High Blood Pressure / Hypertension

Whether to treat older persons with hypertension

By Cardiologist on August 13th, 2011

Although the benefit of treating younger hypertensive patients (<69 yr) was proven by the mid-1980s, many still doubted whether there would be benefit in older persons, with diastolic, systolic and diastolic or isolated systolic hypertension. Although there were substantial numbers of participants over 60 yr in the VA Cooperative Study, in the Australian trial and in the Medical Research Council study, no one older than 69 yr at entry was eligible to participate.

In the 1980s and 1990s, the issue of whether to treat older persons was settled (Table Trials Addressing Whether to Treat Older Persons with Hypertension). The first group of trials entered older subjects with diastolic hypertension. These included the European Working Party in the Elderly (EWPHE) published in 1985, then the Swedish Trial of Old Patients (STOP-Hypertension) in 1991, and finally the Medical Research Council — Elderly (Medical Research Council-E) Study published in 1992. The Medical Research Council-E trial also enrolled older persons with isolated systolic hypertension, who made up 43% of their cohort. These trials clearly showed the benefit of treating older individuals with elevated diastolic blood pressure (>90 mmHg).

Table Trials Addressing Whether to Treat Older Persons with Hypertension

Table  Effects of Therapy in Older Patients with Hypertension (% Relative Risk Reduction)”

The benefit achieved was even greater than that seen in younger hypertensive patients. Table Effects of Therapy in Older Patients with Hypertension (% Relative Risk Reduction)” shows that there is consistent reduction in stroke and coronary artery disease and heart failure, even though none of these studies used an angiotensin-converting enzyme inhibitor.

EWPHE began treatment with a diuretic, and in both STOP and Medical Research Council-E, volunteers got either diuretics or β-blockers as initial therapy. The Medical Research Council-E trial, to the surprise of many, clearly demonstrated the superiority of diuretics compared to β-blockers, perhaps because diuretics were much more effective at reducing systolic blood pressure. β-Blockers in the Medical Research Council-E trial were, in fact, no better than placebo. It is for this reason that the National High Blood Pressure Working Group on Hypertension in the Elderly and the Sixth Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI) did not recommend β-blockers as initial treatment for hypertension in older persons.

Table Trials Addressing What Our Goal for Antihypertensive Therapy Should Be

Two other studies, the Systolic Hypertension in the Elderly Program (SHEP) and the Systolic Hypertension in Europe (Syst-EUR), addressed the issue of whether treating older persons with isolated systolic hypertension (systolic blood pressure > 160 mmHg with diastolic blood pressure <90 mmHg in SHEP and <95 mmHg in Syst-EUR) would also confer benefit. SHEP, whose main results were published in 1991, began treatment with a low dose of chlorthalidone (12.5 mg), increasing it to 25 mg and then adding atenolol (25-50 mg) or reserpine (0.05-0.10 mg) if needed, to reach the blood pressure goal. Syst-EUR, published in 1997, used different classes of agents to lower blood pressure. The initial treatment was a moderately long-acting calcium antagonist (nitrendipine), followed by the angiotensin-converting enzyme inhibitor enalapril, and, finally, the diuretic hydrochlorothiazide.

Both studies had similar results and unequivocally showed the value of treating older persons with isolated systolic hypertension. The benefit was evident within slightly more than 2 yr in Syst-EUR and by 4.5 yr in SHEP, meaning than an older individual with those blood pressures whose life expectancy is presumably at least that long would benefit from treatment and should receive therapy.

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