Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension
- Brent M Egan, MD
Brent M Egan, MD
- Professor of Medicine
- University of South Carolina School of Medicine-Greenville
- Chief Science Officer, Care Coordination Institute
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
Hypertension is a common problem in elderly persons (age greater than 60 to 65 years), reaching a prevalence as high as 60 to 80 percent (figure 1A-B) [1-4]. In the United States, for example, hypertension was observed in 67 percent of adults aged 60 years and older who were participants in the National Health and Nutrition Examination Survey (NHANES) .
A related issue is the risk of developing hypertension over time in an elderly person who is normotensive. This issue was addressed in two reports from the Framingham Heart Study:
●One study examined the incidence of hypertension (defined as blood pressure greater than 140/90 mmHg or use of antihypertensive drug) over a four-year period among individuals who initially had optimal (less than 120/80 mmHg), normal (120 to 129/80 to 84 mmHg), or high-normal (130 to 139/85 to 89 mmHg) blood pressure . There was a progressive increase in the frequency of development of hypertension in patients over age 65 years (16, 26, and 50 percent in the optimal, normal, and high-normal groups, respectively). Similar findings were noted in younger individuals, but the rates of progression were lower.
●The second report estimated that individuals aged 55 to 65 years who do not have hypertension have a 90 percent lifetime risk of developing stage 1 hypertension (blood pressure 140 to 159/90 to 99 mmHg) and a 40 percent lifetime risk of developing stage 2 hypertension (blood pressure ≥160/≥100 mmHg) .
HYPERTENSION AWARENESS AND CONTROL
A report from the National Health and Nutrition Examination Survey (NHANES) evaluated the trends in hypertension prevalence, awareness, treatment, and control in the United States from 1988 to 2008 . The overall results from this analysis are discussed elsewhere. (See "The prevalence and control of hypertension" and "Patient adherence and the treatment of hypertension", section on 'Introduction'.)
- Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation 2011; 123:2434.
- Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988-1991. Hypertension 1995; 25:305.
- Ostchega Y, Dillon CF, Hughes JP, et al. Trends in hypertension prevalence, awareness, treatment, and control in older U.S. adults: data from the National Health and Nutrition Examination Survey 1988 to 2004. J Am Geriatr Soc 2007; 55:1056.
- Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA 2010; 303:2043.
- Vasan RS, Larson MG, Leip EP, et al. Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study: a cohort study. Lancet 2001; 358:1682.
- Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA 2002; 287:1003.
- Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension 2008; 51:1403.
- Egan BM, Li J, Shatat IF, et al. Closing the gap in hypertension control between younger and older adults: National Health and Nutrition Examination Survey (NHANES) 1988 to 2010. Circulation 2014; 129:2052.
- Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000; 355:865.
- National High Blood Pressure Education Program Working Group Report on Hypertension in the Elderly. National High Blood Pressure Education Program Working Group. Hypertension 1994; 23:275.
- National Institute for Health and Clinical Excellence. Hypertension: management of hypertension in adults in primary care (NICE clinical guideline update). http://www.nice.org.uk (Accessed on January 21, 2009).
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507.
- Izzo JL Jr, Levy D, Black HR. Clinical Advisory Statement. Importance of systolic blood pressure in older Americans. Hypertension 2000; 35:1021.
- Franklin SS, Jacobs MJ, Wong ND, et al. Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES) III. Hypertension 2001; 37:869.
- Franklin SS, Gustin W 4th, Wong ND, et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation 1997; 96:308.
- Kannel WB. Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA 1996; 275:1571.
- Franklin SS, Larson MG, Khan SA, et al. Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study. Circulation 2001; 103:1245.
- Chobanian AV. Clinical practice. Isolated systolic hypertension in the elderly. N Engl J Med 2007; 357:789.
- Young JH, Klag MJ, Muntner P, et al. Blood pressure and decline in kidney function: findings from the Systolic Hypertension in the Elderly Program (SHEP). J Am Soc Nephrol 2002; 13:2776.
- Neaton JD, Wentworth D. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med 1992; 152:56.
- Pastor-Barriuso R, Banegas JR, Damián J, et al. Systolic blood pressure, diastolic blood pressure, and pulse pressure: an evaluation of their joint effect on mortality. Ann Intern Med 2003; 139:731.
- Protogerou AD, Safar ME, Iaria P, et al. Diastolic blood pressure and mortality in the elderly with cardiovascular disease. Hypertension 2007; 50:172.
- 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). SHEP Cooperative Research Group. JAMA 1991; 265:3255.
- Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008; 358:1887.
- Somes GW, Pahor M, Shorr RI, et al. The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 1999; 159:2004.
- Vokó Z, Bots ML, Hofman A, et al. J-shaped relation between blood pressure and stroke in treated hypertensives. Hypertension 1999; 34:1181.
- Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006; 144:884.
- Boutitie F, Gueyffier F, Pocock S, et al. J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data. Ann Intern Med 2002; 136:438.
- Appel LJ, Espeland MA, Easter L, et al. Effects of reduced sodium intake on hypertension control in older individuals: results from the Trial of Nonpharmacologic Interventions in the Elderly (TONE). Arch Intern Med 2001; 161:685.
- Whelton PK, Appel LJ, Espeland MA, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA 1998; 279:839.
- Staessen JA, Richart T, Verdecchia P. Reducing blood pressure in people of different ages. BMJ 2008; 336:1080.
