Hypertension in the elderly: Ubiquitous but not innocuous Pantel S. Vokonas, MD

Both the incidence and prevalence of hypertension, primarily systolic hypertension, rise with advancing age in nearly all Western industrialized societies, so that nearly two thirds of men and women older than 65 years can be classified as hypertensive; however, just because the prevalence of hypertension in the elderly is ubiquitous does not mean that it is innocuous. Data from the Framingham Heart Study1 and other studies have documented the role of hypertension, particularly isolated systolic hypertension, as the dominant risk factor for an extensive array of adverse cardiovascular outcomes at an advanced age, including coronary heart disease (CHD) events, stroke, and heart failure. Elevated systolic blood pressure, especially if untreated, is a key risk factor for cognitive impairment at an advanced age, leading to vascular dementia. A strong case can be made for the effective management of hypertension at all ages; however, this problem requires special clinical attention in elderly patients.

In this context, the article by Otieno and Gradman (page 14) provides an excellent review of the epidemiology, pathophysiology, and treatment options for hypertension in the elderly, which should be useful for a wide spectrum of health professionals, including primary care physicians, internists, nurse practitioners, and cardiologists who manage this condition in older persons.

Based on the results of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)2 and a number of other clinical trials,3 a diuretic is still the most well-established and well-validated initial drug option for the management of hypertension in the elderly. Diuretics, although inexpensive and usually well tolerated in older persons, at times may significantly exacerbate, to the point of intolerance, symptoms of frequency and nocturia in men with benign prostatic hyperplasia and stress incontinence in women. Effective management of blood pressure in this population frequently requires more than one drug. The second drug chosen in this clinical situation usually is a beta-adrenergic blocking agent. Beta blockers are well tolerated by most patients, but may cause fatigue and, in some instances, symptomatic bradyarrhythmias.

Of interest, several more recent clinical trials referenced by the authors, including the Systolic Hypertension in Elderly in Europe (Syst-Eur) trial, the Shanghai Trial of Nifedipine in the Elderly (STONE), the Swedish Trial in Old Patients with Hypertension-2 (STOP-2), and the Losartan Intervention for Endpoint Reduction (LIFE) trial, have now confirmed the efficacy and safety of calcium channel blocking agents, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers, alone or combined with other drugs for the management of hypertension in an advanced age group. Antihypertensive drugs in these classes, although considerably more expensive than diuretics and beta blockers, broaden the therapeutic armamentarium to include the majority of agents now used in middle-aged and younger persons in the management of hypertension. In addition to substantial reductions in cerebrovascular events and congestive heart failure, most intervention studies of drug therapy in older persons have consistently demonstrated either beneficial trends or significant reductions in CHD events and mortality for hypertension.4 Such findings appear to be considerably less prominent in clinical trials of predominantly middle-aged hypertensive patients.

Conclusion

Developing an effective regimen of antihypertensive drugs that meets