Download PDF
Arzneimittelforschung 2011; 61(4): 221-228
DOI: 10.1055/s-0031-1296191
Reviews
Editio Cantor Verlag Aulendorf (Germany)

Treatment of arterial hypertension in the very elderly: a meta-analysis of clinical trials

Petra Schall
1   Medical Clinic IV (Geriatrics), Faculty of Medicine Mannheim, University of Heidelberg, Germany
,
Martin Wehling
2   Clinical Pharmacology Mannheim, Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine Mannheim, University of Heidelberg, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
27 November 2011 (online)

    Permissions and Reprints

Abstract

The benefits of lowering blood pressure are obvious for the population up to the age of 65 years, but whether and, if so, which treatment is beneficial in the very elderly population remains still a matter of debate. We conducted a meta-analysis of randomised controlled clinical trials with duration of at least 12 months and the analysis of cardio- and cerebrovascular endpoints in participants aged 75 years and over.

MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials) and the WHO-ISH Collaboration register were searched until October 20, 2009. Further, references from reviews, trials and previously published meta-analyses were analysed. A total of 10 studies were included providing morbidity and mortality data with a total of 8667 participants in the meta-analysis, with separate analyses for studies on isolated systolic hypertension. There were 148 non-fatal strokes and 287 cardiovascular morbidity and mortality events among treated patients, compared with 176 non-fatal strokes (p = 0.02) and 366 cardiovascular morbidity and mortality events (p = 0.0001) among control patients. Rates of heart failure were significantly reduced (64 vs. 121 events; p = 0.00001), total mortality remained unchanged (odds ratio 0.97). Further, 9 studies with 6933 participants were included in the systematic review of blood pressure reduction trials. The average blood pressure achieved at the end of the studies was 164/83 mmHg in the placebo group and 150/83 mmHg in the treatment group. At the beginning of the study blood pressure was 170.6/88.6 mmHg in the placebo group and 175.4/94.6 mmHg in the treatment group. Changes were only significant for systolic blood pressure in the treatment group (p = 0.0008).

Treating healthy subjects aged 75 years and older with moderate to severe hypertension reduces non-fatal strokes, cardiovascular morbidity and mortality and the incidence of heart failure but does not change total mortality.

