Applied Evidence

EYE ON THE ELDERLY—Hypertension care: Striking the proper balance

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How aggressive should treatment be? Which drug combinations should raise red flags? Which drugs should you avoid entirely? Here’s how to safely customize your care.



Practice recommendations
  • Treat systolic hypertension in the elderly to reduce their risk of cardiovascular events and mortality (B).
  • Don’t shy away from treating the very old. Hypertension treatment is beneficial even in patients who are 80 years of age or older (B).
  • Don’t prescribe an angiotensin-converting enzyme inhibitor and an angiotensin receptor blocker for elderly patients without heart failure; the combination increases the risk of adverse effects without reducing cardiovascular events (B).

Strength of recommendation (SOR)

  1. Good-quality patient-oriented evidence
  2. Inconsistent or limited-quality patient-oriented evidence
  3. Consensus, usual practice, opinion, disease-oriented evidence, case series

Esther V. is an 81-year-old Caucasian woman who has been in your practice for a number of years. Her history is significant for a hip fracture 5 years ago and a subsequent diagnosis of osteoporosis. But she’s still able to live on her own, and takes only 1 medication—alendronate 70 mg once a week. Today Mrs. V.’s blood pressure is 150/80 mm Hg, and a chart review indicates that it has been in that range for the past 2 years. In view of her history and her age, would you proceed with treatment, and if so, how would you address her elevated systolic pressure?

Treating high blood pressure in elderly patients like Esther V. is a complicated proposition: While it’s important to mitigate hypertension’s negative effects, physicians need to be mindful that for this patient population, antihypertensive therapy itself involves elevated risks and unique concerns. These include:

  • drug-drug interactions, exacerbated by the multiple medications that many older patients take;
  • the side effect profile of antihypertensive agents, including orthostatic hypotension and the possibility of exacerbating an already heightened risk of falls; and
  • uncertainty about when to initiate therapy, which drugs to choose if a second antihypertensive agent is needed, and when (or whether) a patient is too old to benefit from treatment.

Noncompliance is another potential complication in the elderly, who may have difficulty following a drug regimen or avoid prescription medications because they’re worried about the adverse effects—or the cost—of the drugs.

Thus, it’s not surprising that hypertension so often remains under- or untreated in older patients, a problem highlighted by a 2003 review in which only 27% of elderly patients were found to have reached their blood pressure goal.1

Despite the difficulty of adequately addressing hypertension in this patient population, the benefits do outweigh the risks. The following practical guide will help you overcome common barriers to treatment, avoid dangerous drug combinations, and customize your patient’s care to maximum benefit.

Treat hypertension, regardless of age

The Seventh Report of the Joint National Committee on Prevention, Evaluation, and Treatment of Hypertension (JNC 7) recommends a goal of <140/90 mm Hg for most individuals, and <130/80 mm Hg for those with diabetes mellitus or chronic kidney disease.2 But as patients age, presentations like that of Mrs. V.—elevated systolic pressure and normal diastolic pressure—are increasingly common. Isolated systolic hypertension is thought to be a consequence of the aging process, which results in a reduction in elasticity and compliance of the large arteries, degradation of arterial elastin, and atherosclerosis-associated accumulation of arterial calcium and collagen.3

Certainly, we know that hypertension of any kind is a major risk factor for a number of conditions with significant morbidity and mortality, including coronary artery disease,4 stroke,5 and heart failure.6 In the elderly, treatment of systolic hypertension, even in the absence of diastolic hypertension, has been proven to reduce cardiovascular and renal disease and death.7-9

Extending lives: What the evidence shows

Treating the very old. Hypertension in the Very Elderly (HYVET), the most recent trial, randomized more than 3800 hypertensive patients over the age of 80 in Europe, China, Australia, and Tunisia to receive either a diuretic or placebo. After 2 years, the treatment group had significant reductions in fatal and nonfatal stroke (number needed to treat [NNT]=19), all-cause mortality (NNT=8), cardiovascular death (NNT=15), and heart failure (NNT=67).10

A subset of this trial (HYVET-COG) reviewed the effects of antihypertensive therapy on the development of dementia in the very old. The researchers did not find a statistically significant reduction in the incidence of dementia in the treatment group. But when the HYVET-COG data were combined in a meta-analysis with data from 3 other antihypertensive trials in the elderly, treatment for hypertension was associated with a 13% relative risk reduction for dementia.11 Despite a major limitation of the HYVET trial—participants were typically healthier than the general population within their age group—the findings highlight the benefits of treating hypertension even in the very old.


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