Volume 2, Number 1, March 2001

The management of the elderly with hypertension
Christopher J Bulpitt

Outcome data from randomised controlled trials in hypertensive patients have shown that, in patients aged 65–79 years, there are clear benefits of antihypertensive treatment in those with a sustained systolic blood pressure (SBP) of >160 mmHg, irrespective of diastolic blood pressure (DBP). Although not definitively proven, it is also probable that treating a sustained DBP of >90 mmHg is beneficial.
However, the information from these trials is limited and leaves several questions unanswered.
For example, to what level should BP be lowered by treatment? Epidemiological data have suggested that DBP should not be lowered below 85 mmHg because of a potential increase in coronary heart disease at lower pressures, the so-called 'J-shaped curve'. However, results from the HOT and SHEP studies do not support this theory; although, in SHEP, a DBP <60 mmHg in the actively treated group was associated with higher cardiovascular events, it is probable that this merely reflects a more pronounced response to antihypertensive treatment in patients who are frail, unwell and therefore already at high risk. Most researchers conclude from these studies that the J-shaped increase in mortality at low pressures reflects the fact that concomitant conditions such as coronary artery disease, cancer and dementia all tend to result in low BP.
Data are less convincing regarding SBP. In the HOT, EWPHE, SHEP and SYST-Eur trials, mean SBP was reduced to between 140 and 150 mmHg. Between 30 and 50% of subjects failed to achieve the target of 140–160 mmHg, and of those who did, a large proportion required treatment with more than one drug. In the elderly, side-effects, particularly postural hypotension, may limit the numbers achieving target BP and will increase non-compliance. The current goals in the elderly should be a standing BP of <140/<80 mmHg.
Another unanswered question is over the choice of antihypertensive drugs in the elderly. In the early MRC trials in the elderly, patients treated with beta-blockers tended to fare badly, leading to the suggestion that these drugs should be avoided in this age group. However, these suggestions were not substantiated by the STOP-hypertension 2 study, in which no disadvantages of beta blockade were demonstrated. Two further trials, ASCOT and ALLHAT are currently underway and will provide further information on the optimal choice of drugs for BP-lowering. It should be noted that, in the ALLHAT studies, one of the treatments, the alpha blocker, doxazosin, has been stopped because of an increase in the relative risk for stroke, heart failure and combined cardiovascular disease. However, with the possible exception of α-blockers, the choice of drugs for BP-lowering in the elderly seems not to be of great importance, and that choice will be largely determined by contra-indications, side-effect profiles and quality of life issues.
Finally, the picture for the very elderly remains confusing. Epidemiological evidence suggests that lower BPs are associated with higher mortality, though this may be a function of the hypotensive effects of co-existing serious illness such as heart disease, cancer and dementia. The only trial specifically designed for the very elderly is the ongoing HYVET trial, though very limited data from over 80 year olds recruited into other trials is also available. The consensus from these studies is that treatment should certainly be given to patients with severe hypertension (SBP >200 mmHg, DBP >110 mmHg) and those with evidence of heart failure, angina, renal failure or accelerated hypertension. In other patients, treatment may prevent a stroke, but will not necessarily prolong life expectancy and may adversely affect quality of life.

JRAAS 2001;2:11-13.

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