Treating Systemic Hypertension in Older Persons

Volume 17 - Issue 2 - February 2009

Authors:

Wilbert S. Aronow, MD, FACC, FAHA, FACP, and William H. Frishman, MD, MACP, FACC, FAHA

Author Affiliations:

From the Department of Medicine, Cardiology Division, New York Medical College/Westchester Medical Center, Valhalla, NY.

_____________________________

Introduction

Hypertension in older persons is a major risk factor for coronary events,1-3 for stroke,1,4-6 for congestive heart failure (CHF),1,7,8 and for peripheral arterial disease.9-12 Older persons are more likely to have hypertension and isolated systolic hypertension, to have target organ damage and clinical cardiovascular disease, and to develop new cardiovascular events, and are less likely to have hypertension controlled.

Consider the following clinical vignette: An 83-year-old woman with a prior myocardial infarction had a blood pressure in the sitting position of 172/90 mm Hg in the right brachial artery and of 174/90 mm Hg in the left brachial artery. Her standing blood pressures were similar. Her physician was uncertain whether he should treat her blood pressure because of different published opinions13,14 and because of a debate he had heard at a national meeting in which conflicting opinions were expressed. This article will discuss why this woman should be treated with antihypertensive drug therapy.15,16

In a 30-year follow-up of the Framingham Study, hypertension was present in 57% of 1160 older men (mean age, 80 yr) and in 60% of 2464 older women (mean age, 81 yr) in a nursing home, with two-thirds of these older persons having isolated systolic hypertension.17 Of 1819 older persons (mean age, 80 yr) living in the community and seen in an academic geriatrics practice, 58% had hypertension (37% with isolated systolic hypertension).18 Target organ damage, clinical cardiovascular disease, or diabetes mellitus was present in 70% of the older persons with hypertension.18 The prevalence of hypertension in older residents with diabetes mellitus in a nursing home was 76%.19

The higher the systolic or diastolic blood pressure in older persons, the higher the cardiovascular morbidity and mortality.20 Increased systolic blood pressure and pulse pressure are stronger risk factors for cardiovascular morbidity and mortality in this population than is increased diastolic blood pressure.21,22 An increased pulse pressure found in older individuals with isolated systolic hypertension indicates decreased vascular compliance in the large arteries and is even a better marker of risk than is systolic or diastolic blood pressure.21,22 The Cardiovascular Health Study found in 5202 older men and women that a brachial systolic blood pressure higher than 169 mm Hg increased the mortality rate 2.4 times.23

Barriers to treatment of hypertension include physicians not understanding that frail elderly patients should be treated according to recommended guidelines to reduce cardiovascular morbidity and mortality. Elderly persons with hypertension, if treated appropriately, will have a greater absolute decrease in cardiovascular events such as major coronary events, stroke, CHF, and renal insufficiency, and a greater reduction in dementia24 than younger persons. Another barrier is that some elderly persons living in the community may not be able to afford their antihypertensive medications.25

Antihypertensive Drug Trials in Older Persons

Numerous prospective, double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces the development of new coronary events, stroke, and CHF in older persons.26 Therapy with antihypertensive drugs reduces the incidence of all strokes by 38% in women, by 34% in men, by 36% in older persons, and by 34% in persons older than 80 years.5 The overall data suggest that reduction of stroke in older persons with hypertension is related more to a decrease in blood pressure than to the type of antihypertensive drugs used.5

In the Perindopril Protection Against Recurrent Stroke Study,27 perindopril plus indapamide reduced stroke-related dementia by 34% and cognitive decline by 45%. In the Systolic Hypertension in Europe trial,28 nitrendipine decreased dementia by 55% at 3.9-year follow-up. In 1900 older African Americans, antihypertensive drug treatment decreased cognitive impairment by 38%.29 In the Rotterdam Study,30 antihypertensive drugs decreased vascular dementia by 70%.

On the basis of data available at the time, Aronow13 proposed in an editorial that unless HYVET [HYpertension in the Very Elderly Trial]15 showed that antihypertensive drug therapy was not beneficial in patients age 80 years and older, this group should receive antihypertensive drug treatment. Goodwin14 disagreed with this approach, and his response to Aronow’s editorial13 was accompanied by eight commentaries, some of which supported the treatment of very elderly hypertensive patients and some of which did not.

