Challenges in Antihypertensive Therapy in Older Persons
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High blood pressure increases the risk of cardiovascular (CV) morbidity and mortality in a continuous fashion, even in very old adults. It is also associated with dementia and physical disability. Now it seems evident that treating stage 2 hypertension can reduce CV morbidity and mortality (especially stroke), and dementia to a modest degree in older adults. Although the HYpertension in the Very Elderly Trial was the first to report benefit of antihypertensive therapy in very old adults, the benefits of pharmacological treatment of uncomplicated stage 1 hypertension and lowering blood pressure below 140/90 mm Hg are not well established. In the future, trials of antihypertensive therapy should include functional outcomes, such as cognition, disability, gait impairment, and falls, which are as important as CV morbidity and mortality in older adults. This article summarizes the benefits and remaining challenges of antihypertensive therapy in older adults. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[1]:27-32)
Benefits of Antihypertensive Therapy in Older Adults
High blood pressure is associated with cardiovascular (CV) morbidity and mortality,1 dementia,2 and disability.3 A number of randomized controlled trials of antihypertensive therapy have shown a significant reduction in CV morbidity and mortality in older adults. However, the treatment and control rates among hypertensive older adults have remained poor for the past decade,4 especially so in more advanced age.5 This is in part due to uncertainties from limited evidence to guide antihypertensive therapy in older adults with complex health problems.
Overview of the Available Evidence
Major randomized controlled trials of antihypertensive therapy have been conducted in adults over age 50 years (Table). In general, the mean age of study samples was 62-76 years, with the exception of one trial.6 Trials before the early 1990s compared diuretics and beta blockers to placebo,7-10 whereas trials in the late 1990s compared calcium-channel blockers (CCBs) and angiotensin-converting enzyme inhibitors (ACEIs) to placebo.11,12 All placebo-controlled trials were conducted in stage 2 hypertension, and none achieved the target blood pressure below 140/90 mm Hg. Nevertheless, many, but not all, of the trials showed significant reduction in total and CV mortality, myocardial infarction (MI), stroke, and congestive heart failure (CHF). The extent of risk reduction appeared greater for stroke than for MI.
Since the late 1990s, when the benefit of treatment became evident in older adults, trials compared more versus less aggressive management,13 or newer (eg, ACEIs, angiotensin receptor blockers [ARBs], CCBs) versus older agents (eg, diuretics, beta blockers).14-19 These trials were conducted in patients with stage 2 hypertension, with the exception of three that targeted high-risk patients,14,20,21 most of whom were receiving antihypertensive therapy at entry. It was also shown that the achieved blood pressure below 140/90 mm Hg on treatment was associated with reduced CV events,13 and newer agents were not consistently better than older ones. In fact, thiazide was superior in preventing certain major CV events14 and, therefore, has become a preferred first-line agent.
Recent Advances
In 2008, the results of three major randomized controlled trials were published (Table). The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET)21 compared ramipril, telmisartan, and their combination in high-risk patients without heart failure. Telmisartan was as efficacious as ramipril in reducing major CV events but better tolerated due to lower rates of cough and angioedema.
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