Overview of hypertension treatment in the elderly Edward D. Freis, MD Cardiology in the Elderly 1993, 1:255-257 Keywords: aged, hypertension Because blood pressure in humans rises with age, more and more of us develop hypertension as we grow older. Hypertension is one of the most impor- tant problems in older patients. In this country two thirds of persons older than 65 years of age have hypertension, ie, blood pressure greater than 140/90 mim Hg [1]. Furthermore, the elderly currently repre- sent the most rapidly growing segment of the pop- ulation. Also, the risk for cardiovascular complica- tions is greater at any given level of blood pressure in older patients compared with younger patients [2]. In fact, epidemiologic evidence indicates that hyper- tension is the most important treatable risk factor in the elderly [3]. From the Department of Veterans Affairs Medical Center, Washington, DC, USA. Requests for reprints to Dr. Edward D. Freis, Department of Veterans Affairs, Medical Center, 50 Irving Street Northwest, Washington, DC 20422, USA. © 1993 Current Science ISSN 1058-3661 256 Cardiology in the Elderly June 1993, Vol 1 No 3 In persons older than 50 years of age, systolic blood pressure rises more than diastolic pressure [4]. The continued increase in systolic blood pressure asso- ciated with aging is probably caused by a grad- ual replacement of elastic tissue by collagen in the proximal aorta. The aorta becomes less distensible and causes blood pressure to increase during cardiac ejection, resulting in systolic hypertension. Contrary to previous opinion, it is now known that the risk for developing coronary artery disease or stroke is as great or greater in patients with systolic hyperten- sion as in patients with diastolic hypertension [5]. A meta-analysis of several therapeutic trials in pa- tients of all ages with mild to moderate hyperten- sion has shown a 42% reduction in stroke and a 14% reduction in coronary heart disease after treat- ment with antihypertensive drugs [6]. The greatest protective effect was seen against stroke, whereas that against myocardial infarction was substantially less. Prevention of cardiovascular complications is at least as effective in elderly patients with hyper- tension, including those with isolated systolic hy- pertension, as it is in younger patients. This finding was shown in the Systolic Hypertension in the El- derly Program (SHEP) trial [7], which was limited to elderly patients with isolated systolic hypertension. Over a 4.5-year follow-up period, the drug-treated group showed a 36% reduction in stroke and a sur- prising 27% decrease in complications due to coro- nary heart disease. Treatment was effective even in persons 80 to 85 years of age. A few common sense precautions can allow elderly people to tolerate antihypertensive drugs very well. The most important side-effects of these drugs result from excessive reduction of blood pressure, lead- ing to postural hypotension, fatigue, and weakness. Many elderly patients exhibit much higher blood pressures in the physician’s office than at home. EI- derly patients often react to this so-called “white- coat” phenomenon. When antihypertensive drugs are titrated to high doses based only on office blood pressure readings, hypotension may occur when the patient is at home. To avoid these side-effects, treat- ment should begin with half the usual initial dose. Doses can then be increased gradually as needed, with particular attention not only to the blood pres- sure but also to the patient’s complaints. If these complaints suggest the presence of hypotension, blood pressures should be taken by the patient or a family member in the home. These measurements should be done while the patient is in the upright (as well as the supine) position. It may be neces- sary to switch the patient to treatment with another drug or combination of drugs to obtain effective and symptom-free blood pressure control. In these days of high-pressure advertising cam- paigns aimed at promoting the newest antihyper- tensive agents, we may forget or be uninformed of the safety and effectiveness of older, less ex- pensive drugs (particularly the thiazide diuretics). These agents are highly effective, especially in older patients. For example, the combined data from three Veterans Administration Cooperative Stud- ies [8] indicated that the antihypertensive response to thiazides was greater in older patients than in younger patients. This age-associated difference was not found with propranolol, nadolol, and captopril. The SHEP trial [7] also showed the effectiveness of the thiazide diuretics. Not only are the thiazide diuretics highly effective in the elderly, but, contrary to