Blood Pressure In The Very Old

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Contents

Introduction

  • In reference to patients at least 80 years of age.

Pathology

Complications

Management

  • this recommendation would seem at odds with results of clinical trials (see Clinical-trials below)
  • not an evidence-based recommendation

Clinical-trials

  • [1] 85+
  • Population-based propective study in very old people (>= 85 years) in Finland
  • No randomized trials in this age group have been conducted
  • Systolic blood pressure < 140 mm Hg significantly increases* mortality in the very old (> 85 years of age)
  • Systolic blood pressure > 160 mm Hg does not.*

  • * Relative to systolic blood pressure 140-159 mm Hg
 
* systolic blood pressure    hazard ratio 
*    < 140 mm Hg                1.35 
*  140-159 mm Hg                1.00 
*    > 160                      0.97


  • [2] 471 ambulatory veterans from 10 VA centers aged >= 80 with hypertension
  • The study did not control for antihypertensive therapy.

  • [3] No data, extrapolation

  • [4] 1283 patients >= 80 years of age, with BP 160-220/90-110
  • target BP < 150/80, follow-up 13 months

  • Treatment groups
  • diuretic (bendroflumethiazide)
  • ACE inhibitor (lisinopril)
  • no treatment
  • diltiazem added to treatment groups as needed

  • Results:
  • treatment of blood pressure reduced risk of stroke, but increased risk of mortality & cardiovascular risk in general (it seems overall risk of stroke 3%)

  • [5] 65+, 85+
  • men, 85+: higher systolic BP associated with better survival
  • men, 65+: negative association of diastolic BP with mortality
  • women, 65-85, increased systolic BP associated with increased mortality
  • women, 85+ no association of systolic BP with mortality

  • [6] 75+
  • inverse relationship between systolic BP & diastolic BP with mortality
  • a U-shaped relationship was observed in the 75-80 group for diastolic BP, mortality least for BP 80-90 mm Hg

  • [7] 80+ years of age (review)
  • treatment of HTN increases mortality in elderly > 80
  • higher systolic BP & diastolic BP are associated with decreased mortality

  • [8] 60+ years, 15,693 patients with isolated systolic HTN
  • follow-up (median) 3.8 years
  • systolic BP positively associated with mortality, risk of stroke
  • inverse association of diastolic BP with mortality
  • treatment reduced mortality 13%, stroke 30%, acute coronary syndrome 23%
  • number need to treat for 5 years to prevent 1 major cardiovascular event lower in men than women (18 vs 38) & >= age 70 (19 vs 39) & in patients with prior cardiovascular complications (16 vs 37)

  • [9] 85+ years of age
  • mortality greatest in those with lowest systolic & lowest diastolic blood pressure
  • mortality least in elderly with systolic BP >= 160 mm Hg & diastolic BP >= 90 mm Hg

  • [10] 80+ years of age, mean age 84 years (HYVET study)
  • 3845 patients from Europe, China, Australasia, & Tunisia
  • mean blood pressure 173/91 mm Hg treated with indapamide SA 1.5 mg or placebo + perindopril 2-4 mg or placebo as necessary to achieve BP of 150/80
  • BP lower in treatment group, mean 15/6 mm Hg
  • allegedly, mean BP achieved in treatment group 143/78
  • 30% reduction in mortality from stroke in treated group (p=0.046) 12.4 vs 17.7 per 1000 patient years
  • number need to treat to prevent 1 stroke in 2 years = 100
  • 21% reduction in all-cause mortality (p=0.02) (10% vs 12%)
  • 64% reduction in heart failure
  • fewer adverse effects in the treatment group (358 vs 448)
  • allegedly, only 2 serious adverse events, in the indapamide group (implausible per commentator)
  • trial halted early because of ethical concerns
  • sponsored by manufacturer of study drugs
  • open label 1 year extension of trial
  • all patients treated with study drugs with target of 150/80
  • comparing patients previously treated with study drugs & those previously on placebo,
  • at 6 months BP difference between groups 1.2/0,7 mm Hg
  • no significant differences for stroke (n = 13; RR=1.92)) or cardiovascular events (n = 25; RR=0.78))
  • decrease total mortality (47 deaths; RR=0.48; P=0.02) & cardiovascular mortality (11 deaths; RR=0.19, P=0.03)

  • [11] 85+ years
  • [12] 85-90 years of age
  • higher systolic blood pressure associated with better scores on MMSE & activities of daily living scale
  • during 5 years of follow-up, higher baseline systolic BP was associated with less physical & cognitive decline

