Isolated Systolic Hypertension in the Elderly

KoKo Aung, MD, MPH, Thwe Htay, MD

Disclosures

Cardiovasc Rev Rep. 2003;24(8) 

In This Article

Practical Considerations for Treatment of ISH in the Elderly

Based upon the findings of the SHEP and Syst-Eur trials, the only randomized controlled trials that used morbidity and mortality data as main outcome measures available to date on ISH in the elderly, it is clear that ISH in the elderly up to the age of 80 should be treated. As in younger persons, treatment of ISH in the elderly should begin with lifestyle modifications. Weight reduction, limiting alcohol use, increasing physical activities, and reducing sodium intake are the recommended lifestyle modifications.[32] A randomized controlled trial[33] of 875 elderly hypertensive patients demonstrated that lifestyle modification could be achieved in the elderly patients. It should be noted that very elderly patients, above 80 years of age, were not included in the study.

The sixth report of Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI)[34] recommended that the goal of treatment should be SBP <140 mm Hg, although an interim goal of SBP <160 mm Hg might be acceptable in those patients with marked systolic hypertension. If this goal is not achieved with lifestyle modifications, then pharmacologic treatment is indicated.

However, it should be noted that all three major clinical outcome trials of ISH used the minimum SBP of 160 mm Hg as a selection criterion. It is unclear about the benefit of treating patients with ISH whose SBP is between 141 and 159 mm Hg.

Many antihypertensive agents, including thiazide diuretics, ß blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, and isosorbide dinitrate have been shown to lower SBP in patients with ISH.[35] Thiazide diuretics are preferred first-line agents because they have significantly reduced the multiple end point events in the SHEP trial. The calcium channel blocker nitrendipine is an alterative option since a nitrendipine-based regimen was used in the Syst-Eur trial, which demonstrated a reduction in fatal and nonfatal strokes. Although the major outcome trials of ISH did not use amlodipine, it has been shown that both amlodipine and nitrendipine could achieve comparable blood pressure reduction in treatment of mild to moderate hypertension in the elderly.[36] The study population included, but was not limited to, the elderly ISH patients. Since nitrendipine is not available in the United States, other long-acting dihydropyridine calcium antagonists such as amlodipine are considered to be appropriate alternatives.

Although there are morbidity trials comparing one class of antihypertensive and another, and many participants were, by and large, elderly populations, the participants were not entirely restricted to the elderly ISH patients. It is therefore difficult to extrapolate the findings of these trials to the elderly ISH patients.

Older patients with ISH who have risk factors for cardiovascular disease are prime candidates for anti-hypertensive treatment because the reduction of event rate is most pronounced in such individuals.

A medical record review in a multispecialty practice group[37] showed that ISH represented 76% of uncontrolled blood pressure in the elderly. ISH was often undiagnosed and untreated. Physicians reported treatment thresholds and goals that should be pursued more aggressively in patients aged ≥65 years.

It is uncertain if treating ISH in the patients aged ≥80 carries individual benefits. Generalizations may not be possible because of the limited availability of data. The HYVET study may shed some light in this area. It is likely that in the very old with ISH, antihypertensive treatment improves the quality of life by preventing nonfatal strokes. But there are no systematic quality-of-life outcome studies. At this time, the decision of whether or not to treat these patients should be based on individual circumstances, weighing the benefits and risks of such therapy.

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