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