Pharmacotherapy for hypertension in older adults: a systematic review

Hypertension increases with increasing age. Optimal treatment of hypertension is important to reduce cardiovascular disease. Recent guidelines for hypertension have made recommendations for older adults but are supported by evidence that includes younger individuals. This systematic review evaluates the benefits and harms of antihypertensive agents in adults aged ≥65 years.

We searched MEDLINE and ClinicalTrials.gov for studies from 1996 to 2014. Eligible studies included participants aged ≥65 years with hypertension. Eligible studies had clearly defined treatment assignments, blood pressure (BP) targets, and evaluated endpoints of cardiovascular morbidity, mortality, and/or harms of antihypertensive medications. We abstracted study characteristics, cardiovascular benefits, and harms.

Thirty-one articles met the inclusion criteria. Most studies compared different antihypertensive agents and/or placebo groups. These studies consistently demonstrated reduced cardiovascular morbidity and mortality compared with no treatment. Seven studies examined optimal BP targets. Strict control [systolic BP (SBP)<140 mmHg] was not consistently better than mild control (SBP<150 mmHg) for adults aged ≥65 years. Mild SBP control benefitted subjects in all age ranges over 65 years. Few studies assessed and explicitly reported harms.

In this review, older adults with hypertension had decreased cardiovascular morbidity and mortality with antihypertensives compared with no treatment. Strict control was not consistently better than mild control in older adults. There was enormous heterogeneity in these studies, and reporting of harms stratified by age is lacking. The current evidence is insufficient to determine the safest, most beneficial hypertension regimen in older adults.