Abstract & Commentary
Synopsis: Treatment of SH in older patients with SBP of at least 160 mm Hg is supported by strong evidence. The evidence available to support treatment of patients to the level of 140 mm Hg or those with baseline SBP of 140 to 159 mm Hg is less strong; thus, these treatment decisions should be more sensitive to patient preferences and tolerance of therapy.
Source: Chaudhry SI, et al. JAMA. 2004;292(9):1074-1080.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) defined systolic hypertension (SH) as a systolic blood pressure (SBP) of at least 140 mm Hg and a diastolic blood pressure (DBP) of at least 90 mm Hg. Furthermore, the report concluded that SH was a major public health issue which predominantly affected older individuals and that elevation of the SBP was a more important cardiovascular disease risk factor then was diastolic hypertension; in fact, isolated elevation of the SBP has been found to be the most common finding among patients being treated for hypertension and it appears to be increasing in frequency.1
Chaudhry and associates systematically reviewed the literature on the clinical management of SH in older persons in order to evaluate the available evidence supporting drug treatment of SBP of at least 160 mm Hg (ie, stages 2 and 3 SH), of stage 1 SH (SBP of 140-159 mm Hg) and, of the "oldest old" (ie, greater than 85 years old). They concluded that there was strong evidence from clinical trials to support the treatment of SH in older persons with SBP of at least 160 mm Hg however, large-scale trials to assess the value of antihypertensive therapy for older patients with SBP of 140-159 mm Hg have not been performed and the evidence for improved results after effective drug treatment of these patients appears to be based solely on observational studies that have demonstrated a graded relationship of cardiovascular risk associated with increasing SBP.
Comment by Harold L. Karpman, MD
The benefits of antihypertensive drug therapy in patients with SH were previously reported in a meta-analysis of clinical trials which clearly demonstrated that treatment was associated with 26% fewer cardiovascular events in the treatment groups when compared to the control groups.2 Since most cases of "uncontrolled hypertension" in the United States are, in fact, only stage 1 SH,3 clarification of the benefit of treatment for these patients is quite critical. Observational studies have suggested that stage 1 SH is associated with an increased risk for cardiovascular disease, stroke, cardiovascular death and all-cause mortality4,5 and therefore, it has been implied but not proven that effective drug therapy will reduce the incidence of these events however, to date, no controlled large-scale clinical trials have been performed to assess the value of such therapy in patients with stage 1 SH.
Although the evidence is not strong, numerous trials treating patients older than 85 years have suggested that the benefits secondary to active treatment compared to the placebo groups are of sufficient degree to warrant drug therapy however, treatment decisions have to be tempered by the increased susceptibility to adverse reactions from drug therapy, competing risks from non-BP-related causes and higher cardiovascular events rates in this special group of patients.6 With respect to "white coat" hypertension some studies have suggested that this condition is associated with an increased risk of future cardiovascular events7,9 and others have concluded that there is no important associated risk8,9 and therefore, tolerance of therapy and informed patient preference should guide therapy in these patients at this time. Most published studies support the use of thiazide diuretics along with long-acting calcium channel blockers and/or beta-blockers as first-line therapy to treat SH. Finally, it should be clearly recognized that widened pulse pressures result in an increased risk of cardiovascular disease reaching significance first at 60 mm Hg and becoming even stronger at 70 mm Hg and, therefore, the diastolic blood pressure should be carefully followed especially in the elderly, drug-treated stage 1 SH (140-159 mm Hg SBP) group.10
In summary, there is strong evidence that all SH patients with SBP of at least 160 Hg should be routinely treated in order to reduce cardiovascular events. Recognizing that older patients have especially high cardiovascular risk, current evidence suggests that physicians should not withhold therapy from older patients with a SBP of 140-159 mm Hg solely because of advanced age despite the fact that no large-scale clinical trials have been performed to assess the effectiveness of treatment in this patient group rather, therapy should be determined by balancing potential benefits of treatment with individual patient preferences and tolerance of therapy. Although JNC 7 states that patients should to be treated to SBP targets of < 140 mm Hg and to < 130 mm Hg if they had diabetes mellitus or chronic renal disease, there is no clinical trial data to support this recommendation and therefore, in the older age group especially, treatment decisions should be particularly sensitive to patient preferences and/or tolerance of therapy.
Dr. Karpman, Clinical Professor of Medicine, UCLA School of Medicine, is Associate Editor of Internal Medicine Alert.
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