Hypertension in the Elderly (PDF)

The benefits of treating hypertension in the elderly (p. 47-48)

Over the past few years, increasingly strong evidence from large randomized controlled trials (RCTs) has documented the value of treating hypertension in the elderly. Staessen et al. (2000) analyzed the data from eight placebo-controlled randomized trials involving 15693 elderly patients with ISH (Figure 23). Protection from stroke (a 30% decrease) and coronary disease (a 23% decrease) is quantitatively greater than that shown in multiple RCTs in younger subjects. In particular, the reduction in CHD was almost twice that seen in the younger patients, which is probably a reflection of two factors.

• The elderly start at a much higher risk than the younger and are therefore more likely to achieve benefit over the relatively short duration, i.e. 4–6 years, of these RCTs. If younger patients were treated for 10–20 years they would almost certainly achieve as much benefit.

• Therapy in the more recent RCTs in the elderly was based on low doses of diuretic, which are clearly more cardioprotective than the higher doses of diuretic used in the earlier RCTs in younger patients. As shown by Psaty et al. (1997) (Figure 24), both low doses (up to 25 mg of hydrochlorothiazide or its equivalent) and high doses (50 mg and more) of diuretic provided protection against stroke, as did ß-blocker based therapy. For CHD, however, only low-dose diuretic-based therapy has been beneficial.

Results of more recent trials The 19 RCTs analyzed by Psaty et al. (1997) were published before 1995 and, as noted in Figure 24, all used diuretics and/or ß-blockers. Since 1995, an additional 16 RCTs have been completed and analyzed (Blood Pressure Lowering Treatment, 2000). Of these, six compared the newer antihypertensive agents, angiotensin-converting enzyme inhibitors (ACEIs) and calcium antagonists (CAs) against placebo (Table 10).

The four RCTs comparing ACEIs against placebo involved patients whose

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