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Special considerations in the elderly patient
1Johns Hopkins Hospital, Baltimore, Maryland 21205.
Insights
Verapamil, a calcium blocker, more effectively reduces left ventricular (LV) mass in elderly hypertensive patients than atenolol, a beta-blocker. This reduction improves diastolic filling without impairing cardiac function.
Area of Science:
- Cardiology
- Geriatrics
- Pharmacology
Background:
- Elderly hypertensive patients present unique treatment challenges, including altered physiology and comorbidities.
- The role of reducing left ventricular (LV) mass as a therapeutic target in this population is debated.
Purpose of the Study:
- To compare the efficacy of verapamil (calcium blocker) versus atenolol (beta-blocker) in reducing LV mass in elderly hypertensive patients.
- To assess the impact of LV mass reduction on LV filling and contractile performance.
Main Methods:
- A six-month, double-blind, randomized study involving 42 hypertensive patients over 60 years old.
- Patients received escalating doses of long-acting verapamil or atenolol.
- LV mass was measured using two-dimensional echocardiography; diastolic filling and contractile performance were assessed via gated blood pool scans.
Main Results:
- Both verapamil and atenolol lowered blood pressure, but atenolol required more frequent addition of chlorthalidone.
- Verapamil significantly reduced LV mass index, while atenolol did not.
- LV mass reduction with verapamil was associated with improved peak filling rate and peak filling to peak ejection ratio, without compromising cardiac output or ejection fraction.
Conclusions:
- Verapamil is more effective than atenolol in reducing LV mass in elderly hypertensive patients.
- Reduction of LV mass by verapamil therapy improves diastolic filling and maintains contractile performance.
Abstract:
Special considerations in the treatment of the elderly hypertensive include altered pathophysiology, the increasing likelihood of coexisting disease, and the question of whether reduction of left ventricular (LV) mass should be a therapeutic goal. The objective of our study was to compare the ability of a calcium blocker, verapamil, and a beta-blocker, atenolol, to induce reduction of LV mass and to determine the effects of any such reduction on LV filling and contractile performance. Forty-two hypertensive patients over 60 years of age were randomized to progressively increasing doses of long-acting verapamil or atenolol in a double-blind fashion and followed over a six-month period. Blood pressure decreased in both groups but atenolol-treated subjects more frequently required the addition of chlorthalidone. Despite similar blood pressure reductions, mean LV mass index, determined by two-dimensional echocardiography, was significantly reduced in the verapamil group magnitude of [104 +/- 5 g/m2 to 85 +/- 5 g/m2 (P less than 0.01)] but was not changed in the atenolol group. Following withdrawal of therapy, gated blood pool scan determined peak filling rate and the ratio of peak filling to peak ejection significantly increased in the group evidencing reduction (2.42 +/- 0.2 to 3.31 +/- 0.4 EDV/sec and 0.61 +/- 0.03 to 0.85 +/- 0.05, respectively) but did not change in the group which showed no reduction. Cardiac output and ejection fraction were maintained, both at rest and during mild upright exercise in the group evidencing reduction. Reduction of LV mass occurs more frequently with verapamil than with atenolol therapy in elderly hypertensives. Reduction improves diastolic filling and does not impair contractile performance.