Antihypertensives Up Survival but May Cause Falls in Seniors

Marlene Busko

September 11, 2014

BARCELONA, SPAIN — Rising numbers of older patients with hypertension is reinvigorating debate as to best treatments and the benefits and risks of hypertensive medications in this group.

At last week's European Society of Cardiology (ESC) 2014 Congress , Dr Maciej Ostrowski (Medical University of Lodz, Poland) presented a meta-analysis of 11 trials in patients 65 years or older comparing blood-pressure–lowering therapies against placebo that highlighted the risks and benefits[1].

Across the 11 trials, the therapies were significantly more effective than placebo in lowering blood pressure. Overall, systolic blood pressure was lowered by a mean of 12.43 mm Hg more with therapy and diastolic blood pressure was lowered by a mean of 5.06 mm Hg more with therapy, each compared with placebo.

Overall, in more than 40 000 elderly patients, antihypertensive therapy was associated with significant 13% and 18% lower relative risks of death from all causes and from cardiac causes, respectively, and with a 21% lower relative risk of having a cardiovascular event. Notably, therapy was also linked with a 30% lower risk of strokes.

However, based on only one study, blood-pressure–lowering medication was tied to a 21% increased risk of falls.

"In six years, in 2020, one out of every five European Union citizens will be 65 or older," and by 2030, almost one out of every four citizens will be elderly, Ostrowski said. More than 20% of people living in Germany and Italy and close to that proportion of people living in Portugal, the UK, and Switzerland reached or surpassed this age milestone in 2012.

About three out of four people (76.1%) over the age of 64 have hypertension, according to one Polish study.

Those numbers, coupled with the findings from the meta-analysis, sparked discussion during an ESC press conference as to who should be taking blood-pressure medications and when they should start."Three out of four of our patients will soon be above the age of 70," press-briefing cochair Prof Joep Perk (Linnaeus University, Health and Caring Sciences, Kalmar, Sweden) commented. "Does this mean that we have to put the entire Swedish elderly patient population on drugs?"

Ostrowski replied: "Drugs are not the first intervention in hypertension; we should use all instruments that we have, which include lifestyle modification, if possible . . . and then drugs."

Perk countered that recommending exercise and dietary changes is particularly challenging in older patients. "If you have old, stiff arteries, do you think it is still any use to get our old people in Sweden to run around and eat like rabbits?" he asked.

"Maybe it is too late; maybe it's not," Ostrowski hedged. There is a dearth of high-level evidence to guide clinicians who are treating elderly people with hypertension as well as a "huge need" for more studies, Ostrowski said. Their Blood Pressure Meta-Analysis Collaboration group is conducting a follow-up meta-analysis to determine the optimal blood pressure in older adults, he added.

"Don't Overdo It, but Don't Be Nihilistic"

"This was a very strong summary and clearly showed us that the elderly should receive antihypertensive drugs and it is good, especially for stroke," ESC spokesperson Prof Heinz Drexel (VIVIT-Institut, Feldkirch, Austria) commented to

 
If you have old, stiff arteries, do you think it is still any use to get our old people . . . to run around and eat like rabbits?
 

The message is "Don't overdo it with blood-pressure lowering, but on the other side, which is more important, don't be . . . nihilistic, and that's what we were for decades in the elderly."

Guidelines do not specify which therapies are best for older people, "although we know as clinicians that calcium-channel blockers [such as amlodipine] do even better in older [patients]," whereas diuretics have the same effects at any age, he noted.

Elderly patients are likely to be taking multiple drugs, and a polypill, such as amlodipine with a statin, for example, might be an option for some patients to simplify their drug regimen.

Perk told heartwire that one of the limitations of the meta-analysis is that it used one cutoff point to define hypertension—"1 mm Hg above that, you're sick; 1 mm Hg below, you're healthy."

Like Ostrowski and Drexel, he said, "We should definitely not forget to give elderly people advice on lifestyle, because we know it still works, and of course give them chances with drugs if lifestyle doesn't work.

"In practice, we have been too often accepting of higher blood pressure in elderly people as a normal sign of aging. The belief that normal systolic blood pressure is 100 plus a person's age is still prevalent but is completely wrong," he said.

Ostrowski is a senior medical advisor for Abbott Laboratories Poland in Warsaw and has worked for Sanofi and Hammer-Med.

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