Current Geriatric Diagnosis & Treatment, 1st Edition

Section III - Common Disorders in the Elderly

20. Hypertension

Swarna Meyyazhagan MD

Barbara J. Messinger-Rapport MD, PhD

ESSENTIALS OF DIAGNOSIS

  • Diastolic hypertension in the absence of major risk factors and target organ damage is defined as diastolic blood pressure ≥ 90 mm Hg.
  • Systolic hypertension in the absence of major risk factors and target organ damage is defined as systolic blood pressure ≥ 140 mm Hg.
  • In the presence of normal diastolic blood pressure (< 90 mm Hg), systolic hypertension is referred to as isolated systolic hypertension.

General Considerations

Hypertension in older adults is defined according to Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure VII (JNC VII) criteria as an elevation in systolic or diastolic blood pressure (BP). Hypertension is very common among the elderly, affecting > 50% of noninstitutionalized adults 60 years and older in the United States. It is a major risk factor for cardiovascular and cerebrovascular morbidity and mortality. Despite a slow decrease in incidence of deaths since 1965, the age-adjusted death rates from coronary disease and stroke remain high: 195.6 and 61.5 per 100,000, respectively. Coronary disease is the most common cause of death in men and women 65 years and older. Stroke is the most severely disabling condition affecting older adults.

Aging, higher body weight, smoking, reduced physical activity, and salt intake are major risk factors for hypertension. Alcohol, sleep apnea, and certain medications can also contribute to hypertension in a minority of individuals.

In the presence of normal diastolic BP (< 90), systolic hypertension is referred to as isolated systolic hypertension (ISH). Borderline systolic BP in older adults typically progresses over time into definite hypertension.

Because systolic pressure rises with age and diastolic pressure plateaus or even decreases during the sixth decade (Figure 20-1), isolated diastolic hypertension is rare in the elderly. Diastolic hypertension usually occurs in combination with systolic hypertension in older adults (diastolic-systolic hypertension).

Elevated pulse pressure (PP) is increasingly recognized as an important predictor of cerebrovascular and cardiac risk in older adults. PP increases with age in a manner parallel to the increase in systolic BP.

Differential Diagnosis

Most older hypertensives have primary or essential hypertension. Secondary hypertension refers to hypertension with an identifiable and treatable cause. Renovascular hypertension is the most common cause of treatable secondary hypertension in older persons, although it is not always surgically treatable. Less common causes in older adults include pheochromocytoma, which is rare but increases in incidence with age, Cushing's syndrome, obstructive sleep apnea, and neurological problems such as intracranial tumors.

Four common conditions in older patients are associated with or complicate the diagnosis of hypertension: “white coat,” or “office,” hypertension; postural, or orthostatic, hypotension, postprandial hypotension, and pseudohypertension. White coat hypertension is mild hypertension noted in the physician's office but repeatedly normal measurements at home, at work, or by ambulatory monitoring. End-organ disease, such as left ventricular hypertrophy, hypertensive retinopathy, or nephropathy, is notably absent. White coat hypertension may commonly coexist with metabolic risk factors such as hypercholesterolemia and hyperinsulinemia and may be associated with increased long-term cardiovascular mortality.

Postural hypotension is a 20-mm Hg drop in systolic BP or 10 mm Hg in diastolic BP when rising from a sitting position. Orthostatic hypotension is associated with diabetes, hypertension, low body mass index, and use of antihypertensive medications.

Postprandial hypotension is a 5-20 mm Hg drop in systolic BP after consumption of a warm meal or alcohol. The BP drop may last for 2-3 h. Postprandial hypotension can complicate identification of hypertension as well as hypertension treatment. Postprandial decreases in BP can possibly be managed through a regimen

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of small meals, limited dietary carbohydrates, and consumption of a caffeinated beverage before meals.

 

Figure 20-1. Changes in systolic blood pressure (SBP), diastolic pressure (DBP), and pulse pressure (PP) with aging. SBP and PP increase with age. DBP plateaus or peaks at approximately 55 years. Plotted using data from Framingham Heart Study.

