Hypertension is very common among older adults. 64 percent of older men and 78 percent of older women have high blood pressure, placing them at heightened risk for heart disease including heart failure, stroke, coronary artery disease and atrial fibrillation, as well as chronic kidney disease and diabetes mellitus. Despite its prevalence, rates of blood pressure control remain substantially lower in the elderly than in younger patients. In fact, over age 80, only one in three men and one in four women have adequate control of their blood pressure.
Faced with an aging patient population and compelling data that confirm the benefits of blood pressure-lowering medications in the elderly (≥80 years), the American College of Cardiology (ACC) and the American Heart Association (AHA) has released the first expert consensus document to help clinicians reduce the risks for developing and effectively manage hypertension in older adults.
"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," said Wilbert S. Aronow, M.D., clinical professor of medicine at New York Medical College/Westchester Medical Center and one of the chairs of the ACC/AHA writing committee. "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."
Moreover, most hypertension trials had upper age limits or failed to present age-specific results. But in 2008, results from the Hypertension in the Very Elderly Trial (HYVET) -- the largest clinical trial in very elderly patients with hypertension to date -- began to shift this thinking. According to Dr. Aronow, this was the first study to show clear benefits for using anti-hypertensive therapy in people 80 years and older, including a 30 percent reduction in stroke, 23 percent reduction in cardiac death, 64 percent reduction in heart failure and 21 percent reduction in all-cause mortality.
"HYVET was the main impetus for developing this consensus document, which is designed to provide the medical community with systematic recommendations to lower blood pressure in older adults," said. Dr. Aronow. "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. 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 consensus recommendations addressed in the new ACC/AHA consensus document include:
- There has been uncertainty about the appropriate therapeutic target for patients ≥80 years of age. Levels of less than 140/90 mm Hg in persons 65-79 years and a systolic blood pressure between 140 and 145 mmHg in persons 80 years and older if tolerated were discussed; hypertension in older adults is usually characterized 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)
Experts say the high cost of blood pressure lowering medications also contributes to low rates of blood pressure control in the elderly and should be discussed with patients.
This ACC/AHA expert consensus document was developed in collaboration with the American Academy of Neurology (AAN), the American Geriatrics Society (AGS), the American Society of Hypertension (ASH), the American Society of Nephrology (ASN), the American Society for Preventive Cardiology (ASPC), the Association of Black Cardiologists (ABC), and the European Society of Hypertension (ESH). It will also appear in the May 17, 2011, issue of the Journal of the American College of Cardiology and will be posted ahead of print on the ACC (www.cardiosource.org) and AHA (www.heart.org) web sites.
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