HYVET

In HYVET,15 3845 individuals age 80 years and older (mean age, 83.6 yr) with a sustained systolic blood pressure of 160 mm Hg or higher (mean sitting blood pressure, 173.0/90.8 mm Hg) were randomized to indapamide (sustained release 1.5 mg) or matching placebo. Perindopril 2 mg or 4 mg, or matching placebo, was added if needed to achieve the target blood pressure of 150/80 mm Hg. Median follow-up was 1.8 years. At 2 years, the mean blood pressure was 15.0/6.1 mm Hg lower in the drug treatment group than in the placebo group. In an intention-to-treat analysis, antihypertensive drug treatment reduced the incidence of the primary endpoint (fatal or nonfatal stroke) by 30% (P = 0.06). Antihypertensive drug treatment reduced fatal stroke by 39% (P = 0.05), all-cause mortality by 21% (P = 0.02), death from cardiovascular causes by 23% (P = 0.06), and heart failure by 64% (P < 0.001). The significant 21% reduction in all-cause mortality by antihypertensive drug treatment was unexpected. The benefits of antihypertensive drug treatment began to be apparent during the first year of follow-up.

The prevalence of baseline cardiovascular disease was only 12% in the patients in HYVET. In a cohort of patients (mean age, 80 yr) with hypertension seen in a university geriatrics practice, 70% had baseline cardiovascular disease, target organ damage, or diabetes mellitus.18 An elderly population such as this one with a high prevalence of cardiovascular disease would be expected to have a greater absolute reduction in cardiovascular events resulting from antihypertensive drug therapy.

Use of Antihypertensive Drug Therapy in Older Persons

We agree with the recommendations of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)26 that the goal of treatment of hypertension in elderly persons is to lower the blood pressure to less than 140/90 mm Hg and to less than 130/80 mm Hg in older persons with diabetes mellitus or chronic renal insufficiency. Elderly persons with diastolic hypertension should have their diastolic blood pressure reduced to 80 to 85 mm Hg.31

Most elderly persons with hypertension will need two or more antihypertensive drugs to control their hypertension.26,32 In elderly persons with hypertension in an academic nursing home, 27% received one antihypertensive drug, 43% received two antihypertensive drugs, 22% received three antihypertensive drugs, 6% received four antihypertensive drugs, and 3% received five antihypertensive drugs.32 It is important to measure blood pressure in both arms and to use the arm with the higher blood pressure during follow-up of treatment.33 It is also very important to measure blood pressure in older persons in the upright position as well as in the sitting position.

We agree with the recommendations of JNC 7 that diuretics should be used as initial drugs in the treatment of older persons with hypertension and no associated medical conditions because these drugs have been demonstrated to reduce cardiovascular events and mortality in controlled clinical trials.26 However, elderly persons with hypertension have a very high prevalence of associated medical conditions. The selection of antihypertensive drug therapy in these persons depends on their associated medical conditions. If the blood pressure is greater than 20/10 mm Hg above the goal blood pressure, drug therapy should be initiated with two antihypertensive drugs, one of which should be a thiazide-type diuretic.26

Elderly persons with prior myocardial infarction should be treated with beta blockers and angiotensin-converting enzyme (ACE) inhibitors, and not treated with alpha blockers or calcium channel blockers.34-42 In an observational prospective study of 1212 elderly men and women in a nursing home with prior myocardial infarction and hypertension treated with beta blockers, ACE inhibitors, diuretics, calcium channel blockers, or alpha blockers, at 40-month follow-up, the incidence of new coronary events in persons treated with one antihypertensive drug was lowest in older residents treated with beta blockers or ACE inhibitors.41 In those treated with two antihypertensive drugs, the incidence of new coronary events was lowest in persons treated with beta blockers plus ACE inhibitors.41

