on mortality and the progression to severe complications after treatment, and no significant difference was identified compared with antihypertensive drugs alone. No severe adverse events were reported. Thirteen TCPMs used in complementary therapy significantly decreased systolic BP by 3.94 to 13.50 mmHg and diastolic BP by 2.28 to 11.25 mmHg. QOL was significantly improved by TCPM plus antihypertensive drugs compared with antihypertensive drugs alone.This systematic review provided the first classification of clinical evidence for the effectiveness of TCPM for EH. The usage of TCPMs for EH was supported by evidence of class level III. As a result of the methodological drawbacks of the included studies, more rigorously designed randomized controlled trials that focus on mortality and cardiovascular events during long-term follow-up are warranted before TCPM can be recommended for hypertensive patients. Two TCPMs, Song ling xue mai kang capsules and Yang xue qing nao granules, should be prioritized for further research.     

The role of ACE inhibitors in the treatment of hypertensive elderly patients

Hypertension has a high prevalence among elderly patients. Randomised trials have already demonstrated that treating healthy older persons with hypertension is highly efficacious. Nevertheless some questions have arisen. On the one hand the generalizability of these trial results, particularly for older persons with serious medical comorbidities and poor functional status, is not clear. On the other hand different antihypertensive drugs have shown to be effective. Which drug for which patient? Even data from randomised intervention trials showing that the treatment affects cardiovascular morbidity and mortality, were missing, ACE inhibitors have been used for more than a decade to treat high blood pressure. For a younger population the captopril prevention project showed no differences between ACE inhibitors and conventional antihypertensive treatment (diuretics, beta-blocker) concerning the primary endpoints (myocardial infarction, stroke and other cardiovascular death). The STOP-2 study also confirmed these results for elderly patients. When treating elderly patients one must be aware of physiological changes with age and the comorbidities. Of significance among this patient group is declining renal function. Admissions for uraemia that are related to the use of ACE inhibitors are still commonplace, although many cases are preventable by monitoring renal function, but guidelines are still missing. Concerning the comorbidities ACE inhibitors have benefits compared to other antihypertensive drugs, especially in cases of heart failure, diabetes and coronary heart disease.     

Cerebral complications of hypertension in the elderly]

PURPOSE: This review focuses on cerebral complications of hypertension, which include stroke, impairment of cognitive function, dementia, and possibly depression and anxiety. These conditions are major causes of morbidity and mortality in the elderly. CURRENT KNOWLEDGE AND KEY POINTS: Not only elevated diastolic blood pressure, but also isolated systolic hypertension and elevated pulse pressure play an important role in the development of brain complications. Randomised placebo-controlled trials have provided evidence that reduction of hypertension decreases safely and effectively morbidity and mortality rates in the elderly. The new classes of drugs, in particular calcium-channels blockers and angiotensin-converting enzyme inhibitors, have been shown to be as effective as the originally used diuretics and beta-blockers. FUTURE PROSPECTS AND PROJECTS: Several trials are currently in progress and should provide more information on the benefit of antihypertensive treatment in very elderly persons (Hypertension in the Very Elderly Trial, HYVET) and secondary prevention of stroke (PROGRESS). The importance of assessing new dosages of the presently used antihypertensive drugs as well as the benefit of new classes of drugs is emphasised. Further trials specifically focusing on the prevention of dementia by antihypertensive drugs are needed to confirm the results of the Syst-Eur Vascular Dementia Project. The benefit of calcium antagonists in the prevention of dementia in elderly hypertensive patients should be assessed in the Dementia Prevention in Hypertension trial (DEPHY).     

Management of Global Risk Across the Continuum of Hypertensive Heart Disease

Identification and management of cardiovascular (CV) risk factors are essential to help prevent CV disease and slow its progression. Long-term epidemiologic data show that hypertension is associated with a two- to four-fold increase in CV morbidity and mortality; moreover, antihypertensive therapy has been proven to significantly reduce the risk of CV events. Clinical trial data also suggest that different antihypertensive agents generally provide similar reductions in CV risks and outcomes. Beta blockers have historically played an integral role in hypertension treatment, particularly among patients at high CV risk; however, a recent meta-analysis, based primarily on the use of atenolol, found that β blockers may provide less clinical benefit as initial therapy than other classes of antihypertensive agents. Beta blockers are heterogeneous, and atenolol data may not be representative of other β blockers. Newer β blockers, which provide both cardioselective β₂-adrenergic receptor blockade and endothelium-dependent vasodilation, may prove to be more effective in reducing CV morbidity and mortality. Intensive strategies to control global CV risk have been shown to significantly reduce CV events. The challenge remains to develop effective risk assessment tools to identify at-risk patients who often go undetected.