Clinical Geriatrics

To the Editor:

I have several comments about the article by Drs. Aronow and Frishman, both distinguished cardiologists, on “Treating Systemic Hypertension in Older Persons.”1 There is no question that hypertension, particularly systolic hypertension, is a common problem in the elderly and should be treated, but at what level and to what goal? The authors state that “We agree with the recommendations of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7), 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.”

A Swedish study of blood pressure in the very old showed that systolic blood pressure, diastolic blood pressure, and pulse pressure were all inversely associated with four-year mortality, with systolic blood pressure being the strongest predictor.2 The systolic blood pressure associated with the lowest mortality was 164 mm Hg (95% confidence interval, 154-184 mm Hg). A recent study indicated that the beneficial effects associated with lower blood pressure for a common age-related outcome, dementia, are age-related, apparently restricted to persons younger than age 75.3 In a previous publication, I have stated that the “levels of treatment for hypertension in patients older than 85 should be raised, and that clinicians, at the least, should be cautious in prescribing antihypertensive medication in this group of the oldest old.4

Albert J. Finestone, MD, MSc, FACP
Director, Institute on Aging
Associate Dean CME, Emeritus
Adjunct Professor of Medicine
Temple University School of Medicine
Philadelphia, PA
Consortium Project Director, Geriatric Education Center of Pennsylvania Partially HRSA Funded (Consortium of University of Pittsburgh, Penn State University, and Temple University)

References

1. Aronow WS, Frishman WH. Treating systemic hypertension in older persons. Clinical Geriatrics 2009;17:28-32.

2. Molander L, Lövheim H, Norman T, et al. Lower systolic blood pressure is associated with greater mortality in people aged 85 and older. J Am Geriatr Soc 2008;56:1853-1859. Published Online: September 22, 2008.

3. Li G, Rhew IC, Shofer JB, et al. Age-varying association between blood pressure and risk of dementia in those aged 65 and older: A community-based prospective cohort study. J Am Geriatr Soc 2007;55:1161-1167.

4. Finestone AJ. Reprise: “One size may not fit all.” J Clin Hypertens (Greenwich) 2008;10:887.

Drs. Aronow and Frishman respond:

The controversy whether patients aged 80 years and older with hypertension should be treated with antihypertensive drug therapy1 or not treated with antihypertensive drug therapy2 has been settled by the results from the HYpertension in the Very Elderly Trial (HYVET).3 Compared to placebo, antihypertensive drug therapy administered in a study of 3845 persons (mean age, 83.6 yr) reduced at 1.8-year median follow-up fatal or nonfatal stroke by 30% (P = 0.06), fatal stroke by 39% (P = 0.05), all-cause mortality by 21% (P = 0.02), cardiovascular mortality by 23% (P = 0.06), and heart failure by 64% (P < 0.001).3

The data by Molander et al4 and by Li et al5 are observational data, not data collected in a randomized, double-blind, placebo-controlled antihypertensive drug study. These data cannot be used as guidelines to treat hypertension.

However, we need data on target blood pressure for the elderly.6 Should our target blood pressure goal in the elderly be a systolic blood pressure less than 140 mm Hg, less than 130 mm Hg, or less than 120 mm Hg?6 How low should the diastolic blood pressure be allowed to reach? Further research is needed to answer these questions.

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