New Guidance Covers Ways to Prevent and Treat Hypertension in Elderly Patients

For the first time, clinicians have guidelines on the prevention and treatment of hypertension specifically in individuals aged 65 years or older. The guidance, released in April, comes from an expert panel convened by the American College of Cardiology and the American Heart Association (Aronow WS et al. J Am Coll Cardiol. 2011;57[20]:2037-2114).

Although hypertension is prevalent in this older population, found in 64% of men and 78% of women, control is far less common, said Wilbert S. Aronow, MD, clinical professor of medicine at New York Medical College/Westchester Medical Center and a cochair of the expert panel. “If you take a population age 70 or older, one-third of men and one-fourth of women are adequately treated,” Aronow said. “And many clinicians are still unwilling to treat patients with hypertension; they believe it will increase mortality.”

That belief has been reinforced over the years by studies suggesting that lowering blood pressure, while reducing risks of stroke and vascular complications, might increase risks for other adverse conditions. Moreover, rigorous study of hypertension control in the very old (those aged 80 years and older) has been nonexistent. But a 2008 study changed the landscape.

The study, Hypertension in the Very Elderly Trial (HYVET), looked at treatment of 3845 patients aged 80 years or older randomized to antihypertensive therapy (indapamide [sustained release] with or without perindopril) or placebo. Compared with those receiving placebo, those enrolled in the active treatment group reduced their sitting mean systolic and diastolic blood pressures by 15.0 and 6.1 mm Hg and saw a 64% reduction in the rate of heart failure, a 23% reduction in the rate of death from cardiovascular causes, and a 21% reduction in the rate of death from any cause (Beckett NS et al. N Engl J Med. 2008;358[18]:1887-1898). And while the HYVET investigators were unable to show treatment benefit regarding the study's primary end point of fatal or nonfatal stroke (the trial was stopped after about 2 years of follow-up for ethical reasons), the findings were compelling enough for Aronow to suggest developing and issuing guidelines for this patient population.

While HYVET provided the impetus for compiling a guidance document, the lack of rigorous research on other elements regarding the prevention and management of hypertension in individuals aged 65 years or older means that many of the panel's recommendations are based on expert opinion.

The evaluation of an elderly patient with known or suspected hypertension should begin with an accurate blood pressure measurement. Blood pressure for this population should be measured with the patient standing for 1 to 3 minutes to evaluate for postural hypotension or hypertension, the guidance said.

Once a blood pressure reading is taken, the physician needs to determine whether it represents hypertension. In the younger population, a systolic and diastolic blood pressure reading of less than 120 and 80 mm Hg, respectively, is considered normotensive and serves as a treatment goal for those with prehypertension or hypertension. Blood pressures increase naturally in elderly patients due to age-associated stiffening of the large arteries, so the expert panel suggests a systolic and diastolic blood pressure goal in uncomplicated hypertension of below 140 and 90 mm Hg, respectively, for those aged 65 years or older. They also state that it is unclear whether target systolic blood pressure should be the same in patients aged 65 to 79 years as in patients older than 80 years.

George L. Bakris, MD, a member of the expert panel and director of the Hypertensive Diseases Unit at the University of Chicago Pritzker School of Medicine, said physicians should not get too hung up on targets, especially those set for patients with uncomplicated hypertension. “I don't know who these ‘uncomplicated’ patients are; everyone I see over age 65 has at least 5 complications and all relate to cardiovascular risk,” Bakris said. “So I say that one should try to get to 140 mm Hg, but if the person can't tolerate these lower pressures, the evidence would say that levels of 150/80 mm Hg are good enough to reduce risk.”

If hypertension is determined, physicians should then identify reversible and treatable causes, evaluate for organ damage, assess for other cardiovascular disease risk factors and comorbid conditions affecting prognosis, and identify barriers to treatment adherence. Physicians should also pay particular attention to quality-of-life factors when making therapeutic decisions because symptomatic well-being, cognitive function, physical activity, and sexual function diminish with aging and disease.

