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Guest Editorial: What Is the Appropriate Treatment of Hypertension in Elders?

^a Divisions of Cardiology and Geriatrics, Westchester Medical Center/New York Medical College, Valhalla.

Wilbert S. Aronow, FGSA, Cardiology Division, New York Medical College, 23 Pebble Way, New Rochelle, NY 10804 E-mail: wsaronow{at}aol.com.

THE article titled "Age-Related Bias in the Management of Hypertension: A National Survey of Physicians' Opinions on Hypertension in Elderly Adults" published in this issue of the Journal of Gerontology: Medical Sciences reports questionnaire data answered by 39% of physicians randomly selected from the American Geriatrics Society mailing list ⁽¹⁾. These data indicate a need for intensive education of geriatricians about the appropriate treatment of hypertension in elders.

About 60% of persons in the United States between the ages of 65 and 75 years and 70% of those aged 75 years and older have hypertension ⁽²⁾. More than 60% of these persons with hypertension have isolated systolic hypertension ⁽³⁾. Hypertension was present in 665 of 1160 men (57%) with a mean age of 80 years ⁽⁴⁾. Systolic and diastolic hypertension was present in 20% of these men and isolated systolic hypertension in 37% of these men ⁽⁴⁾. Hypertension was present in 1471 of 2464 women (60%) with a mean age of 81 years ⁽⁴⁾. Systolic and diastolic hypertension was present in 21% of these women and isolated systolic hypertension in 39% of these women ⁽⁴⁾. In Tainan City, southern Taiwan, the prevalence of hypertension was 59% in older men and 62% in older women ⁽⁵⁾.

Of 1819 persons, mean age 80 years, living in the community and seen in an academic geriatrics practice, 372 persons (20%) had systolic and diastolic hypertension, 679 persons (37%) had isolated systolic hypertension, and 1051 persons (58%) had hypertension ⁽⁶⁾. In this study, hypertension was present in 554 of 1075 older whites (52%), in 279 of 394 older African Americans (71%), in 202 of 325 older Hispanics (62%), and in 16 of 25 older Asians (64%) ⁽⁶⁾. Target organ damage, clinical cardiovascular disease, or diabetes mellitus (risk group C) was present in 738 of the 1051 older persons (70%) with hypertension ⁽⁶⁾. The other 313 older persons (30%) with hypertension had at least one major risk factor other than diabetes mellitus (risk group B) ⁽⁶⁾.

The higher the systolic or diastolic blood pressure in older persons, the greater the morbidity and mortality from cardiovascular disease ⁽⁷⁾. Increased systolic blood pressure is a stronger risk factor for cardiovascular morbidity and mortality in older persons than is increased diastolic blood pressure ⁽⁸⁾⁽⁹⁾. An increased pulse pressure found in older persons 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 ⁽⁸⁾⁽⁹⁾. 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 ⁽¹⁰⁾. Hypertension in elders is a major risk factor for new coronary events ^(11)(12), for stroke ^(13)(14)(15), for congestive heart failure (CHF) ^{(16)(17)(18)(19)}, and for peripheral arterial disease ^(20)(21).

A meta-analysis of five studies of treatment of hypertension in elderly adults indicated that antihypertensive treatment significantly reduced the incidence of strokes by 34% and of new coronary events by 19% ⁽²²⁾. Because coronary events are much more common than strokes, antihypertensive treatment will prevent a greater number of coronary events than strokes in older persons in terms of absolute numbers. In the Systolic Hypertension in the Elderly Program, drug therapy with the step 1 drug, chlorthalidone, 12.5 mg–25 mg daily, and the step 2 drug, atenolol, 25 mg–50 mg daily, caused at 4.5-year follow-up a 49% significant reduction in the development of CHF in older men and women ⁽²³⁾.

Gueyffier and colleagues ⁽²⁴⁾ performed a meta-analysis of data from all patients aged 80 years and older in randomized, controlled trials of antihypertensive drugs through direct contact with the study investigators. This meta-analysis of data from 1670 participants aged 80 years and older showed that antihypertensive drug treatment significantly reduced strokes by 34%, major cardiovascular events by 22%, and CHF by 39% ⁽²⁴⁾. Unless data from the ongoing Hypertension in the Very Elderly trial ⁽²⁵⁾ show that antihypertensive drug treatment is not beneficial in very elderly hypertensive patients, this very elderly group should be treated. At this time, we cannot justify an age threshold beyond which hypertension should not be treated.

I agree with the recommendation of the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of Hypertension (JNC VI) that the goal of treatment of hypertension in older persons is to reduce the blood pressure to less than 140/90 mm Hg if possible ⁽²⁶⁾. Older persons with diastolic hypertension should have their diastolic blood pressure decreased to 80 to 85 mm Hg ⁽²⁷⁾. However, only 26% of persons with hypertension older than 60 years of age and only 17% of men and 21% of women older than 75 years of age have their blood pressure reduced to 140/90 mm Hg or lower ⁽⁷⁾. The older you are, the more likely you will have hypertension and isolated systolic hypertension, the more likely you are to have target organ damage and clinical cardiovascular disease, the more likely you are to develop new cardiovascular events, and the less likely you are to have hypertension controlled.

I agree with the recommendation of JNC VI that diuretics or beta blockers 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 decrease cardiovascular morbidity and mortality in controlled clinical trials ⁽²⁶⁾. However, older persons with hypertension have a very high prevalence of associated medical conditions. The selection of antihypertensive drugs administered to these persons depends on their associated medical conditions.