Key words

Antihypertensive treatment - Clinical endpoints - Elderly - Hypertension
 

  • References

  • 1 Franklin SS, Gustin W 4th, Wong ND, Larson MG, Weber MA, Kannel WB et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. Circulation. 1997; 96: 308-15
    CrossrefPubMedGoogle Scholar
  • 2 World Health Organisation International Society of Hypertension Writing Group. World Health Organisation(WHO)/International Society of Hypertension (ISH) Statement on Managment of Hypertension. J Hypertens. 2003; 21: 1983-92
    CrossrefPubMedGoogle Scholar
  • 3 Pieper L, Wittchen HU, Glaesmer H, Klotsche J, Marz W, Stalla G et al. Cardiovascular high-risk constellations in primary care. DETECT Study 2003. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2005; 48: 1374-82
    PubMedGoogle Scholar
  • 4 Sharma AM, Wittchen HU, Kirch W, Pittrow D, Ritz E, Göke B et al. HYDRA Study Group. High prevalence and poor control of hypertension in primary care: cross-sectional study. J Hypertens. 2004; 22: 479-86
    CrossrefPubMedGoogle Scholar
  • 5 Boutitie F, Gueyffier F, Pocock S, Fagard R, Boissel JP. J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data. Ann InternMed. 2002; 136: 438-48
    PubMedGoogle Scholar
  • 6 Organisation for Economic Co-Operation and Development. Overview Ageing and Transport Mobility Needs and Safety Issues, 2002, Available from: http://www.oecd org/dataoecd/34/52/1907724.pdf accessed 23/11/2010.
    PubMed
  • 7 Gueyffier F, Bulpitt C, Boissel JP, Schron E, Ekbom T, Fagard R et al. Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. INDANA Group. Lancet. 1999; 353: 793-6
    CrossrefPubMedGoogle Scholar
  • 8 Davidson RA, Caranasos GJ. Should the elderly hypertensive be treated? Evidence from clinical trials. Arch Intern Med. 1987; 147: 1933-7
    CrossrefPubMedGoogle Scholar
  • 9 Staessen J, Amery A, Fagard R. Isolated systolic hypertension in the elderly. J Hypertens. 1990; 8: 393-405
    CrossrefPubMedGoogle Scholar
  • 10 Thijs L, Fagard R, Lijnen P, Staessen J, Van Hoof R, Amery A. A meta-analysis of outcome trials in elderly hypertensives. J Hypertens. 1992; 10: 1103-9
    CrossrefPubMedGoogle Scholar
  • 11 Celis H, Fagard R, Staessen J, Thijs L, Amery A. The older hypertensive: assessment and treatment. Neth J Med. 1993; 43: 66-77
    PubMedGoogle Scholar
  • 12 Leonetti G, Cuspidi C, Fastidio M, Lonati L, Chianca R. Arterial hypertension as a risk factor in the elderly and its treatment. J Hypertens. 1992; 2: 3-7
    PubMedGoogle Scholar
  • 13 Bejan-Angoulvat T, Saadatian-Elahi M, Wright JM, Schron EB, Lindholm LH, Fagard R et al. Treatment of hypertension in patients 80 years and older: the lower the better? A meta-analysis of randomised controlled trials. J Hypertens. 2010; 28: 1366-72
    CrossrefPubMedGoogle Scholar
  • 14 Musini VM, Tejani AM, Bassett K, Wright JM. Pharmacotherapy for hypertension in the elderly. Cochrane Database Syst Rev. 2009; 4: CD000028
    PubMedGoogle Scholar
  • 15 Beckett NS, Bulpitt Ch, Peters R, Fletcher AE, Staessen JA, Liu L et al. Treatment of Hypertension in Patients 80 years of age or older. N Engl J Med. 2008; 358: 1887-98
    CrossrefPubMedGoogle Scholar
  • 16 JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res. 2008; 31: 2115-27
    CrossrefPubMedGoogle Scholar
  • 17 Moher D, Liberati A, Tetzlaff J, Altman DG the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009; 151: 264-9
    CrossrefPubMedGoogle Scholar
  • 18 Bulpitt CJ, Beckett NS, Cooke J, Dumitrascu DL, Gil-Extremera B, Nachev C et al. Results of the pilot study for the Hypertension in the Very Elderly Trial. J Hypertens. 2003; 21: 2409-17
    CrossrefPubMedGoogle Scholar
  • 19 Coope J, Warrender TS. Randomised trial of treatment of hypertension in elderly patients in primary care. Br Med J (Clin Res Ed) 1986; 293: 1145-51
    CrossrefPubMedGoogle Scholar
  • 20 Casiglia E, Spolaore P, Mazza A, Ginocchio G, Colangeli G, Onesto C et al. Effect of two different therapeutic approaches on total and cardiovascular mortality in a Cardiovascular Study in the Elderly (CASTEL). Jpn Heart J. 1994; 35: 589-600
    CrossrefPubMedGoogle Scholar
  • 21 SHEP Cooperative Research Group. 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; 265: 3255-64
    CrossrefPubMedGoogle Scholar
  • 22 Black DM, Brand RJ, Greenlick M, Hughes G, Smith J. Compliance to treatment for hypertension in elderly patients: the SHEP pilot study. J Gerontol. 1986; 42: 552-7
    PubMedGoogle Scholar
  • 23 Amery A, Birkenhager W, Brixko P, Bulpitt C, Clement D, Deruyttere M et al. Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet. 1985; 8442: 1349-54
    PubMedGoogle Scholar
  • 24 Lindholm LH, Hansson L, Dahlof B, Ekbom T, Hedner T, De Faire U et al. The Swedish Trial in old patients with hypertension-2 (STOP-hypertension-2): a progress report. Blood Press. 1996; 5: 300-4
    CrossrefPubMedGoogle Scholar
  • 25 Mulrow C, Lau J, Cornell J, Brand M. Pharmacotherapy for hypertension in the elderly. Cochrane Database Syst Rev. 2000; 2: CD000028
    PubMedGoogle Scholar
  • 26 Hollander M, Koudstaal PJ, Bots ML, Grobbee DE, Hofman A, Breteler MM et al. Incidence, risk and case fatality of first ever stroke in the elderly population: The Rotterdam Study. J Neurol Neurosurg Psychiatry. 2003; 74: 317-21
    CrossrefPubMedGoogle Scholar
  • 27 Hoppe UC, Böhm M, Drexler H, Hasenfuß G, Lemke B, Osterspey A, Pauschinger M. Therapie der chronischen und akuten Herzinsuffizienz. UPDATE 2009; Herz- und Kreislaufforschung e.V. German Cardiac Society. Available from: http://leitlinien.dgk.org/images/pdf/leitlinien_pocket/2009_pll_1_herzinsuffizienz-update2009.pdf accessed 23/11/2010.
    PubMedGoogle Scholar
  • 28 Ogihara T, Nakao K, Fukui T, Fukiyama K, Fujimoto A, Ueshima K et al. The optimal target blood pressure for antihypertensive treatment in Japanese elderly patients with high-risk hypertension: a subanalysis of the Candesartan Antihypertensive Survival Evaluation in Japan (CASE-J) trial. Hypertens Res. 2008; 31: 1595-601
    CrossrefPubMedGoogle Scholar
  • 29 Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G et al. 2007 ESH-ESC Practice Guidelines for the Management of Arterial Hypertension: ESH-ESC Task Force on the Management of Arterial Hypertension. J Hypertens. 2007; 25: 1751-62
    CrossrefPubMedGoogle Scholar
  • 30 Dahlöf B, Devereux RB, Kjeldsen SE, Julius S, Beevers G, de Faire U et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002; 359: 995-1003
    CrossrefPubMedGoogle Scholar
  • 31 Jamerson KA, Bakris GL, Wun CC, Dahlöf B, Lefkowitz M, Manfreda S et al. Rationale and design of the avoiding cardiovascular events through combination therapy in patients living with systolic hypertension (ACCOMPLISH) trial: the first randomized controlled trial to compare the clinical outcome effects of first-line combination therapies in hypertension. Am J Hypertens. 2004; 17: 793-801
    PubMedGoogle Scholar