The first treatment options are similar to those that would be proposed for a younger patient. Physicians should suggest lifestyle modification because this may be the only treatment needed for milder forms of hypertension in elderly patients. Modifications should center on smoking cessation, reducing excess body weight and mental stress, modifying excessive sodium and alcohol intake, and increasing physical activity.

If medical therapy is warranted, the guidelines call for physicians to begin treating elderly patients with hypertension by prescribing the lowest dose of a drug and to increase the dosage gradually to the maximum tolerated dose to achieve a target blood pressure. If the blood pressure response is inadequate after reaching a full dose of a single drug, a second drug from another class should be added, provided the initial drug is tolerated; if a diuretic is not the initial drug, it is usually indicated as the second drug. Finally, if 2 drugs do not work, then a third from yet another class should be added, but the expert panel warned that on average, elderly patients are taking more than 6 prescription drugs, so polypharmacy, nonadherence, and potential drug interactions are important concerns.

For the initial therapy, the panel recommends a thiazide diuretic: hydrochlorothiazide, chlorthalidone, or bendrofluazide. Other drugs to consider as add-on therapies include angiotensin-converting enzyme inhibitors, β-blockers, angiotensin receptor blockers, and calcium channel blockers.

For patients aged 80 years or older, a target systolic blood pressure reading of 140 mm Hg to 145 mm Hg is considered acceptable. The expert panel recommends initiating treatment with a single drug, preferably a low-dose thiazide, calcium antagonist, or renin-angiotensin-aldosterone system blocker, followed by a second drug if needed. Octogenarians should also be seen frequently, with standing blood pressure being checked for excessive orthostatic decline. And while researchers have not determined the blood pressure values below which vital organ perfusion is impaired in this population, the panel suggested that systolic blood pressure under 130 mm Hg and diastolic blood pressure under 65 mm Hg should be avoided.

Perhaps not surprisingly with a first-ever guideline, the authors acknowledged that work remains to be done. Priorities include establishing a working definition of the term “elderly,” as chronological years does not necessarily establish the state of being elderly; determining blood pressure values for diagnosing hypertension, as well as setting targets for treatment in this population; identifying which drugs will be most effective in reducing cardiovascular events in patients requiring medical therapy; and discovering whether there are subgroups of eldery patients with hypertension in whom treatment is not beneficial.

Franz H. Messerli, MD, professor of clinical medicine at Columbia University College of Physicians and Surgeons, in New York City, finds the guidance generally appropriate, but he does not think hydrochlorothiazide should be the first-line therapy. “Like so many guidelines in the past, they recommend low doses of hydrochlorothiazide, and to the practicing physician, that translates to the doses of 12.5 mg to 25 mg—and at that dose, it is a lousy antihypertensive drug,” said Messerli, who added that if a “thiazide-type” diuretic is indicated, either chlorthalidone or indapamide should be selected.

Messerli finds the elderly population difficult to treat for hypertension. “We have to be rather thoughtful when we treat elderly hypertensive patients, as they are more prone to the adverse effect of antihypertension drugs and have more comorbid disease, and are at risk of orthostatic hypertension, dizziness, and falls,” Messerli said. “Hip fracture in the elderly is one of the most deadly conditions they can get.”

Aronow added cost as another factor for physicians to consider when treating elderly patients for hypertension. “The older you are, the less money you have, and you may not be able to purchase these drugs,” Aronow said.

The guidance was developed in collaboration with the American Academy of Neurology, the American Geriatrics Society, the American Society of Hypertension, the American Society of Nephrology, the American Society for Preventive Cardiology, the Association of Black Cardiologists, and the European Society of Hypertension.

Yet even with all these collaborators, Aronow said it is still difficult to get physicians to buy in to treating elderly patients for hypertension. “This is an important public health problem,” Aronow said. “It is much more cost-effective to treat hypertension than to treat the outcomes from hypertension.”