Large therapeutic studies in elderly patients with hypertension

Hypertension, including isolated systolic hypertension, is one of the major risk factors for stroke and coronary heart disease in elderly subjects, and is a common antecedent of heart failure, because it increases the risk either directly through increased after-load or indirectly as a risk factor for acute myocardial infarction. The proportion of people aged 65 and above is increasing. It is well documented that hypertension treatment in elderly patients reduces cardiovascular morbidity and mortality more than could be expected from the results of trials in middle-aged subjects. Most of the trials on old and new antihypertensive drugs have yielded similar results. Nevertheless, evidence in subjects above 80 years of age is still limited. Hypertension (systolic-diastolic) and isolated systolic hypertension should be treated in elderly patients, starting with low doses of medication, particularly diuretics alone or in combination with beta-blockers or angiotensin-converting enzyme inhibitors. Isolated systolic hypertension could also be treated with a long-acting calcium antagonist starting with low doses. The large therapeutic studies, because of the limitations imposed upon conclusions by the selection and exclusion criteria, by the statistical techniques that established the trial designs and by other study-related constraints, cannot be applied to all elderly patients seen in daily practice. Specifically patients may differ in age, severity of illness, presence of morbidity and a myriad of other clinical nuances. Non-pharmacological measures such as lifestyle modifications (losing weight, limiting alcohol intake, reducing sodium intake and exercise), should be instituted or improved if they existed, to maximise the benefit and minimise the risk inherent in pharmacological treatment. A medical approach may reconcile the results of these large therapeutic studies with 'real life' quality of life and patients' preferences in order to improve treatment compliance.