Pseudohypertension is a significantly higher pressure measured in the periphery (eg, brachial site) compared with a direct arterial measurement. Arterial rigidity from extensive atherosclerosis is considered to be responsible for this relatively rare phenomenon. Although it can be diagnosed by direct intra-arterial measurement, this invasive technique is usually unnecessary. The presence of Osler's sign (a palpable radial artery when BP cuff is inflated above the systolic BP) is suggestive but not diagnostic of this condition. Pseudohypertension may be suspected in those who appear resistant to an adequate drug regimen, those who become very symptomatic to a gentle pharmacological regimen, and those with very elevated BPs but no clinical evidence of end-organ disease. Incidental radiographs of the distal extremities may reveal extensive arterial calcification.

Clinical Findings

  1. SYMPTOMS & SIGNS

Most older hypertensives are asymptomatic. A minority may present with dizziness, palpitations, or headache. A morning headache, usually occipital, may be characteristic of stage III hypertension. End-organ damage, such as stroke, CHF, or renal failure, may be the initial presentation.

  1. PATIENT HISTORY

A history suggesting postprandial or orthostatic hypotension may be elicited. These syndromes may reflect long-standing hypertension or the presence of associated problems that need to be considered in treating hypertension.

Patient history should be directed toward the possibility of secondary hypertension, focusing on recent weight gain, polyuria, polydipsia, muscle weakness, history of headaches, palpitations, diaphoresis, weight loss, anxiety, and sleep history (eg, daytime somnolence, loud snoring, early morning headaches).

Symptoms suspicious for target organ damage include headache, transient weakness or blindness, claudication, chest pain, and shortness of breath. Comorbid conditions such as diabetes mellitus, coronary artery disease (CAD), heart failure, chronic obstructive pulmonary disease, gout, and sexual dysfunction are important to elicit because they will impact coronary risk factor stratification and choice of initial therapy.

Medication history should include previous BP medications, current prescription drugs, over-the-counter drugs, and herbal supplements. Nonsteroidal anti-inflammatory drugs, cold medications, and some herbal supplements are particularly important because they may increase BP.

Lifestyle issues, including smoking, alcohol intake, drug use, regular exercise, and degree of physical activity, should be assessed. A dietary history targeting sodium (which can raise BP), fat intake (which can contribute to cardiovascular risk), and alcohol (which can raise BP if excessive) is important as well.

  1. PhYSICAL EXAMINATION

The physical examination focuses on the confirmation of hypertension and identification of possible secondary causes. Verification of the diagnosis of hypertension can be done by measuring BP at different times using an appropriate cuff size after a comfortable rest ideally without the influence of alcohol, caffeine, or tobacco. BP is measured in both arms using standard techniques. Given the relatively high prevalence of orthostatic hypotension in older adults, standing BPs are measured as well.

  1. LABORATORY TESTS

Complete blood count, renal and metabolic panel, lipid profile, thyroid-stimulating hormone (TSH), urinalysis, and 12-lead electrocardiogram are included in the initial evaluation.

Evidence should be sought for end-organ target disease (ie, ophthalmological vascular changes, carotid bruits, distended neck veins, third or fourth heart sound, pulmonary rales, reduced peripheral pulses). A

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cognitive evaluation (eg, the Mini-Mental State Examination) is also helpful in tracking longitudinal cognitive changes in the older hypertensive patient. Secondary causes, including renal bruits (renal artery stenosis); moon face, buffalo hump, and abdominal striae (Cushing's syndrome); tremor, hyperreflexia, and tachycardia (thyrotoxicosis) should be assessed.

