Treatment of hypertension in the elderly

The outcome of treatment in elderly hypertensives is examined in six major randomized controlled trials. Thiazide diuretics were first- or second-line drugs in each, and beta-blockers were first- or second-line drugs in four.

All compared immediate active treatment, with drugs added stepwise until blood pressure was controlled, versus withholding antihypertensive treatment unless blood pressure exceeded predetermined safety levels.

Because placebo-treated patients required active treatment and actively treated patients required more than one drug, benefits were underestimated and the comparisons were not of single drugs with each other or with placebo. The incidence of fatal stroke was reduced by 33%, of fatal coronary events by 26% and cardiovascular mortality by 22%. Because cardiovascular risk varied among the trial populations, the absolute benefit from treatment varied markedly.

In trials representative of unselected patients, treatment of diastolic hypertension might prevent cardiovascular complications in 1.4-2.2% of patients each year and fatal cardiovascular complications in 0.5-1.3% each year. In isolated systolic hypertension, treatment might prevent cardiovascular complications in 1.1% of patients each year. Generally, diuretic treatment proved superior to treatment with beta-blocker, and drugs of both types were well tolerated. There is a strong case for treating elderly hypertensives with a diuretic-based regimen.