Abstract
An elevated systolic but not diastolic blood pressure level represents a common finding in elderly patients and is associated with an increased risk for developing coronary artery disease, cerebrovascular disease, peripheral artery disease, progressive cognitive decline and renal failure. Although less frequently, elderly patients manifest not only with systolic but also diastolic hypertension. Also in this case, the elderly patient will present an increased risk for developing hypertension-related abnormalities. Based on several trials conducted in patients ≥65 years and one single trial in patients ≥80 years the most recent European guidelines recommend antihypertensive treatment in elderly hypertensive patients with a systolic blood pressure ≥60 mmHg, with a systolic target between 140 and 150 mmHg. In fit elderly patients <80 years treatment may be considered at a systolic level ≥140 mmHg with a target SBP <140 mmHg if treatment is well tolerated. Despite of the above, at least three issues related to antihypertensive drug treatment in aged individuals are still debated, particularly after the publication of a recent large scale clinical trial that included also 2.636 patients ≥75 years and a study in nursing home residents ≥80 years, i.e. the frailest oldest patients: (1) the blood pressure threshold at which antihypertensive drug should be initiated, (2) the blood pressure targets of the therapeutic intervention, and (3) the approach to frail elderly hypertensive patients. This review will critically review the evidence available so far on these important issues as well as the position of current guidelines and consensus statements.
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Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, Stoyanovsky V, Antikainen RL, Nikitin Y, Anderson C, Belhani A, Forette F, Rajkumar C, Thijs L, Banya W, Bulpitt CJ, HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887–98.
Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meat-analysis of 147 randomized trials in the context of expectations from prospective epidemiological studies. Br Med J. 2009;338:b1665.
Zanchetti A, Thomopoulos C, Parati G. Randomized controlled trials of blood pressure lowering in hypertension: a critical reappraisal. Circ Res. 2015;116:1058–107. (The paper reviews the benefits of antihypertensive treatment analyzing results of randomized clinical trials as well as of meta-analyses).
Grassi G, Quarti-Trevano F, Casati A, Dell’Oro R. Threshold and target for blood pressure lowering in the elderly. Curr Atheroscler Rep. 2016;18(12):70.
SPRINT Research Group, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC Jr, Fine LJ, Cutler JA, Cushman WC, Cheung AK, Ambrosius WT. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103–16.
Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J, Chalmers J, Rodgers A, Rahimi K. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957–67.
Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, Christiaens T, Cifkova R, De Backer G, Dominiczak A, Galderisi M, Grobbee DE, Jaarsma T, Kirchhof P, Kjeldsen SE, Laurent S, Manolis AJ, Nilsson PM, Ruilope LM, Schmieder RE, Sirnes PA, Sleight P, Viigimaa M, Waeber B, Zannad F, Task Force Members. 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(7):1281–357.
Benetos A, Bulpitt CJ, Petrovic M, Ungar A, Agabiti Rosei E, Cherubini A, Redon J, Grodzicki T, Dominiczak A, Strandberg T, Mancia G. An expert opinion from the European Society of Hypertension-European Union Geriatric Medicine Society Working Group on the management of hypertension in very old, frail subjects. Hypertension. 2016;67(5):820–5.
Kjeldsen SE, Stenehjem A, Os I, Van de Borne P, Burnier M, Narkiewicz K, Redon J, Agabiti Rosei E, Mancia G. Treatment of high blood pressure in elderly and octogenarians: European Society of Hypertension statement on blood pressure targets. Blood Press. 2016;25(6):333–6.
Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, Fine LJ, Haley WE, Hawfield AT, Ix JH, Kitzman DW, Kostis JB, Krousel-Wood MA, Launer LJ, Oparil S, Rodriguez CJ, Roumie CL, Shorr RI, Sink KM, Wadley VG, Whelton PK, Whittle J, Woolard NF, Wright JT Jr, Pajewski NM, SPRINT Research Group. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA. 2016;315(24):2673–82.
Benetos A, Gautier S, Labat C, Salvi P, Valbusa F, Marino F, Toulza O, Agnoletti D, Zamboni M, Dubail D, Manckoundia P, Rolland Y, Hanon O, Perret-Guillaume C, Lacolley P, Safar ME, Guillemin F. Mortality and cardiovascular events are best predicted by low central/peripheral pulse pressure amplification but not by high blood pressure levels in elderly nursing home subjects: the PARTAGE (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population) study. J Am Coll Cardiol. 2012;60:1503–11.
Benetos A, Labat C, Rossignol P, Fay R, Rolland Y, Valbusa F, Salvi P, Zamboni M, Manckoundia P, Hanon O, Gautier S. Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents: the PARTAGE Study. JAMA Intern Med. 2015;175:989–95.
Mossello E, Pieraccioli M, Nesti N, Bulgaresi M, Lorenzi C, Caleri V, Tonon E, Cavallini MC, Baroncini C, Di Bari M, Baldasseroni S, Cantini C, Biagini CA, Marchionni N, Ungar A. Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs. JAMA Intern Med. 2015;175(4):578–85.
Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, Kenerson JG, Flack JM, Carter BL, Materson BJ, Ram CV, Cohen DL, Cadet JC, Jean-Charles RR, Taler S, Kountz D, Townsend R, Chalmers J, Ramirez AJ, Bakris GL, Wang J, Schutte AE, Bisognano JD, Touyz RM, Sica D, Harrap SB. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens. 2014;32:3–15.
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA, Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–56.
Ogliari G, Westendorp RG, Muller M, Mari D, Torresani E, Felicetta I, Lucchi T, Rossi PD, Sabayan B, de Craen AJ. Blood pressure and 10-year mortality risk in the milan geriatrics 75+ cohort study: role of functional and cognitive status. Age Ageing. 2015;44:932–7.
Odden MC, Covinsky KE, Neuhaus JM, Mayeda ER, Peralta CA, Haan MN. The association of blood pressure and mortality differs by selfreported walking speed in older Latinos. J Gerontol A Biol Sci Med Sci. 2012;67:977–83.
Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Ann Forciea M, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ, Harrington RA, Bates ER, Bhatt DL, Bridges CR, Eisenberg MJ, Ferrari VA, Fisher JD, Gardner TJ, Gentile F, Gilson MF, Hlatky MA, Jacobs AK, Kaul S, Moliterno DJ, Mukherjee D, Rosenson RS, Stein JH, Weitz HH, Wesley DJ. ACCF/AHA 2011 expert consensusdocument on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Soc Hypertens. 2011;5:259–352.
Rakugi H, Ogihara T, Goto Y, Ishii M, JATOS Study Group. Comparison of strict- and mild-blood pressure control in elderly hypertensive patients: a per-protocol analysis of JATOS. Hypertens Res. 2010;33:1124–8. doi:10.1038/hr.2010.144.
Ogihara T, Saruta T, Rakugi H, Matsuoka H, Shimamoto K, Shimada K, Imai Y, Kikuchi K, Ito S, Eto T, Kimura G, Imaizumi T, Takishita S, Ueshima H, Valsartan in Elderly Isolated Systolic Hypertension Study Group. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension. 2010;56:196–202.
Warwick J, Falaschetti E, Rockwood K, Mitnitski A, Thijs L, Beckett N, Bulpitt C, Peters R. No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: an investigation of the impact of frailty upon treatment effect in the HYpertension in the Very Elderly Trial (HYVET) study, a double-blind, placebo-controlled study of antihypertensives in people with hypertension aged 80 and over. BMC Med. 2015;13:78.
Beckett N, Peters R, Tuomilehto J, Swift C, Sever P, Potter J, McCormack T, Forette F, Gil-Extremera B, Dumitrascu D, Staessen JA, Thijs L, Fletcher A, Bulpitt C. HYVET Study Group Immediate and late benefits of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial. BMJ. 2011;344:d7541.
Peters R, Beckett N, Forette F, Tuomilehto J, Clarke R, Ritchie C, Waldman A, Walton I, Poulter R, Ma S, Comsa M, Burch L, Fletcher A. Bulpitt C; HYVET investigators. Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial. Lancet Neurol. 2008;7(8):683–9.
Parati G, Ochoa JE, Bilo G, Zanchetti A. SPRINT blood pressure: sprinting back to Smirk’s basal blood pressure? Hypertension. 2017;69(1):15–9.
Drawz PE, Pajewski NM, Bates J, Bello NA, Cushman WC, Dwyer JP, Fine LJ, Goff DG, Haley WE, Krousel-Wood M, McWilliams A, Rifkin DE, Slinin Y, Taylor A, Townsend R, Wall B, Wright JT, Rahman M. Effect of intensive versus standard clinic-based hypertension management on ambulatory blood pressure: results from the SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory blood pressure study. Hypertension. 2017;69:42–50.
Benetos A, Buatois S, Salvi P, Marino F, Toulza O, Dubail D, Manckoundia P, Valbusa F, Rolland Y, Hanon O, Gautier S, Miljkovic D, Guillemin F, Zamboni M, Labat C, Perret-Guillaume C. Blood pressure and pulse wave velocity values in the institutionalized elderly aged 80 and over: baseline of the PARTAGE study. J Hypertens. 2010;28:41–50.
Benetos A, Labat C, Rossignol P, Fay R, Rolland Y, Valbusa F, Salvi P, Zamboni M, Manckoundia P, Hanon O, Gautier S. Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents: the PARTAGE Study. JAMA Intern Med. 2015;175(6):989–95.
Peters R, Beckett N, Fagard R, Thijs L, Wang JG, Forette F, Pereira L, Fletcher A, Bulpitt C. Increased pulse pressure linked to dementia: further results from the Hypertension in the Very Elderly Trial—HYVET. J Hypertens. 2013;31(9):1868–75.
