Treating Systemic Hypertension in Older Persons

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Citation:

Pages 28 - 32

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.

References:

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