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Treatment of hypertension in the elderly
Warren J Elliott1, Henry R Black
1Department of Preventive Medicine, Rush Medical College of Rush University at Rush-Presbyterian- St. Luke's Medical Center, 1700 West Van Buren Street, Chicago, IL 60612, USA. welliott@rush.edu
Insights
Treating hypertension in older adults is crucial for reducing vascular disease and death. Achieving individualized blood pressure goals is more beneficial than selecting specific initial antihypertensive drugs.
Area of Science:
- Gerontology
- Cardiology
- Pharmacology
Background:
- Hypertension is a primary risk factor for vascular disease and mortality in developed countries, particularly affecting older populations.
- Antihypertensive drug therapy has shown significant reductions in myocardial infarctions and strokes in clinical trials involving older individuals.
- While lifestyle modifications can lower blood pressure, evidence for reducing actual cardiovascular events is lacking.
Purpose of the Study:
- To evaluate the optimal initial treatment strategies for hypertension in older adults.
- To determine the most effective approach for managing hypertension to reduce cardiovascular risk in the elderly.
- To assess the impact of achieving specific blood pressure goals versus initial drug choice on long-term outcomes.
Main Methods:
- Review of numerous clinical trials and treatment guidelines for hypertension in older patients.
- Analysis of data regarding the efficacy and safety of various antihypertensive drug classes.
- Consideration of comorbidities influencing treatment decisions in elderly hypertensive individuals.
Main Results:
- Alpha blocker monotherapy is no longer recommended due to increased cardiovascular event rates observed in trials.
- The traditional strategy of initiating therapy with a diuretic is likely to be supported by ongoing research.
- Achieving the patient's target blood pressure goal yields greater benefits than the choice of initial antihypertensive agent.
Conclusions:
- Individualized blood pressure targets are paramount in managing hypertension in older adults.
- The focus should be on attaining the appropriate blood pressure goal, as this is directly related to future cardiovascular risk reduction.
- Treatment decisions should consider patient-specific factors and avoid limiting initial choices to a single drug class.
Abstract:
Hypertension is a common condition among older people in most developed countries, and is a very important, if not the most important, risk factor for all subtypes of vascular disease and death. Many clinical trials in older people have demonstrated significant reductions in myocardial infarctions and strokes when antihypertensive drugs are provided. Lifestyle modifications are still recommended because they can lower a surrogate end point--blood pressure--but there are no data showing they reduce event rates. It is not appropriate to limit the choice of initial drug for hypertensive older individuals to a single class of agents, since so many older people have other medical problems that affect this decision. Monotherapy with an alpha blocker, however, is no longer recommended, even for men with hypertension and benign prostatic hypertrophy, as doxazosin was associated with a higher rate of cardiovascular events in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. The classic strategy of an initial diuretic (for at least 1 month) will likely be verified by the final results of ongoing randomized trials, expected in 2003. Until then, this strategy is effective, inexpensive, and unlikely to cause many adverse effects. Probably the most important exhortation, however, should be to achieve the blood pressure goal appropriate for the patient's risk status. Numerous clinical trials in older hypertensive patients have shown that more benefits accrue when the goal blood pressure is achieved than if a specific antihypertensive agent is chosen as initial therapy. Future cardiovascular risk may be related directly to the blood pressure attained, rather than to how it was attained.