Complications

Older persons with hypertension have higher absolute risks of cardiovascular and cerebrovascular events. They are also more likely to have other comorbid conditions that worsen these outcomes. Thus, preventing target organ damage in older adults with hypertension is vital to reducing morbidity and mortality from hypertension. Target organ damage can occur overtly, in the form of heart failure or arrhythmia, or more subtly, in the form of a neuropsychiatric deficit such as cognitive impairment. Hypertension is the major risk factor for stroke, which is the third leading cause of death and the primary cause of serious disability in adults 65 years of age and older. Approximately 66% of first strokes are attributable to hypertension; systolic hypertension is the most important risk factor. Atrial fibrillation is often a complication of hypertensive disease in older adults; 15% of strokes occur in people with atrial fibrillation.

Hypertension is also a risk factor for heart disease, including myocardial infarction, congestive heart failure (CHF), and sudden death. Diastolic dysfunction increases with age secondary to reduced vascular compliance and increased impedance to left ventricular ejection related to aging myocardium.

Other important complications include chronic renal insufficiency, end-stage renal disease, malignant hypertension, and encephalopathy. These disorders are most common with severe or poorly controlled hypertension. Dementia, including Alzheimer's disease, may be associated with previously uncontrolled hypertension in middle-aged or older adults. The association may be particularly strong in diabetic hypertensive individuals.

Table 20-1. Classification of blood pressure, stratification of cardiovascular risk, & initial treatment strategies.

Class

SBP (mm Hg)

 

DBP (mm Hg)

Lifestyle modification

No compelling indication

With compelling indication

Normal

< 120

and

< 80

Encourage

Prehypertension

120-139

or

80-89

Yes

No drugs

Drugs for compelling indication

Stage I

140-159

or

90-99

Yes

Thiazide first choice

Drug for compelling indication ± thiazide or other drugs

Stage II

≥ 160

or

≥ 100

Yes

Combination therapy for most, usually including thiazide; caution for orthostasis

Drug for compelling indication ± thiazide or other drugs

Adapted from Chobanian AV et al: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003;289:2560. Used with permission.

American Heart Association: 2002 Heart and Stroke Statistical Update. American Heart Association, 2002.

Chobanian AV et al: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003;289:2560. [PMID: 12748199]

Kannel WB: Elevated systolic blood pressure as a cardiovascular risk factor. Am J Cardiol 2000;85:251. [PMID: 10955386]

Luukinen H et al: Prognosis of diastolic and systolic orthostatic hypotension in older persons. Arch Intern Med 1999;159:273. [PMID: 99142645]

Staessen JA et al: Risks of untreated and treated isolated systolic hypertension in the elderly: Meta-analysis of outcome trials. Lancet 2000;355:865. [PMID: 10752701]

Treatment

  1. HYPERTENSION

The general objective of hypertension management for both community-dwelling and nursing home patients is to reduce morbidity and mortality by early diagnosis and treatment with the least invasive methods at minimum cost. Classification of BP, stratification for cardiovascular risks, and management strategies according to JNC VII guidelines are shown in Table 20-1. Major risk factors are enumerated in Table 20-2. Treatment of hypertension in the oldest old is not clearly associated with a mortality benefit, but does appear to reduce the risk of stroke and congestive heart failure.

Little information is available to guide clinicians regarding hypertension management in nursing home residents, typically a frail, elderly group. One issue constraining hypertension treatment may be delineation of

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the goals of therapy. A frail elder with multiple comorbidities may have a limited life expectancy. The potential reduction in stroke benefit from antihypertensive medication may not be realized in this case, and the side effects of the medication may be less justifiable. A higher target BP and a less aggressive approach to treatment of hypertension may be acceptable in such cases.

Table 20-2. Cardiovascular risk stratification in patients with hypertension.

Cardiovascular risk stratification

Target organ damage

Hypertension

Heart

   Tobacco

   Left ventricular hypertrophy

   BMI ≥ 30

   Angina or prior myocardial infarction

   Physical Inactivity

   Prior coronary revascularization

   Dyslipidemia

   Heart failure

Diabetes

Brain

   Renal insufficiency

   Stroke or transient ischemic attack

Age (> 55 for men, > 65 years for women)

Chronic renal disease

Family history of premature cardiovascular disease (men < 55 years, women < 65 years)

Peripheral arterial disease
Retinopathy

Adapted from Chobanian AV et al: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003;289:2560. Used with permission.