  • [13] 80+ years of age, meta-analysis
  • treating hypertension in very old patients reduces stroke & heart failure with no effect on total mortality

    [19] 80+ years of age
  • systolic blood pressure < 135 mm Hg associated with increased mortality

More General Terms

Additional Terms

References

  1. Rastas S. Association between blood pressure and survival over 9 years in a general population aged 85 and older. J Am Geriatr Soc 2006; 54:912 PMID: [1]
  2. Oates DJ, Berlowitz DR, Glickman ME, Silliman RA, Borzecki AM. Blood pressure and survival in the oldest old. J Am Geriatr Soc. 2007 Mar;55(3):383-8. PMID: [2]
  3. Forette et al, Does the benefit of antihypertensive treatment outweigh the risk in the very elderly hypertensive patients: J Hypertens 2000, 18(suppl 3):S9-S12 PMID: [3]
  4. Bulpitt CJ et al, Results of the pilot study for the Hypertension in the Very Elderly Trial J Hypertens 2003, 21:2409 PMID: [4]
  5. Satish S et al, The relationship between blood pressure and mortality in the oldest old J Am Geriatr Soc 2001, 49:367 PMID: [5]
  6. Hakala S-M et al, Blood pressure and mortality in an older population: A 5 year follow-up of the Hesinki Ageing Study Eur Hear J 1997, 18:1019 PMID: [6]
  7. Goodwin JS Embracing Complexity: a consideration of hypertension in the very old J Gerontol, Medical Sciences 2003, 58A: 653 PMID: [7]
  8. Staessen JA et al, Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of the outcome trials. The Lancet 2000, 355:865 PMID: [8]
  9. Mattila K et al, Blood pressure and five year survival in the very old British Medical Journal 1988, 296:887 PMID: [9]
  10. Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L et al; the HYVET Study Group. Treatment of Hypertension in Patients 80 Years of Age or Older. N Engl J Med. 2008 Mar 31; PMID: [10]
    - Kostis JB Treating hypertension in the very old N Engl J Med 2008, March 31 PMID: [11]
    - Beckett NS et al. Immediate and late benefits of treating very elderly people with hypertension: Results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial. BMJ 2012 Jan 4; 344:d7541 PMID: [12]
  11. Molander L et al. Lower systolic blood pressure is associated with greater mortality in people aged 85 and older. J Am Geriatr Soc 2008 Oct; 56:1853. PMID: [13]
  12. Sabayan B et al. High blood pressure and resilience to physical and cognitive decline in the oldest old: The Leiden 85-Plus Study. J Am Geriatr Soc 2012 Nov; 60:2014. PMID: [14]
  13. Bejan-Angoulvant T1, Saadatian-Elahi M, Wright JM et al Treatment of hypertension in patients 80 years and older: the lower the better? A meta-analysis of randomized controlled trials. J Hypertens. 2010 Jul;28(7):1366-72. PMID: [15]
  14. Medical Knowledge Self Assessment Program (MKSAP) 15, 16 American College of Physicians, Philadelphia 2009, 2012
  15. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  16. Medscape: Dec 18, 2013 JNC 8 at Last! Guidelines Ease Up on BP Thresholds, Drug Choices. [16]
    - James PA et al 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. Published online December 18, 2013 <PubMed> PMID: [17] <Internet> [18]
    - Bauchner H et al Updated Guidelines for Management of High Blood Pressure Recommendations, Review, and Responsibility. JAMA. Published online December 18, 2013. <PubMed> PMID: [19] <Internet> [20]
    - Peterson ED et al Recommendations for Treating Hypertension. What Are the Right Goals and Purposes? JAMA. Published online December 18, 2013. <PubMed> PMID: [21] <Internet> [22]
    - Sox HC Assessing the Trustworthiness of the Guideline for Management of High Blood Pressure in Adults. JAMA. Published online December 18, 2013. <PubMed> PMID: [23] <Internet> [24]
  17. Mossello E et al. Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs. JAMA Intern Med 2015 Apr; 175:578 <PubMed> PMID: [25] <Internet> [26]
  18. Ogliari G et al. Age- and functional status-dependent association between blood pressure and cognition: The Milan Geriatrics 75+ Cohort Study. J Am Geriatr Soc 2015 Sep; 63:1741 PMID: [27]
  19. Delgado J, Masoli JAH, Bowman K et al Outcomes of Treated Hypertension at Age 80 and Older: Cohort Analysis of 79,376 Individuals. J Am Geriatr Soc. 2017 May;65(5):995-1003. PMID: Free PMC Article&dopt=Abstract

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