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Pharmacotherapy for hypertension in the elderly
1Audie L. Murphy Division-Ambulatory Care (11C6), 7400 Merton Minter Blvd, San Antonio, TX, USA, 78284. HTNCRG@VERDICT.UTHSCSA.EDU
Insights
Antihypertensive drug therapy significantly reduces cardiovascular morbidity and mortality in elderly individuals. Treatment with diuretics or beta-blockers is effective for older adults with hypertension, though side effect data is inconsistent.
Area of Science:
- Gerontology
- Cardiovascular Medicine
- Pharmacology
Background:
- Hypertension is a prevalent condition in the elderly, increasing the risk of cardiovascular events.
- Long-term data on the efficacy and safety of antihypertensive drug therapy in older populations is crucial.
Purpose of the Study:
- To quantify the long-term effects of antihypertensive drug therapy on morbidity and mortality in elderly individuals.
- To characterize co-morbid risk profiles of participants in relevant clinical trials.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) of at least one year duration in hypertensive elders (≥60 years).
- Data abstraction by two independent reviewers on morbidity, mortality, and trial characteristics.
- Searches included major databases (MEDLINE, Cochrane Library) and expert consultations.
Main Results:
- Fifteen RCTs involving 21,908 elderly subjects were analyzed.
- Antihypertensive drug therapy, particularly with diuretics or beta-blockers, significantly reduced cardiovascular morbidity and mortality (e.g., cardiovascular morbidity/mortality reduced from 177 to 126 per 1000 over 5 years).
- Total mortality was also reduced; however, data on dropouts due to side effects varied widely and were often unreported.
Conclusions:
- RCTs demonstrate that treating hypertension in healthy older individuals is highly effective.
- Low-dose diuretics or beta-blockers show clear benefits for systolic or diastolic hypertension in individuals aged 60-70.
- Differential treatment effects based on specific risk factors or co-morbidities could not be determined from the available trial data.
Objectives:
To quantify the long-term effects of antihypertensive drug therapy on morbidity and mortality in the elderly. To characterize co morbid risk profiles of trial participants.
Search Strategy:
Electronic search of WHO-ISH Collaboration register (August 1997), The Cochrane Library (1997; Issue 1), MEDLINE (1966 to April 1997) and two Japanese databases (1973-1995); references from reviews, trials and 10 previously published meta-analyses; and experts.
Selection Criteria:
Randomized controlled trials of at least one year duration in hypertensive elders (at least 60 years old) assessing antihypertensive drug therapy and providing morbidity and mortality data.
Data Collection And Analysis:
At least two independent reviewers abstracted data on morbidity and mortality results and trial characteristics. The following outcomes were assessed: total mortality; coronary heart disease (CHD) mortality; combined CHD morbidity and mortality; cerebrovascular mortality; combined cerebrovascular morbidity and mortality; cardiovascular mortality; combined cardiovascular morbidity and mortality; and drop outs due to side effects of treatment.
Main Results:
Fifteen trials including 21,908 elderly subjects were identified. The average prevalence of cardiovascular risk factors, cardiovascular disease, and competing co morbid diseases was lower among trial participants than the general population of hypertensive elderly persons. Most subjects were 60 to 80 years old. Most trials were conducted in Western, industrialized countries and evaluated diuretic and beta-blocker therapies. Event rates per 1000 participants over approximately 5 years indicated that antihypertensive drug therapy was beneficial. Cardiovascular morbidity and mortality was reduced from 177 to 126 events (95% CI of the difference 31 to 73). Cardiovascular mortality was reduced from 69 to 50 deaths (95% CI of the difference 9 to 31). Total mortality was reduced from 129 to 111 deaths (95% CI of difference 4 to 28). The data from the three trials restricted to persons with isolated systolic hypertension indicated a significant benefit: cardiovascular morbidity and mortality over approximately 5 years was reduced from 157 to 104 events per 1000 participants (95% CI of the difference 12 to 89). Numbers of participants who dropped out of trials secondary to adverse drug effects were often not reported. The four trials that did report this data showed a wide variation in drop out rates ranging from no significant differences between treatment and control groups to as many as one out of four patients dropping out due to side effects of treatment.
Reviewer'S Conclusions:
Randomized controlled trials establish that treating healthy older persons with hypertension is highly efficacious. Benefits of treatment with low dose diuretics or beta-blockers are clear for persons in their 60s to 70s with either diastolic or systolic hypertension. Differential treatment effects based on patient risk factors, pre-existing cardiovascular disease and competing co-morbidities could not be established from the published trial data.