Giorgini P, Rubenfire M, Das R, Gracik T, Wang L, Morishita M, Bard RL, Jackson EA, Fitzner CA, Ferri C, Brook RD. Particulate matter air pollution and ambient temperature: opposing effects on blood pressure in high-risk cardiac patients. J Hypertens. 2015;33(10):2032–8.
Giorgini P, Di Giosia P, Ferri L, Ferri C. Cardiovascular events in patients with the chronic obstructive bronchopulmonary disease. J Cardiovasc Med. 2016. doi:10.2459/JCM.0000000000000437.
Corrao G, Mazzola P, Monzio Compagnoni M, Rea F, Merlino L, Annoni G, Mancia G. Antihypertensive medications, loop diuretics, and risk of hip fracture in the elderly: a population-based cohort study of 81,617 Italian patients newly treated between 2005 and 2009. Drugs Aging. 2015;32:927–36.
Butt DA, Mamdani M, Austin PC, Tu K, Gomes T, Glazier RH. The risk of hip fracture after initiating antihypertensive drugs in the elderly. Arch Intern Med. 2012;172(22):1739–44.
Whelton PK, Appel LJ, Espeland MA, Applegate WB, Ettinger WH Jr, Kostis JB, Kumanyika S, Lacy CR, Johnson KC, Folmar S, Cutler JA. 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(11):839–46.
Juanola-Falgarona M, Salas-Salvadó J, Buil-Cosiales P, Corella D, Estruch R, Ros E, Fitó M, Recondo J, Gómez-Gracia E, Fiol M, Lapetra J, Lamuela-Raventós RM, Serra-Majem L, Pintó X, Muñoz MA, Ruiz-Gutiérrez V, Alfredo Martínez J, Castro-Quezada I, Bulló M, PREvencion con DIeta MEDiterranea Study Investigators. Dietary glycemic index and glycemic load are positively associated with risk of developing metabolic syndrome in middle-aged and elderly adults. J Am Geriatr Soc. 2015;63(10):1991–2000.
Claas SA, Arnett DK. The role of healthy lifestyle in the primordial prevention of cardiovascular disease. Curr Cardiol Rep. 2016;18(6):56.
Appel LJ. Lifestyle modification as a means to prevent and treat high blood pressure. J Am Soc Nephrol. 2003;14(7 Suppl 2):S99–102.
Goh KL, Bhaskaran K, Minassian C, Evans SJ, Smeeth L, Douglas IJ. Angiotensin receptor blockers and risk of dementia: cohort study in UK Clinical Practice Research Datalink. Br J Clin Pharmacol. 2015;79(2):337–50.
Li NC, Lee A, Whitmer RA, Kivipelto M, Lawler E, Kazis LE, Wolozin B. Use of angiotensin receptor blockers and risk of dementia in a predominantly male population: prospective cohort analysis. BMJ. 2010;340:b5465.
Coca A, Monteagudo E, Doménech M, Camafort M, Sierra C. Can the treatment of hypertension in the middle-aged prevent dementia in the elderly? High Blood Press Cardiovasc Prev. 2016;23(2):97–104.
Puttnam R, Davis BR, Pressel SL, Whelton PK, Cushman WC, Louis GT, Margolis KL, Oparil S, Williamson J, Ghosh A, Einhorn PT, Barzilay JI, for the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Collaborative Research Group. Association of 3 Different Antihypertensive Medications With Hip and Pelvic Fracture Risk in Older Adults: Secondary Analysis of a Randomized Clinical Trial. JAMA Intern Med. 2017;177(1):67–76.
Studenski S, Perera S, Patel K, Rosano C, Faulkner K, Inzitari M, Brach J, Chandler J, Cawthon P, Barrett Connor E, Nevitt M, Visser M. Kritchevsky, Badinelli S, Harris T, Newman AB, Cauley J, Ferrucci L, Gurainick J. Gait speed and survival in older adults. JAMA. 2011;305:50–8.
Romero-Ortuno R, Soraghan C. A Frailty Instrument for primary care for those aged 75 years or more: findings from the Survey of Health, Ageing and Retirement in Europe, a longitudinal population-based cohort study (SHARE-FI75+). BMJ Open. 2014;4:e006645.
Pajewski NM, Williamson JD, Applegate WB, Berlowitz DR, Bolin LP, Chertow GM, Krousel-Wood MA, Lopez-Barrera N, Powell JR, Roumie CL, Still C, Sink KM, Tang R, Wright CB, Supiano MA, SPRINT Study Research Group. Characterizing frailty status in the systolic blood pressure intervention trial. J Gerontol A Biol Sci Med Sci. 2016;71(5):649–55.
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Ferri, C., Ferri, L. & Desideri, G. Management of Hypertension in the Elderly and Frail Elderly. High Blood Press Cardiovasc Prev 24, 1–11 (2017). https://doi.org/10.1007/s40292-017-0185-4
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DOI: https://doi.org/10.1007/s40292-017-0185-4