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Benefits of treating hypertension in the elderly: should age affect treatment decisions?
1Mater Hospital, Dublin, Republic of Ireland.
Insights
Treating hypertension in the very elderly (>=80 years) remains uncertain due to limited trial data. Current evidence suggests benefits, especially with complications, favoring diuretics.
Area of Science:
- Gerontology
- Cardiovascular Medicine
- Clinical Pharmacology
Background:
- Established benefits of hypertension treatment for morbidity and mortality exist.
- Previous trials included limited numbers of very elderly patients (>=80 years).
- Meta-analyses on this subgroup yielded inconclusive results, compounded by varied therapeutic agents.
Purpose of the Study:
- To address the uncertainty surrounding the value of treating hypertension in the very elderly.
- To provide conclusive evidence on the benefits or risks of antihypertensive treatment in this population.
- To guide clinical decisions on initiating, continuing, and managing hypertension treatment in very elderly individuals.
Main Methods:
- Extraction and meta-analysis of existing data on hypertensive very elderly patients.
- Initiation of the Hypertension in the Very Elderly Trial (Hyvet) for conclusive evidence.
- Examination of the J-curve hypothesis in elderly patients, deemed spurious upon review.
Main Results:
- Existing meta-analyses are inconclusive regarding treatment benefits in the very elderly.
- The J-curve hypothesis, a concern for elderly treatment, appears spurious.
- The Hyvet study is underway to provide definitive results, but outcomes are not yet available.
Conclusions:
- Current recommendations suggest treating very elderly patients with hypertension, particularly those with complications or target organ damage.
- For relatively healthy, mild-to-moderate hypertension cases, a 'lower the blood pressure the better' approach is advised.
- Low-dose diuretics are recommended as the first-line therapy for hypertension in the very elderly.
Abstract:
Do the benefits of treating hypertension extend equally to all age groups, particularly the very elderly? Several large controlled trials have been published in recent years that confirm the benefits of the treatment of hypertension in terms of morbidity and mortality. However, these trials included only relatively small numbers of patients aged > or = 80 years. Data regarding such patients have been extracted and subjected to meta-analysis, but with inconclusive results. Further difficulties arise as a result of the range of therapeutic agents employed. Therefore, uncertainty still surrounds the value of treating very elderly patients with hypertension. The J-curve hypothesis, i.e. that a blood pressure threshold exists below which there is an increase in the rate of cardiac events, has been a concern in treating elderly patients. Upon close examination, this appears to be spurious. The Hypertension in the Very Elderly Trial study sets out to provide conclusive evidence for the benefits or otherwise of treating hypertension in the very elderly and has just commenced. The results of this trial will not be available for some time. In the meantime, should physicians initiate or continue treatment for very elderly individuals with hypertension? If so, what regimens should be employed and should target blood pressure levels be set? At the present time, it would appear sensible to provide treatment for very elderly patients with hypertension, particularly those with evidence of complications or target organ damage. In relatively healthy individuals with mild-to-moderate hypertension, the guiding principle should be 'the lower the blood pressure the better'. Regarding the choice of therapeutic agent, a low-dose diuretic remains the first choice therapy.