previous opinion, they are also safe [9]. They do not increase the incidence of coronary heart disease, a finding that has now been convincingly shown by most clinical trials, in- cluding two recent trials in elderly patients [7,10]. The Medical Research Council of Great Britain trial [10] showed that thiazide diuretics were more ef- fective than B-blockers in preventing stroke in el- derly patients, whereas the SHEP trial [7] found that diuretic treatment resulted in a reduction of both stroke and, to a lesser extent, coronary heart disease. Some patients have an aversion to taking drugs and would rather bear the Spartan discipline of weight reduction or salt restriction. How effective are these nonpharmacologic approaches to treatment? Neither is as reliably effective as drug treatment. The most effective nondrug treatment has been weight reduc- tion, especially when it is combined with exercise. The problem for many patients is in maintaining this Spartan lifestyle over long periods. Salt restriction is less dependable in controlling hy- pertension. Even after reducing salt intake by half (to about 5 g/d), blood pressure will only decrease, on average, by 1 or 2 mm Hg. Further salt restriction is especially difficult because processed foods contain salt. During the past 40 years, we have seen great ad- vances in the control of hypertension. Previously, hy- pertension was considered to be “essential” in na- ture. Despite these misguided beginnings, it has re- cently been proven that reduction of elevated blood pressure was of great benefit to all patients, in- cluding the elderly [11]. Malignant hypertension has practically disappeared. Congestive heart fail- ure (once a common complication), renal failure, and stroke have been greatly reduced, and some evi- dence suggests that blood pressure reduction may lower, at least in part, the incidence of coronary artery disease. The combination of antihypertensive treatment and control of blood lipids should further reduce this cardiovascular complication. We have emerged from darkness into light and by doing so have provided great benefit to vast numbers of pa- tients with this disorder. Annotated references and recommended reading Of special interest Of outstanding interest THE 1988 JOINT NATIONAL COMMITTEE: The 1988 Report of the Joint National Committee on Detection, Evalua- tion and Treatment of High Blood Pressure. Arch Intern Med 1988, 148:1023-1038. THE WORKING GROUP ON HYPERTENSION IN THE ELDERLY: Statement on Hypertension in the Elderly. JAMA 1986, 256:70-74. CASTELLI WP, WILSON PWE, LEVY D, ANDERSON K: Car- diovascular Risk Factors in the Elderly. Am J Cardiol 1989, 63:12H-19H. DEPARTMENT OF HEALTH AND HUMAN SERVICES: Blood Pressure Levels in Persons from 18-74 Years of Age in 1978-1980 and Trends in Blood Pressure from 1960-1980 in the United States. Vital and Health Statistics Series II. No. 234; July 1988:37. This article discusses the increasing incidence of hypertension, particularly systolic hypertension, with age. 5. ABERNATHY J, BORHANI NO, HAWKINS CM, Crow R, ENTWISILE G, JONES JW, ET AL.: Systolic Blood Pressure as an Independent Predictor of Mortality in the Hyper- tension Detection and Follow-up Program. Am J Prev Med 1986, 2:123-132. REVIEW IN DEPTH Isolated systolic hypertension An interesting article that emphasizes the importance of systolic blood pressure as a risk factor. 6. COLLINS R, PETRO R, MACMAHON S, HEBERT P, FIEBACH NH, EBERLEIN KA, ET AL.: Blood Pressure Stroke and Coronary Heart Disease. Part 2, Short-Term Reductions in Blood Pressure: Overview of Randomized Drug Trials in Their Epidemiological Context. Lancet 1990, 1:827-838. SHEP COOPERATIVE RESEARCH GROUP: Prevention of Stroke by Antihypertensive Drug Treatment in Older Persons with Isolated Systolic Hypertension. Final Re- sults of the Systolic Hypertension in the Elderly Pro- gram (SHEP). JAMA 1991, 265:3255-3264. A well-controlled trial showing the effectiveness of treatment in patients with isolated systolic hypertension. 8. 9. 10. FrREIS ED: Age and Antihypertensive Drugs: (Hy- drochlorothiazide, Bendroflumethiazide, Nadolol and Captopril). Am J Cardiol 1988, 61:117-121. FREIS ED: The Cardiotoxicity of Thiazide Diuretics. Re- view of the Evidence. J Hypertens 1990, 8:S23-S32. MRC WORKING PARTY: Medical Research Council Trial of Treatment of Hypertension in Older Adults. Br Med ] 1992, 304:405-412. A large controlled trial demonstrating the safety and effectiveness of treating hypertension in the elderly. 11. VETERANS ADMINISTRATION COOPERATIVE STUDY GROUP: Effects of Treatment in Hypertension. II Results in Pa- tients with Diastolic Blood Pressure Averaging 90-114 mm Hg. JAMA 1970, 213:1143-1152. 257