Choosing the optimum therapy for older hypertensive patients

The older hypertensive patient (greater than or equal to 60 years) is at progressive risk of suffering from cardiovascular complications of hypertension (heart attack, congestive heart failure, stroke, occlusive peripheral arterial disease and renal failure). In this age group, hypertension is quantified as a blood pressure equal to or greater than 160/95mm Hg (average of 3 times 3 readings). With an increasing baseline risk, the returns of antihypertensive treatment increase, at least up to the age of 80 years. Prospective therapeutic trials have shown considerable benefits regarding prevention of stroke and congestive heart failure. This particularly applies to thiazide-type diuretics. Before any treatment is undertaken, the cardiovascular status of the older hypertensive patient should be assessed with utmost care, because target organ damage may turn the normalisation of blood pressure into a disadvantage. The profiles of currently available drugs are reviewed against the background of aging. There is not yet any firm evidence to support the thesis that some drug classes are better suited than others for treating older hypertensive patients, although some caution with alpha 1-blockers and centrally acting agents seems appropriate. Finally, some practical recommendations are presented on the build-up of optimum therapy in individual patients.