The benefit of beta blockers in reducing new coronary events in elderly patients with prior myocardial infarction is especially increased in elderly patients with diabetes mellitus,37 peripheral arterial disease,38 abnormal left ventricular ejection fraction (LVEF),36 complex ventricular arrhythmias with abnormal LVEF43 or normal LVEF,44 and CHF with abnormal LVEF45 or normal LVEF.46 Beta blockers should also be used to treat elderly patients with hypertension who have angina pectoris,47 myocardial ischemia,48 supraventricular tachyarrhythmias (eg, atrial fibrillation with a rapid ventricular rate),49,50 hyperthyroidism,51 preoperative hypertension,26 migraine,26 or essential tremor.26

Beta blockers such as propranolol, timolol, metoprolol, and carvedilol should be used to treat older persons with myocardial infarction.52 Beta blockers with intrinsic sympathomimetic activity should not be used to treat patients after myocardial infarction. The hydrophilic beta blocker atenolol is not as efficacious as propranolol, timolol, metoprolol, or carvedilol in treating hypertension in older persons.52,53

In addition to beta blockers, older persons with CHF should be treated with diuretics and ACE inhibitors.54,55 ACE inhibitors or angiotensin II type 1 receptor blockers should be administered to older persons with diabetes mellitus, chronic renal insufficiency, or proteinuria.26 Compared with amlodipine, ramipril significantly decreased progression of renal disease in 1094 African Americans with hypertensive nephrosclerosis.56 If the older patient cannot tolerate an ACE inhibitor because of cough, angioneurotic edema, rash, or altered taste sensation, an angiotensin II type 1 receptor blocker should be administered.57 Compared to ramipril alone, the addition of telmisartan to ramipril in patients (mean age, 67 yr) with vascular disease or high-risk diabetes mellitus did not improve the efficacy of the primary outcome of cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure at 56-month median follow-up, but increased hypotensive symptoms (4.8% vs 1.7%), syncope (0.3% vs 0.2%), and renal dysfunction (1.1% vs 0.7%).58

Diuretics and ACE inhibitors are recommended by JNC 7 to prevent recurrent stroke in older persons with hypertension.26,27 Thiazide diuretics should be used to treat older patients with osteoporosis.26

It is very important to treat other cardiovascular risk factors in elderly nursing home residents with hypertension to reduce cardiovascular events and mortality. Smoking must be stopped, dyslipidemia must be treated,59-62 and diabetes mellitus must be controlled.19,63-67

The initial antihypertensive drug should be administered at the lowest dose and gradually increased to the maximum dose. If the antihypertensive response to the initial drug is inadequate after reaching the full dose of drug, a second drug from another class should be given if the person is tolerating the initial drug. If the person is having no therapeutic response or significant adverse effects, a drug from another class should be substituted. If a diuretic is not the initial drug, it is usually indicated as the second drug. If the antihypertensive response is inadequate after reaching the full dose of two classes of drugs, a third drug from another class should be added.

Before adding new antihypertensive drugs, the physician should consider possible reasons for inadequate response to antihypertensive drug therapy, including nonadherence to therapy, pseudoresistance, volume overload, drug interactions (eg, use of nonsteroidal anti-inflammatory drugs, caffeine, antidepressants, nasal decongestants, sympathomimetics), and associated conditions such as increasing obesity, smoking, excessive intake of ethyl alcohol, and insulin resistance.26 In addition, the causes of secondary hypertension should be identified and treated.26,68

Falls or syncope in older persons may be due to orthostatic or postprandial hypotension.69 Management of orthostatic and postprandial hypotension in older persons is discussed in detail elsewhere.69 The dose of antihypertensive drug may need to be decreased or another antihypertensive drug given. Older frail persons are most susceptible to orthostatic and postprandial hypotension.69 Measurement of blood pressure in the upright position, especially after eating, is indicated in these persons.69

Additional Considerations

There was a significantly lower incidence of adequate blood pressure control in older persons with hypertension who had to pay for medications prescribed by their physician.25 This problem needs to be addressed if we are to decrease the great amount of cardiovascular morbidity and mortality caused by inadequate control of hypertension.

Many nursing home physicians are reluctant to adequately treat hypertension in their frail patients. Physician education needs to be intensified to provide better medical care of the elderly through the use of optimal doses of drugs found to be effective and safe by evidence-based studies, and, therefore, recommended by JNC 7 guidelines.26

The authors report no relevant financial relationships.

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