Blood Pressure In The Very Old

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Contents 1 Introduction 2 Pathology 3 Clinical-trials 4 Complications 5 Management 6 More General Terms 7 References

Introduction

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

Pathology

• older individuals have lower arterial compliance & increased vascular resistance
• pulse pressure is often increased
• U-shape relationship of diastolic blood pressure & mortality
• diastolic blood pressure < 70 mm Hg associated with higher mortality [12]; U point may be > 70 mm Hg [1,2,6,9] (also see diastolic blood pressure)

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

• inverse relationship* of blood pressure with mortality

• up to 139 mm Hg systolic
• up to 89 mm Hg diastolic
  

• * Veterans with higher blood pressure (up to 139 mm Hg systolic) & (up to 89 mm Hg diastolic) had lower mortality than veterans with lower blood pressure.
  

• hazard ratio for a 10 mm Hg increase in blood pressure

• 0.82 up to 139 mm Hg (systolic)
• 0.85 up to 89 mm Hg (diastolic)
  

• for systolic blood pressure > 140 mm Hg & diastolic blood pressure> 90 mm Hg, no association with blood pressure & mortality
  

• 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 & 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
  

• [11] 85+ years

• systolic blood pressure, diastolic blood pressure & pulse pressure were all inversely associated with mortality
• systolic blood pressure was the strongest predictor
• systolic blood pressure <120 mmHg correlated with greater 4-year all-cause mortality alone & when controlling for health status
• suggestion of a U-shaped mortality curve for the adjusted model, with systolic blood pressure of 164 mmHg associated with the lowest mortality.

Complications

• elderly are susceptible to orthostatic hypotension if antihypertensive therapy is initiated or increased too rapidly

Management

• treat the diastolic blood pressure

• treat diastolic hypertension (> 90 mm Hg) [10]
• lower systolic blood pressure until < 160 mm Hg or diastolic blood pressure < 70 mm Hg

More General Terms

• geriatrics

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 N 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. Medical Knowledge Self Assessment Program (MKSAP) 15, American College of Physicians, Philadelphia 2009

blood pressure in the very old