Persons with prior myocardial infarction should be treated with beta blockers and angiotensin-converting enzyme (ACE) inhibitors and not treated with calcium channel blockers or alpha blockers ^{(28)(29)(30)(31)(32)(33)(34)(35)}. In an observational prospective study of 1212 older men and women with a mean age of 80 years 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 persons treated with beta blockers or ACE inhibitors ⁽³⁵⁾. In older persons treated with two antihypertensive drugs, the incidence of new coronary events was lowest in persons treated with beta blockers plus ACE inhibitors ⁽³⁵⁾.

The benefit of beta blockers in decreasing coronary events in older persons with prior myocardial infarction is especially increased in persons with diabetes mellitus ⁽³¹⁾, symptomatic peripheral arterial disease ⁽³²⁾, abnormal left ventricular ejection fraction (LVEF) ^(30)(36), complex ventricular arrhythmias with abnormal LVEF ⁽³⁷⁾ or normal LVEF ⁽³⁸⁾, and with CHF with abnormal LVEF ⁽³⁹⁾ or normal LVEF ⁽⁴⁰⁾. Beta blockers should also be used to treat older persons with hypertension who have angina pectoris ⁽⁴¹⁾, myocardial ischemia ⁽⁴²⁾, supraventricular tachyarrhythmias such as atrial fibrillation with a rapid ventricular rate ⁽⁴³⁾, hyperthyroidism ⁽⁴⁴⁾, preoperative hypertension, migraine, or essential tremor.

In addition to beta blockers, older persons with CHF should be treated with diuretics and ACE inhibitors ^(45)(46). ACE inhibitors should also be administered to persons with diabetes mellitus, renal insufficiency, or proteinuria ⁽²⁶⁾. The blood pressure should be reduced to 130/85 mm Hg or lower in persons with diabetes mellitus or renal insufficiency and to 125/75 mm Hg or lower in persons with proteinuria in excess of 1 gram per 24 hours ⁽²⁶⁾.

Compared with amlodipine, ramipril significantly reduced renal disease progression in 1094 African Americans with hypertensive nephrosclerosis ⁽⁴⁷⁾. In addition, a meta-analysis of 109 treatment studies found that ACE inhibitors were more effective than other antihypertensive drugs in decreasing left ventricular mass ⁽⁴⁸⁾. If the older person cannot tolerate an ACE inhibitor because of cough, rash, or altered taste sensation, an angiotensin II type 1 receptor antagonist should be administered. In the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan Study involving 1513 patients with type 2 diabetes mellitus and nephropathy, compared with placebo, losartan significantly reduced the incidence of a doubling of the serum creatinine concentration by 25%, end-stage renal disease by 28%, and first hospitalization for CHF by 32% ⁽⁴⁹⁾.

Thiazide diuretics should be used in persons with osteoporosis. Alpha blockers are useful in treating men with benign prostatic hypertrophy. However, compared with doxazosin, chlorthalidone significantly decreased the risk of combined cardiovascular events, especially CHF, in high-risk hypertensive persons ⁽³⁴⁾.

The initial hypertensive drug should be given 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 administered 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 drugs, the physician should consider possible reasons for inadequate response to antihypertensive drug treatment including nonadherence to therapy, pseudoresistance, volume overload, drug interactions (nonsteroidal antiinflammatory drugs, sympathomimetics, nasal decongestants, antidepressants, caffeine, etc.), and associated conditions including increasing obesity, smoking, excessive ethanol intake, and insulin resistance. Causes of secondary hypertension should be identified and treated.

Falls or syncope in older persons may be due to orthostatic or postprandial hypotension ^(50)(51). Management of orthostatic and postprandial hypotension in older persons is discussed in detail elsewhere ⁽⁵⁰⁾. The dose of antihypertensive drug may need to be decreased or another antihypertensive drug administered.

Older persons with hypertension must have other modifiable risk factors controlled. Cigarette smoking must be stopped. Diet and exercise should be used to reduce weight in overweight persons.

The risk of cardiovascular events is increased in older persons with diabetes mellitus and is related to the duration of diabetes mellitus, hemoglobin A_1c values, and the presence of smoking, hypertension, and hypercholesterolemia ⁽⁵²⁾. Of 531 older diabetics seen by endocrinologists, general internists, and geriatricians in an urban academic medical center, 85% of diabetics had a systolic blood pressure higher than 130 mm Hg, and 20% of the diabetics had a diastolic blood pressure higher than 85 mm Hg ⁽⁵³⁾. In older persons with hypertension with a high prevalence of central obesity, impaired glycemic control was common but was not associated with fasting hyperinsulinemia or peripheral insulin resistance ⁽⁵⁴⁾.

Each 10-mm Hg reduction in updated mean systolic blood pressure in the United Kingdom Prospective Diabetes Study was associated with a significant 11% reduction in myocardial infarction ⁽⁵⁵⁾. In this study, each 1% reduction in updated mean hemoglobin A_1c was associated with a significant 14% reduction in myocardial infarction ⁽⁵⁶⁾. The lowest risk of complications occurred in persons with hemoglobin A_1c values less than 6.0%.

Finally, hyperlipidemia must be treated in older persons with hypertension ^{(28)(57)(58)(59)(60)(61)(62)}. In an observational prospective study of 488 men and 922 women with a mean age of 82 years with prior myocardial infarction and a serum low-density lipoprotein cholesterol 125 mg/dl, compared with no lipid-lowering drug treatment, statins caused at 36-month follow-up a significant independent reduction in incidence of new coronary events of 50% ⁽⁵⁹⁾, a significant independent reduction in incidence of new atherothrombotic brain infarction of 60% ⁽⁶⁰⁾, and a significant independent reduction in incidence of CHF of 48% ⁽⁶²⁾.

Received February 22, 2002

Accepted February 27, 2002

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