  1. Nonpharmacological therapy—Lifestyle interventions may benefit older hypertensives and can include the following:
  2. Weight reduction if overweight (5-kg threshold; 10 kg reduces BP 10-8 mm Hg). Care must be taken with older adults to maintain adequate nutrient intake should weight reduction be recommended.
  3. Reduction in dietary sodium.
  4. Increased consumption of fruits and vegetables and decreased consumption of dairy and animal fat (the DASH diet).
  5. Limiting alcohol consumption to no more than 2 standard drinks per day for men (1 standard drink daily for women and lighter weight men). A standard drink is one 12-oz bottle of beer or wine cooler, one 5-oz glass of wine, or 1.5 oz of 80-proof distilled spirits.
  6. Increasing physical activity to 30-45 min of aerobic activity 4 or more days per week. If this is not attainable, any increase in physical activity is likely to be beneficial.
  7. Smoking cessation. Older adults may be less tolerant of recommended adjuvant smoking cessation therapies, such as bupropion, clonidine, and nortriptyline.

Use of nonpharmacological measures to control hypertension in the nursing home setting may be limited because residents are often limited in their activities of daily living and unable to participate in moderate exercise. Also, weight loss is a problem rather than a goal for most nursing home residents. If their diet is restricted in salt or animal and dairy fat, they may lose weight, strength, and essential nutrients.

  1. Pharmacological therapy—Antihypertensive medication improves cardiovascular and cerebrovascular outcomes in older adults with BP ≥ 160/90 mm Hg. The absolute benefit of hypertension treatment tends to be greater in men, in patients aged 70 or older, in those with previous cardiovascular complications, and in the presence of wider PP. Treatment prevents stroke more effectively than coronary events, although both outcomes are improved by antihypertensive treatment.

The key to achieving maximal benefit and minimal risk in older adults is to “start low and go slow.” Lower initial doses of antihypertensives minimize the risk of postural and postprandial hypotension as well as ischemic symptoms, especially in frail older adults.

Route of administration may be an issue in nursing home residents with dysphagia and those who are unwilling to take pills. A clonidine or nitroglycerin patch may be beneficial in BP management in these situations. Because orthostatic hypotension and postprandial hypotension may contribute to the risk of falling, it may be appropriate to titrate antihypertensives in the standing position. Also, BP tends to be highest before breakfast in the nursing home resident, so titration of antihypertensives later in the day may also be desirable.

Table 20-3 summarizes data on antihypertensive agents commonly used in older patients.

  1. Diuretics—Thiazide and related diuretics are the preferred first-line treatment in older adults and have proved particularly effective in blacks and in salt-sensitive hypertensive patients. Diuretics have been shown

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to lower cerebrovascular and cardiovascular morbidity and mortality, decrease left ventricular mass, and prevent heart failure. In low doses, thiazides have advantages of low cost and possible preservation of bone mineral density in older women. Side effects of thiazides include hypokalemia, hyponatremia, orthostatic hypotension, urinary incontinence, sexual dysfunction, and exacerbation of gout. Thiazides may be ineffective in patients with a creatinine clearance of < 30 mL/min and can be replaced by loop diuretics (eg, furosemide) when a diuretic agent is necessary.

Table 20-3. Pharmacotherapy for hypertension.

