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#22 Treating Hypertension in the Very Elderly: What we know so far?


CLINICAL QUESTION
QUESTION CLINIQUE
In patients over age 80, what are the risks and benefits of treating hypertension (and are there different targets)?


BOTTOM LINE
RÉSULTAT FINAL
Treating hypertension in healthy elderly patients age 80 is effective.  Exact targets are uncertain but the primary trial used 150/80 as a target and another trial showed benefit with a systolic BP <120. The benefit of treating the frail elderly or those with orthostasis and/or a standing systolic BP of <140 remains uncertain.



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EVIDENCE
DONNÉES PROBANTES
One large randomized controlled trial (RCT) specifically addresses this situation: 
  • HYVET1 RCT, 3,845 patients, mean follow-up 2.1 years, 60% female, ≥80years (mean age 83.5), Blood Pressure (BP) >160 systolic.   
    • Indapamide (SR 1.5mg) +/- perindopril (2-4mg) (target BP <150/80 mmHg) or placebo 
    • Outcomes:   
      • Mortality: Number Needed to Treat (NNT)=47 (Treatment 10% versus 12%). 
      • Any cardiovascular disease (CVD): NNT=34 (Treatment 7% versus 10%). 
      • Heart failure: NNT=35 (Treatment 3% vs 1.1%) 
    • Potential limitations:  
      • Stopping early can exaggerate benefit.2  
      • The healthy elderly population (≤12% CVD history, <7% diabetes) may limit broad application. 
      • Patients with a standing systolic BP <140 were excluded from the study; few subjects had orthostasis (7.9-8.8%).  
    • In the subgroup of 2636 SPRINT trial patients >75 years old3 (see Tools for Practice #37), target systolic BP <120 mm Hg versus <140 mm Hg reduced mortality (NNT=39), any CVD (NNT=29), and heart failure (NNT=63) over 3.1 years. 
Context:   
  • A systematic review extracting data on patients ≥80 years old from 7 trials (1670 patients) found antihypertensive therapy significantly reduced CVD events but left uncertainty regarding the effect on mortality.4  
  • A meta-analysis of patients >80 years old (3 trials, 8,221 patients) found no difference between target BP <140/90 and 150-160/90 mm Hg.5 
  • HYVET was specifically designed to address hypertension in the healthy very elderly and for that population would be more reliable than pooled subgroup data.   
    • Note: Target BP of HYVET was 150/80, higher than that of most guidelines.   
    • Most trials,4 including HYVET,1 used thiazide diuretics as the first line therapy. 
    • A 1-year extension of HYVET showed sustained benefits.6 
  • The 2017 Canadian7 guidelines changed the BP target for elderly to <140/90 mm Hg, whereas American8 guidelines recommend target systolic BP <130 mm Hg for non-institutionalized, ambulatory patients >65 years old. 
updated dec 6 2017 by ricky


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Author(s)
Auteur(s)
  • G. Michael Allan MD CCFP
  • Laurie Mallery MD FRCP (Geriatric Medicine)

1. Beckett NS, Peters R, Fletcher AE, et al. N Engl J Med 2008;358:1887-98.

2. Montori VM, Devereaux PJ, Adhikari NK, et al. JAMA 2005;294: 2203-9.

3. Williamson JD, Supiano MA, Applegate WB, et al. JAMA 2016;315:2673-82.

4. Gueyffier F, Bulpitt C, Boissel JP, et al. Lancet 1999;353:793–96.

5. Garrison SR, Kolber MR, Korownyk CS, McCracken RK, Heran BS, Allan GM. Cochrane Database Syst Rev 2017;8:CD011575

6. Beckett N, Peters R, Tuomilehto J, et al. BMJ 2012;344:d7541.

7. Leung AA, Daskalopoulou SS, Dasgupta K, et al. Can J Cardiol 2017;33:557-76.

8. Whelton PK, Carey RM, Aronow WS, et al. J Am Coll Cardiol 2017;Nov 13[Epub ahead of print]:doi:10.1016/j.jacc.2017.11.006.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.

Most recent review: 06/12/2017

By: Ricky D Turgeon BS(Pharm), ACPR, PharmD

Comments:

Evidence Updated: SPRINT trial subgroup added; Bottom Line: Added SPRINT trial implication.

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