Treatment of Older Persons with Hypertension
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Older persons are more likely to have hypertension and isolated systolic hypertension. They are also more likely to have target organ damage and clinical cardiovascular disease, and to develop cardiovascular events. Finally, the reality is that they are also less likely to have their hypertension controlled. Consequently, the need for antihypertensive treatment in this patient population remains crucial. The use of such drug therapy results in a reduction of coronary events, stroke, and heart failure in older persons.
This article examines the evidence supporting the incidence and prevalence of hypertension in older persons as well as associated medical conditions, and discusses treatment goals and the appropriate choice of medication depending on the specific needs of the older patient being managed. The choice of drug therapy varies between those with hypertension and without associated medical conditions, for whom diuretics should serve as initial therapy, and those with hypertension and associated medical conditions. Within the latter group, the selection of drug therapy will depend on which associated medical conditions are involved.
FINDINGS ON HYPERTENSION IN OLDER PERSONS
In a 2002 study of a population of older persons residing in a long-term care facility, hypertension was present in 57% of 1160 older men and in 60% of 2464 older women, with two-thirds of these older persons having isolated systolic hypertension.1 In another study of 1819 older men and women living in the community, 58% had hypertension, with two-thirds of these older persons having isolated systolic hypertension.2 In this study, hypertension was present in 52% of older white persons, in 71% of older African Americans, in 62% of older Hispanics, and in 64% of older Asians.2 Target organ damage, clinical cardiovascular disease, or diabetes mellitus was present in 70% of these older persons with hypertension.2
The higher the systolic or diastolic blood pressure in older persons, the greater the cardiovascular morbidity and mortality.3 Increased systolic blood pressure and pulse pressure are stronger risk factors for cardiovascular morbidity and mortality in older persons than is increased diastolic blood pressure.4 The Cardiovascular Health Study5 found that a brachial systolic blood pressure higher than 169 mm Hg increased the 5-year mortality 2.4 times in 5202 older men and women.
Hypertension in older persons is a major risk factor for coronary events,6,7 stroke,8,9 congestive heart failure (CHF),10-12 and peripheral arterial disease.13,14 Older persons are more likely to have hypertension and isolated systolic hypertension, to have target organ damage and clinical cardiovascular disease, and to develop cardiovascular events, and are less likely to have hypertension controlled.
Many prospective, double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces the development of coronary events, stroke, and CHF in older persons.15 Treatment with antihypertensive drug therapy reduces the incidence of all strokes by 34% in men, 38% in women, 36% in older persons, and 34% in persons older than 80 years.16 The overall data suggest that reduction of stroke in persons with hypertension is related more to a reduction in blood pressure than to the type of antihypertensive drugs used.16
Gueyffier et al17 performed a meta-analysis of data from all persons 80 years of age and older in randomized controlled trials of antihypertensive drugs through direct contact with the study investigators.
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