Drug group

Initial dose

Typical range

Cost (30 tabs)

Indications in addition to hypertension

Side effects/comments

Diuretic

   HCTZ

6.25-12.5 mg/day

25 mg/day

$5–15

Typical first-line therapy

Hypokalemia, hypercalcemia, hyperuricemia, hyponatremia, metabolic alkalosis, increased frequency (all less likely at low doses)

Calcium channel blockers

   Dihydropyridines
      Amlodipine

2.5 mg/day

2.5–10 mg/day

$33–67

Typical first-line therapy

Flush, headache, local ankle edema (dose related)

      Felodipine

2.5 mg/day

5–10 mg/day

$34–70

Typical first-line therapy

Flush, headache, local ankle edema (dose related)

   Nondihydropyridines
      Verapamil

120 mg/day

120–240 mg qd-bid

$22–30

Angina, arrhythmias

Constipation, conduction block, CHF, transaminase elevation

      Diltiazem (ER)

120–180 mg/day

240–480 mg/day

$30–123

Angina

Conduction block, CHF, transaminase elevation

α-Blocker

   Terazosin

1–2 mg/day

1–5 mg/day

$50

BPH, hypertension

Postural hypotension (dose related); not as beneficial as diuretic in reducing CV events

   Doxazosin

1–2 mg/day

1–8 mg/day

$20–35

BPH, hypertension

Same as for terazosin

β-Blocker

   Atenolol

25 mg/day

25–50 mg/day

$5–45

CAD, systolic dysfunction

Bronchospasm, second- and third-degree heart block, fatigue, sleep disturbance; caution with diabetics, peripheral arterial disease; atenolol is renally excreted; serum levels are significantly higher in older adults and those with known renal insufficiency

   Metoprolol

25 mg bid

50–100 mg bid

$15–40

CAD, systolic dysfunction

Bronchospasm, second- and third-degree heart block, fatigue, sleep disturbance; caution with diabetics, peripheral arterial disease; metoprolol is renally excreted; serum levels are significantly higher in older adults and those with known renal insufficiency

α-β Blocker

   Carvedilol

3.125 mg bid

6.25–12.5 mg bid

$55

CAD, systolic dysfunction

Bronchospasm, second- and third-degree heart block, fatigue, sleep disturbance; caution with diabetics, peripheral arterial disease; carvedilol is renally excreted; serum levels are significantly higher in older adults, and those with known renal insufficiency

Centrally acting

   Clonidine

0.1 mg bid

0.1–2 mg bid-tid

$6–30

Second- or third-line therapy or when unable to tolerate oral therapy (eg, patch)

Fatigue, dry mouth, lethargy, rebound hypertension when abruptly discontinued, fluid retention

   Clonidine patch (TTS)

0.1 mg/day (TTS-1)

0.1–0.2 mg/day (TTS-1 or 2)

$42–102

Direct vasodilators

   Hydralazine

10 mg tid or

50 mg bid-qid

$4–24

Afterload reduction in CHF

Headache, tachycardia, lupus syndrome, fluid retention

ACEIs

   Captopril

   25 mg qpm
12.5 mg bid

25 mg bid-tid

$4–50

Diabetics, CHF, LV dysfunction after MI

Cough, rash, loss of taste, hyperkalemia; rarely leukopenia and angioedema

   Enalapril

2.5 mg qd

5–20 mg/day

$30–100

Diabetics, CHF, LV dysfunction after MI

Cough, rash, loss of taste, hyperkalemia; rarely leukopenia and angioedema

   Lisinopril

5 mg/day

10–40 mg/day

$20–50

Diabetics, CHF, LV dysfunction after MI

Cough, rash, loss of taste, hyperkalemia; rarely leukopenia and angioedema

Angiotensin-receptor blockers

   Losartan

25 mg/day

50–100 mg/day

$42–60

May be considered for diabetes, CHF if intolerant to ACEIs

Hyperkalemia, angioedema

   Valsartan

80 mg/day

80–320 mg/day

$45–90

May be considered for diabetes, CHF if intolerant to ACEIs

Hyperkalemia, angioedema

HCTZ, hydrochlorothiazide; qd, every day; bid, twice daily; ER, extended release; CHF, congestive heart failure; BPH, benign prostatic hypertrophy; CV, cardiovascular; CAD, coronary artery disease; tid, 3 times daily; qpm, every night; qid, 4 times daily; LV, left ventricular; MI, myocardial infarction; ACEIs, angiotensin-converting enzyme inhibitors.