- Staessen JA, Fagard R, Thijs L, 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.
- Liu L, Wang JG, Gong L, et al. Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Systolic Hypertension in China (Syst-China) Collaborative Group. J Hypertens 1998; 16:1823.
- Staessen JA, Richart T, Birkenhäger WH. Less atherosclerosis and lower blood pressure for a meaningful life perspective with more brain. Hypertension 2007; 49:389.
- Chaudhry SI, Krumholz HM, Foody JM. Systolic hypertension in older persons. JAMA 2004; 292:1074.
- Kostis JB, Davis BR, Cutler J, et al. Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group. JAMA 1997; 278:212.
- Ofili EO, Cohen JD, St Vrain JA, et al. Effect of treatment of isolated systolic hypertension on left ventricular mass. JAMA 1998; 279:778.
- Franse LV, Pahor M, Di Bari M, et al. Hypokalemia associated with diuretic use and cardiovascular events in the Systolic Hypertension in the Elderly Program. Hypertension 2000; 35:1025.
- Staessen JA, Fagard R, Thijs L, et al. Subgroup and per-protocol analysis of the randomized European Trial on Isolated Systolic Hypertension in the Elderly. Arch Intern Med 1998; 158:1681.
- Tuomilehto J, Rastenyte D, Birkenhäger WH, et al. Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. Systolic Hypertension in Europe Trial Investigators. N Engl J Med 1999; 340:677.
- Forette F, Seux ML, Staessen JA, et al. Prevention of dementia in randomised double-blind placebo-controlled Systolic Hypertension in Europe (Syst-Eur) trial. Lancet 1998; 352:1347.
- Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party. BMJ 1992; 304:405.
- Khan N, McAlister FA. Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta-analysis. CMAJ 2006; 174:1737.
- Messerli FH, Grossman E, Goldbourt U. Are beta-blockers efficacious as first-line therapy for hypertension in the elderly? A systematic review. JAMA 1998; 279:1903.
- Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281.
- Vanhanen H, Thijs L, Birkenhäger W, et al. Associations of orthostatic blood pressure fall in older patients with isolated systolic hypertension. Syst-Eur Investigators. J Hypertens 1996; 14:943.
- Applegate WB, Davis BR, Black HR, et al. Prevalence of postural hypotension at baseline in the Systolic Hypertension in the Elderly Program (SHEP) cohort. J Am Geriatr Soc 1991; 39:1057.
- Gangavati A, Hajjar I, Quach L, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc 2011; 59:383.
- Tinetti ME, Han L, Lee DS, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med 2014; 174:588.
- Butt DA, Mamdani M, Austin PC, et al. The risk of hip fracture after initiating antihypertensive drugs in the elderly. Arch Intern Med 2012; 172:1739.
- Benetos A, Labat C, Rossignol P, et al. Treatment With Multiple Blood Pressure Medications, Achieved Blood Pressure, and Mortality in Older Nursing Home Residents: The PARTAGE Study. JAMA Intern Med 2015; 175:989.
- Odden MC, Peralta CA, Haan MN, Covinsky KE. Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty. Arch Intern Med 2012; 172:1162.
- Blood Pressure Lowering Treatment Trialists' Collaboration, Turnbull F, Neal B, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008; 336:1121.
- Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007; 115:2761.
- Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009; 338:b1665.
- ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288:2981.
- Hansson L, Lindholm LH, Ekbom T, 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.
- Wright JT Jr, Probstfield JL, Cushman WC, et al. ALLHAT findings revisited in the context of subsequent analyses, other trials, and meta-analyses. Arch Intern Med 2009; 169:832.
- Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008; 359:2417.
- Wing LM, Reid CM, Ryan P, et al. A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly. N Engl J Med 2003; 348:583.
- Davis BR, Furberg CD, Wright JT Jr, et al. ALLHAT: setting the record straight. Ann Intern Med 2004; 141:39.
- Frohlich ED. Treating hypertension - what are we to believe? N Engl J Med 2003; 348:639.
- Lindholm LH, Carlberg B, Samuelsson O. Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005; 366:1545.
- Bradley HA, Wiysonge CS, Volmink JA, et al. How strong is the evidence for use of beta-blockers as first-line therapy for hypertension? Systematic review and meta-analysis. J Hypertens 2006; 24:2131.
- Egan BM, Zhao Y, Axon RN, et al. Uncontrolled and apparent treatment resistant hypertension in the United States, 1988 to 2008. Circulation 2011; 124:1046.
- Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. JAMA 2016; 315:2673.
- HYPERTENSION AWARENESS AND CONTROL
- ISOLATED SYSTOLIC HYPERTENSION
- Importance of diastolic pressure
- EVIDENCE FOR EFFICACY OF BLOOD PRESSURE LOWERING
- Lifestyle modifications
- Antihypertensive therapy
- - Meta-analysis
- - SHEP trial
- - Syst-Eur trial
- - MRC trial
- - HYVET trial
- More versus less intensive blood pressure lowering
- DRUG THERAPY
- General principles
- - Problem of orthostatic hypotension
- - Problem of frailty
- Choice of antihypertensive drugs
- - ALLHAT trial
- - Long-acting calcium channel blockers
- - Angiotensin inhibition
- - Beta blockers
- - ACCOMPLISH trial of combination therapy
- - Summary of antihypertensive drug choice
- Uncontrolled hypertension
- Resistant hypertension
- GOAL BLOOD PRESSURE
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS