Treatment of Older Persons with Hypertension
Older persons are more likely to have hypertension and isolated systolic hypertension. They are also more likely to have target organ damage and clinical cardiovascular disease, and to develop cardiovascular events. Finally, the reality is that they are also less likely to have their hypertension controlled. Consequently, the need for antihypertensive treatment in this patient population remains crucial. The use of such drug therapy results in a reduction of coronary events, stroke, and heart failure in older persons. This article examines the evidence supporting the incidence and prevalence of hypertension in older persons as well as associated medical conditions, and discusses treatment goals and the appropriate choice of medication depending on the specific needs of the older patient being managed. The choice of drug therapy varies between those with hypertension and without associated medical conditions, for whom diuretics should serve as initial therapy, and those with hypertension and associated medical conditions. Within the latter group, the selection of drug therapy will depend on which associated medical conditions are involved.
FINDINGS ON HYPERTENSION IN OLDER PERSONS
In a 2002 study of a population of older persons residing in a long-term care facility, hypertension was present in 57% of 1160 older men and in 60% of 2464 older women, with two-thirds of these older persons having isolated systolic hypertension.1 In another study of 1819 older men and women living in the community, 58% had hypertension, with two-thirds of these older persons having isolated systolic hypertension.2 In this study, hypertension was present in 52% of older white persons, in 71% of older African Americans, in 62% of older Hispanics, and in 64% of older Asians.2 Target organ damage, clinical cardiovascular disease, or diabetes mellitus was present in 70% of these older persons with hypertension.2 The higher the systolic or diastolic blood pressure in older persons, the greater the cardiovascular morbidity and mortality.3 Increased systolic blood pressure and pulse pressure are stronger risk factors for cardiovascular morbidity and mortality in older persons than is increased diastolic blood pressure.4
The Cardiovascular Health Study5 found that a brachial systolic blood pressure higher than 169 mm Hg increased the 5-year mortality 2.4 times in 5202 older men and women. Hypertension in older persons is a major risk factor for coronary events,6,7 stroke,8,9 congestive heart failure (CHF),10-12 and peripheral arterial disease.13,14 Older persons are more likely to have hypertension and isolated systolic hypertension, to have target organ damage and clinical cardiovascular disease, and to develop cardiovascular events, and are less likely to have hypertension controlled. Many prospective, double-blind, randomized, placebo-controlled studies have demonstrated that antihypertensive drug therapy reduces the development of coronary events, stroke, and CHF in older persons.15 Treatment with antihypertensive drug therapy reduces the incidence of all strokes by 34% in men, 38% in women, 36% in older persons, and 34% in persons older than 80 years.16 The overall data suggest that reduction of stroke in persons with hypertension is related more to a reduction in blood pressure than to the type of antihypertensive drugs used.16
Gueyffier et al17 performed a meta-analysis of data from all persons 80 years of age and older in randomized controlled trials of antihypertensive drugs through direct contact with the study investigators. In 1670 persons 80 years and older, antihypertensive drug therapy reduced strokes by 34%, major cardiovascular events by 22%, and CHF by 39%.17 I 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)15 that the goal of treatment of hypertension in older persons is to decrease the blood pressure to lower than 140/90 mm Hg and to 130/80 mm Hg or lower in older persons with diabetes mellitus or chronic renal insufficiency.15 Older persons with diastolic hypertension should have their diastolic blood pressure reduced to 80-85 mm Hg.18 Most older persons with hypertension will require two or more antihypertensive drugs to control their hypertension.15,19 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.20 It is also very important to measure blood pressure in older persons in the upright position as well as in the sitting position. For additional information on medications available for treatment of hypertension, please see the findings of JNC 7.15
CHOICE OF ANTIHYPERTENSIVE DRUG THERAPY
I agree with the recommendation 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 morbidity and mortality in controlled clinical trials.15 However, older persons with hypertension have a very high prevalence of associated medical conditions. As mentioned previously, the selection of antihypertensive drug therapy in these persons depends on their associated medical conditions. If the blood pressure is more than 20/10 mm Hg above the goal blood pressure, drug therapy should be started with two antihypertensive drugs, one of which should be a thiazide-type diuretic.15 Persons with prior myocardial infarction (MI) should be treated with beta blockers and angiotensin-converting enzyme (ACE) inhibitors, and not treated with calcium-channel blockers or alpha blockers.21-29
In an observational prospective study of 1212 older men and women with prior MI 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.28 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.28 The benefit of beta blockers in reducing new coronary events in older persons with prior MI is especially increased in older persons with diabetes mellitus,24 peripheral arterial disease,25 abnormal left ventricular ejection fraction (LVEF),23 complex ventricular arrhythmias with abnormal LVEF30 or normal LVEF,31 and CHF with abnormal LVEF32 or normal LVEF.33
Beta blockers should also be used to treat older persons with hypertension who have angina pectoris,34 myocardial ischemia,35 supraventricular tachyarrhythmias such as atrial fibrillation with a rapid ventricular rate,36 hyperthyroidism,37 preoperative hypertension,15 migraine,15 or essential tremor.15 Beta blockers such as propranolol, timolol, metoprolol, and carvedilol should be used to treat older persons with MI.38 Beta blockers with intrinsic sympathomimetic activity should not be used to treat persons after MI. The hydrophilic beta blocker atenolol is not as efficacious as propranolol, timolol, metoprolol, or carvedilol in treating hypertension in older persons.38
In addition to beta blockers, older persons with CHF should be treated with diuretics and ACE inhibitors.39,40 ACE inhibitors or angiotensin II type 1 receptor blockers should be given to older persons with diabetes mellitus, chronic renal insufficiency, or proteinuria.15 Compared with amlodi-pine, ramipril significantly reduced progression of renal disease in 1094 African Americans with hypertensive nephrosclerosis.41 If the older person 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.42 Diuretics and ACE inhibitors are recommended by JNC 7 to prevent recurrent stroke in older persons with hypertension.15
Thiazide diuretics should be used to treat older persons with osteoporosis.15 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 the 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.15
Causes of secondary hypertension should be identified and treated.15 Falls or syncope in older persons may be due to orthostatic or postprandial hypotension.43 Management of orthostatic and postprandial hypotension in older persons is discussed in detail elsewhere.43 The dose of the antihypertensive drug may need to be reduced or another antihypertensive drug administered when treating these types of hypotension. Older persons with hypertension must have other modifiable risk factors treated. Cigarette smoking must be stopped. Diet and exercise should be used to decrease weight in overweight persons. Each 10 mm Hg decrease in updated mean systolic blood pressure in the United Kingdom Prospective Diabetes Study44 was associated with a significant 11% decrease in MI. In this study, each 1% reduction in updated mean hemoglobin A1c was associated with a significant 14% decrease in MI.45 The lowest risk of complications occurred in persons with hemoglobin A1c values of less than 6.0%.45 Hyperlipidemia must be treated in older persons with hypertension.15,21,46-49
In an observational prospective study of 488 men and 922 women (mean age, 82 years) with prior MI and a serum low-density lipoprotein cholesterol of 125 mg/dL or higher, compared with no lipid-lowering drug treatment, statins caused a significant independent reduction in incidence of new coronary events of 50%,47 a significant independent reduction in incidence of new stroke of 60%,48 and a significant independent reduction in incidence of CHF of 48% at 36-month follow-up.49 Finally, 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.19 This problem needs to be addressed if we are to reduce the great amount of cardiovascular morbidity and mortality caused by inadequate control of hypertension.