  1. Angiotensin-converting enzyme inhibitors & receptor blockers—The known renoprotective effects of angiotensin-converting enzyme (ACE) inhibitors and ACE receptor blockers (ARBs) in type 2 diabetes make ACE inhibitors and ARBs desirable first-line drugs in older diabetic hypertensives. ACE inhibitors also appear to improve vascular outcomes in high-risk patients, including diabetics and those with established vascular disease. ARBs have not been studied as extensively and are thus primarily used when there is intolerance to ACE inhibitors.
  2. β-blockers—Older adults are less responsive than younger adults to β-blockers and are less likely to have BP control with β-blocker as a sole agent. In addition, compared with diuretics, β-blockers may proffer less reduction in cerebrovascular and cardiovascular events in older antihypertensive patients. However, they are warranted for the treatment of hypertensive patients with CAD for secondary prevention of myocardial infarction, for rate control with exercise in atrial fibrillation, and for reducing mortality and hospital readmission in patients with left ventricular systolic dysfunction.
  3. Calcium channel blockers—Nitrendipine (not currently available in United States), a dihydropyridine calcium channel blocker (CCB) related to amlodipine and felodipine, significantly decreases the risk of cerebrovascular morbidity and mortality. Dihydropyridine CCBs available in the United States include nifedipine, amlodipine, and felodipine. However, CCBs are a heterogeneous group, and the benefits of one class of CCBs may not necessarily be extrapolated to another. Diltiazem and verapamil, 2 commonly used nondihydropyridine CCBs, have negative inotropic and chronotropic effects on left ventricular systolic function compared with amlodipine or felodipine. They may be used as adjunctive agents in patients with renal parenchymal disease and resistant hypertension but should be used with caution in systolic dysfunction.
  4. α-blockers—Selective α1-adrenergic antagonists (eg, terazosin, doxazosin) may be useful for managing hypertension in the setting of benign prostatic hypertrophy. Their major side effects are orthostatic hypotension, reflex tachycardia, and headache. The findings of slightly increased risk of stroke and cardiovascular events and a doubled risk of CHF in the doxazosin arm of the ALLHAT trial compared with chlorthalidone suggest that the α-antagonists should not be chosen as a first-line antihypertensive agent.
  5. Combination drugs—JNC VII recommends that combination drug therapy be initiated for stage II hypertension (systolic BP ≥ 160 or diastolic BP ≥ 100). In the ALLHAT trial, approximately half of these high-risk older hypertensives required combination therapy. Participants on lisinopril and amlodipine were more likely to require combination therapy than those assigned chlorthalidone. This finding supports the JNC recommendation that a diuretic be a primary choice for an antihypertensive agent.

Combination drugs potentiate antihypertensive activity by acting at different sites simultaneously. Formulations that combine low doses of different classes of drugs improve BP control while minimizing the adverse effects of either drug. These drugs may in some cases be priced competitively with either of the combination agents, reducing the patient's out-of-pocket expenses as well. Lower cost, increased ease of compliance, and potential for fewer side effects make combination drugs attractive for use in older adults once the need for more than 1 agent is established.

  1. DIABETES & HYPERTENSION

Type 2 diabetes is 2.5 times more likely to develop in hypertensives compared with normotensives and greatly increases cardiovascular risk. At recommended doses, there is no demonstrated increased risk of diabetes with the antihypertensive agents from the ACE inhibitors, CCB, ARB, or thiazide diuretic classes. There may be an increased risk of diabetes with β-blockers use in hypertensive individuals, but the added risk may be small compared with the benefits and the risk conferred by hypertension alone.

  1. RESISTANT HYPERTENSION

Hypertension is considered resistant if BP cannot be reduced to goal with an appropriate triple-drug regimen, including a diuretic (plus ACE inhibitor, CCB, β-blocker, or ARB) and if each of the 3 drugs is at or near maximum recommended doses. With ISH in older adults, resistant hypertension is defined as the inability to lower systolic BP to < 160 mm Hg with a similar regimen.

