Treatment of elderly patients with hypertension

In their review, Gradman and Morsy emphasize the need to treat isolated systolic hypertension (ISH) and systolic/diastolic hypertension in elderly patients. They note the lesser efficacy of beta blockers in reducing cardiovascular events. They also cite the target blood pressure of < 140/90 mm Hg (< 130/80 for patients with diabetes or renal impairment) recommended in the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Most subjects in the studies cited were in their 60s and 70s; yet today, we would hardly consider a 62-year-old “elderly.” Increasingly, our dilemma lies with patients in their 80s and 90s, most with ISH. Should they be treated as aggressively as younger patients? Should a systolic pressure of 140 to 160 mm Hg, or even 170 mm Hg, be treated? To what target level should it be lowered?

In this age group (over 80 years of age), there are reasons for caution. First, mortality, if anything, is inversely related to systolic pressure.^1,2 Second, the benefit of treatment is not clear. A recent meta-analysis showed a reduction of stroke (36%) and cardiovascular events (22%) with treatment, but also an increase in mortality (14%; P = .05).³ Whether those with mild systolic pressure elevation (ie, 160-180 mm Hg) derived benefit is unclear. The Hypertension in the Very Elderly Trial (HYVET)-pilot study showed similar results.⁴ No studies have assessed the benefit of treating a systolic pressure of 140 to 160 mm Hg.

A third issue is quality of life. Drug side effects can be particularly problematic in the elderly. Beta blockers and central alpha agonists cause fatigue. Calcium channel blockers aggravate constipation and cause edema, which can increase nocturia and interrupt sleep. Nondihydropyridine calcium channel blockers cause fatigue. Diuretics are associated with hypokalemia, hyponatremia, gout, and other effects. Issues such as orthostatic hypotension, unsteadiness, and falls have not been adequately assessed, although the HYVET-pilot study showed an orthostatic drop in blood pressure of ≥ 20 mm Hg in 8% of treated subjects.⁵ In addition, the effect of treatment on mental acuity in the very old has also not been adequately studied.

What conclusions can we draw? The treatment of hypertension in the elderly is clearly helpful. However, treatment of patients over 80 years of age, particularly with mild ISH, is less well clarified. Assessment of home blood pressure is helpful. Individuals at high risk for stroke (eg, severe elevation of systolic pressure or prior stroke) should be treated. Vigorous individuals with a longer expected life span might also be candidates for intervention. However, the lack of reduction—and possible increase&mdash;in mortality and the frequency of adverse effects argue in favor of caution, given the inadequate evidence, in treating a systolic pressure of 140 to 160 mm Hg in this age group. There is also no evidence supporting a target systolic pressure as low as 140 mm Hg in patients of this age.

Beta blockers are not a good choice for treatment in the absence of other compelling indications. Diuretics and calcium channel blockers are effective but have side effects. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are better tolerated, but might be less effective than diuretics. Should an octogenarian, let alone a nonagenarian, with a systolic pressure below 160 mm Hg, or even below 170 mm Hg, be treated? The paucity of evidence of treatment benefit argues in favor of caution.