Hypertension in the elderly: Balance known benefits of treatment against the risks

College of Physicians and Surgeons of Alberta Optimized Prescribing with Seniors

John, an 85-year-old man, presents to your office complaining of light-headedness. He was recently admitted to hospital for congestive heart failure (CHF) and was started on furosemide, metoprolol and ramipril. He has a history of hypertension, dyslipidemia, benign prostatic hypertrophy and osteoarthritis. For these he was taking hydrochlorthiazide, discontinued during his hospital admission, atorvastatin, tamsulosin and acetaminophen.

Issue

Hypertension is very common in the elderly and is often undertreated leading to serious complications. However, seniors are more at risk and prone to side effects from medications for hypertension and CHF. It is critical to consider the impact of age on pharmacotherapy in the provision of optimal health care for seniors.

Bottom Line

There have been many informative studies on treating hypertension in the elderly. The current guideline for treating hypertension in those over age 60 is a target systolic blood pressure (SBP) of 150/90 mmHg. This target needs to be balanced with the adverse effects and cost of taking multiple medications.

Background

The prevalence of hypertension rises with age with a mean prevalence of 28.7% <65 years and 65.6% >65 years.1 It is the most common condition seen in the primary practitioner’s office and is the leading modifiable factor in morbidity and mortality worldwide.2 This was echoed in the 2010 Global burden of disease study that looked at 67 factors.3 If not treat appropriately, Hypertension can lead to myocardial infarction, cerebrovascular accident, renal failure and even death. The Cochrane review shows decreased cardiovascular and cerebrovascular morbidity and mortality, demonstrating the benefits of treating hypertension in the elderly.4

Recommended targets

  • The new target SBP for patients over age 60 has increased from the old guideline of 140/90 to 150/90 mmHg and is recommended by the Eighth Joint National Committee (JNC-8), the Systolic Hypertension in the Elderly Program (SHEP) and Syst-Eur trial results.5,6,7
  • The SPRINT (Systolic Blood Pressure Intervention Trial) found aggressive lowering of SBP of <120 mmHg resulted in significantly less fatal and nonfatal cardiovascular events and all-cause mortality.8 Similar results were seen in a Korean population where cardiovascular events decreased but not cardiovascular or all-cause mortality.9 The SPRINT findings came from a relatively stable population with no diabetes, history of cerebrovascular accident, heart failure, chronic renal failure or more severe hypertension, so it is difficult to apply to the general population.
  • The ACCORD trial looked at identical SBP targets (<120 mmHg versus <140 mmHg) but the results were not statistically significant.10
  • The Canadian Hypertension Education Program makes a Grade C recommendation of a SBP <150 mmHg for the very elderly (>80 years), only.11
  • The American Heart Association and American Stroke Association (AHA/ASA) still recommend SBP <140 mmHg.

Overtreatment

There are multiple risks associated with overtreatment.12 The disadvantages of overtreatment include:

  1. Side effects of unnecessary medications and higher doses and drug interactions.
  2. With more medications there is less medication adherence.13
  3. A reported J- or U-curve increase in cardiovascular risk.14
  4. There is a suspected increase in falls with serious injury.15,16
  5. System issues of unnecessary office visits, medication prescriptions and laboratory testing. With the target of <140/90 mmHg only about 50% of patients meet the target. Even in the controlled clinical SPRINT, 50% of patients in the intensive group were above 120 mmHg. Therefore meeting the <120 mmHg in the general population would be difficult and lead to increased medication and office visit costs.
  6. Hypotension/Syncope.
  7. Renal failure and electrolyte abnormalities.8
    In a review of 16 trials it was concluded there is potential for harm with more aggressive blood pressure treatment with no benefit.17
    As research builds the evidence base for hypertension, particularly in the elderly age group, treatment guidelines are evolving. Until more studies lead to clearer consensus, it remains essential in the elderly to balance the known benefits of treatment against the risks.

References

  1. Sarki AM, Nduka CU, Stranges S,et al. Prevalence ofHypertension in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Medicine (Baltimore). 2015 Dec;94(50):e1959. doi: 10.1097/MD.0000000000001959. Review.
  2. Pimenta E, Oparil S. Management of hypertension in the elderly.Nat Rev Cardiol.2012;9:286–296. doi: 10.1038/nrcardio.2012.27.
  3. Lim SS,Vos T,Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224-2260.
  4. Musini VM, Tejani AM, Bassett K, Wright JM. Pharmacotherapy for hypertension in the elderly. Cochrane Database Syst Rev 2009;(4):CD000028.
  5. 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 Feb 5;311(5):507–20.
  6. 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 Jun 26;265(24):3255–64.
  7. 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 Sep 13;350(9080):757–64.
  8. Ko MJ, Jo AJ, Park CM, et al. Level of Blood Pressure Control and Cardiovascular Events : SPRINT Criteria Versus the 2014 Hypertension Recommendations. Journal of the American College of Cardiology. Volume 67, Issue 24, 21 June 2016, Pages 2821–2831.
  9. Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575-1585.
  10. Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575-1585.
  11. Daskalopoulou S, Rabi D, Zarnke. The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2015;31:549-568.
  12. 12. Handler J. 2014 Hypertension Guideline: Recommendation for a Change in Goal Systolic Blood Pressure. Perm J. 2015 Summer;19(3):64-8.
  13. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med. 2003 Jan 2;348(1):42–9.
  14. Sim JJ, Shi J, Kovesdy CP, Kalantar-Zadeh K, Jacobsen SJ. Impact of achieved blood pressures on mortality risk and end-stage renal disease among a large, diverse hypertension population. J Am Coll Cardiol. 2014 Aug 12;64(6):588–97.
  15. 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 Apr;174(4):588–95.
  16. Emdin C, Rahimi K, Neal B, et al. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. JAMA. 2015:313(6):603–615
  17. Filippone EJ, Foy A, Newman E. Goal-directed antihypertensive therapy: lower may not always be better. Cleve Clin J Med. 2011 Feb;78(2):123–33.