The common causes of resistant hypertension include patient noncompliance with medications and diet, a suboptimal medication regimen, drug interaction, pseudotolerance (salt, water retention), and office hypertension. Secondary hypertension and pseudohypertension should also be considered.

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When secondary causes for hypertension have been ruled out, the patient's compliance with dietary salt can be estimated by obtaining a 24-h urine collection for sodium. If the patient's hypertension remains resistant, other medications can be added to the triple therapy. Clonidine in tablet form or by transdermal patch, or another centrally acting sympatholytic agent, can be used in low doses to avoid side effects of sedation and orthostatic hypotension. Minoxidil, reserpine, and hydralazine are used cautiously because of their high rates of side effects in older patients.

ALLHAT Collaborative Research Group: Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: The antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA 2000;283:1967. [PMID: 20248526]

Chobanian AV et al: The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA 2003;289:2560. [PMID: 12748199]

Gress TW et al: Hypertension and antihypertensive therapy as risk factors for type 2 diabetes mellitus. Atherosclerosis Risk in Communities Study. N Engl J Med 2000;342:905. [PMID: 10738048]

Hansson L et al: Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: The Captopril Prevention Project (CAPPP) randomised trial. Lancet 1999; 353:611. [PMID: 10030325]

LaCroix AZ et al: Low-dose hydrochlorothiazide and preservation of bone mineral density in older adults. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2000; 133:516. [PMID: 11015164]

Messerli FH et al: Are beta-blockers efficacious as first-line therapy for hypertension in the elderly% A systematic review. JAMA 1998;279:1903. [PMID: 98296020]

Staessen JA et al: Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997;350:757. [PMID: 97443133]

EVIDENCE-BASED POINTS

  • Systolic BP and PP are more important predictors of cardiovascular risk than diastolic BP.
  • Thiazide diuretics are effective initial therapy with significant evidence for cerebrovascular and cardiovascular event reduction.
  • Other agents that can improve outcomes in elderly hypertensive individuals include β-blockers (especially in CAD and CHF), ACE inhibitors (in diabetic nephropathy and CHF), and dihydropyridine CCBs.
  • α-Blockers are less effective at improving outcomes than diuretics.
  • Effective management of hypertension may prevent disability, mortality, and cognitive decline in older adults.

REFERENCES

ALLHAT Collaborative Research Group: Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: The antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). JAMA 2000;283:1967. [PMID: 20248526]

Brown MJ et al: Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the International Nifedipine GITS study: Intervention as a goal in hypertension treatment (INSIGHT). Lancet 2000;356:366. [PMID: 10972368]

Forette F et al: Prevention of dementia in randomised double-blind placebo-controlled systolic hypertension in Europe (Syst-Eur) trial. Lancet 1998;352:1347. [PMID: 9802273]

Hansson L et al: Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: The Nordic diltiazem (NORDIL) study. Lancet 2000;356:359. [PMID: 10972367]

Hansson L et al: Randomised trial of old and new antihypertensive drugs in elderly patients: Cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study. Lancet 1999;354:1751. [PMID: 10577635]

Kjeldsen SE et al: Effects of losartan on cardiovascular morbidity and mortality in patients with isolated systolic hypertension and left ventricular hypertrophy: A losartan intervention for endpoint reduction (LIFE) substudy. JAMA 2002;288:1491.

Kostis JB et al: Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA 1997;278:212. [PMID: 9218667]

SHEP Cooperative Research Group: Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;265:3255. [PMID: 2046107]

Staessen JA et al: Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997;350:757. [PMID: 9297994]

RELEVANT WORLD WIDE WEB SITES

American College of Cardiology: http://www.acc.org

American Heart Association: http://www.americanheart.org

American Society of Hypertension: http://www.ash-us.org

Cardiosource: http://www.cardiosource.com

Centers for Disease Control and Prevention: http://www.cdc.gov/nchs/fastats/hypertens.htm

Lifeclinic: http://www.bloodpressure.com

National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov