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New guidance for elderly with high BP

US issues first clinical guidance for treating elderly with hypertension

Louise Prime

Tuesday, 26 April 2011

Elderly patients would benefit from much better control of their hypertension, agree experts. A consensus document developed by the American College of Cardiology and American Heart Association, in collaboration with the European Society of Hypertension, is the first guidance specifically to address hypertension in the over-65s.

Almost two-thirds of men and more than three-quarters of women aged 65 years or more have hypertension, but control is generally very poor in this age group, say the ACC and AHA, especially for the more elderly patients. Among the over-80s, only a third of men and a quarter of women have their blood pressure adequately controlled.

One of the chairs of the ACC/AHA writing committee, Professor Wilbert S. Aronow, said that two of the reasons for such poor control were lack of research in older patients, and doctors’ fear that antihypertensive treatment itself can cause problems in the elderly. He said: “Adequate control of high blood pressure in the elderly can significantly reduce cardiovascular events and mortality, and is much more cost-effective than treating heart problems that result from uncontrolled hypertension.

“The real concern is that a majority of elderly people have suboptimal control of their blood pressure and – until recently – many clinicians didn’t treat hypertension in octogenarians because they worried that doing so would increase mortality.”

He said that more recent studies had begun to address these concerns, showing that even in patients aged 80 or more, treating hypertension could reduce heart failure risk by 64%, stroke risk by 30%, and cardiac and all-cause mortality by 23% and 21% respectively.

“Treating hypertension in the elderly is particularly challenging because they usually have several health problems and a greater prevalence of cardiovascular risk factors and cardiac events,” said Professor Aronow.

“There also needs to be greater vigilance to avoid treatment-related side effects such as electrolyte disturbances, renal dysfunction, and excessive orthostatic blood pressure decline.”

Some of the recommendations in the new ACC/AHA consensus document include:

  • Setting a therapeutic target of <140/90mmHg in people aged 65-79 years and a systolic blood pressure of 140-145mmHg in people 80 years and older if tolerated; hypertension in older adults is usually characterised by an elevated systolic blood pressure and a normal or low diastolic BP due to age-associated stiffening of the large arteries.
  • Use of medications as appropriate. Angiotensin converting enzyme (ACE) inhibitors, beta blockers, angiotensin receptor blockers, diuretics and calcium channel blockers are all effective in lowering blood pressure and reducing cardiovascular outcomes among the elderly; clinicians should select medications based on efficacy, tolerability, specific comorbidities, and cost. For example, if someone has had a heart attack, they should be started on a beta blocker and an ACE inhibitor.
  • Initiation of antihypertensive drugs in this population should generally be at the lowest dose with gradual increments as tolerated.
  • Routine monitoring of blood pressure, including taking blood pressure measures in the standing position.
  • Encouragement of lifestyle changes to prevent and treat hypertension among older adults; these include regular physical activity, restriction of salt, weight control, smoking cessation and avoiding excessive alcohol intake (more than two drinks for men and one drink for women).

The ACC/AHA expert consensus document will appear in the 17 May issue of the Journal of the American College of Cardiology. The full paper can be read online in the AHA journal Circulation.

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