Published online before print March 10, 2008, doi: 10.1161/HYPERTENSIONAHA.108.110205
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(Hypertension. 2008;51:817.)
© 2008 American Heart Association, Inc.
Editorial Commentaries |
Older Patients Need Better Guidelines for Optimal Treatment of High Blood Pressure
1 Size Fits Few
From the Mount Sinai School of Medicine, New York, NY; and the Englewood Hospital and Medical Center, Englewood, NJ.
Correspondence to Lawrence R. Krakoff, Department of Medicine, Englewood Hospital and Medical Center, 350 Engle St, Englewood NJ 07631. E-mail Lawrence.Krakoff{at}ehmc.com
Effective drug-based treatment of hypertension is now a mainstay of adult preventive medicine. The first clinical trials demonstrated the benefit of lowering diastolic pressure in middle-aged participants.1 Extension of drug treatment to older populations with high systolic pressures has likewise been clearly shown to prevent cardiovascular disease and is universally accepted for medical practice.2 The high prevalence of predominant or isolated systolic hypertension in older groups, coupled with the evidence from trials, has then led to guidelines that exhort the need to treat and control hypertension based on goal blood pressures far lower than had been accepted in the past.3 These efforts have been successful, as recent surveys from the United States and England report higher control rates for older groups compared with previous assessments. In part, these trends may be attributable either to more older patients receiving any drug treatment or to more aggressive deployment of drug classes and higher doses. On the other hand, where treatment of hypertension is already widely available, as in the US Veterans’ Affairs system, control rates for hypertension now are higher in middle-aged groups compared with older ones.4 In assessing the effect of age on control of hypertension, it is crucial that all of the relevant factors be included: adherence to medication; use of appropriate medications, ie, drug classes and dosing; and explanation of dropout or refusal rates (adverse effects, cost, and health beliefs). Present practice databases may contain relevant information for some of these factors so that exploration of their content may reveal helpful insights.
The report by Bailey et al5 in this issue of Hypertension takes advantage of such a database from a single center, the Mayo Clinic, one that has a deserved reputation for clinical excellence. It is likely that physicians treating hypertension in this setting are well informed as to present guidelines and maintain a high level of skill in treating hypertension. Thus, a summary of clinical experience for treating hypertension may be seen as reflecting a high standard of care. Rather than simply reporting control rates for hypertension, Bailey et al5 have explored 2 innovative strategies for portraying the spectrum of control. First, use of the Kaplan–Meier model has been applied as stratified by age. Second, the complex morass of drug selection and dosing has been simplified into a single metric, "intensity of treatment" that sums drug classes and fraction of maximal dosing into a single number. "Intensity," which replaces "time," which is most familiar in Kaplan–Meier analyses, is considered from 2 perspectives, the lowest intensity needed for control and the intensity at which no further increase is made, based on an assumption that neither the physician nor the patient is willing to go further down the road of more drug treatment. The resulting analysis permits a graphic combined view of the relationship between age and effort of treatment. What new insights are then portrayed by this approach?
For every age range studied, increased treatment intensity was associated with increased control of hypertension. This effect might be because of higher intensity resulting from increased doses of fewer drugs or because of more drug classes at lower doses. The effect of age on control rates is also readily apparent. Older patients less often met guideline based on control rates in an age-related graded manner. The shape of these relationships, as best summarized in Figure 2, may be the most important finding of the study: a plateau of control in relation to treatment intensity that is distinct for each age group and descends from highest in the young to the lowest in the old. This finding, although descriptive in summarizing a clinic experience, nonetheless implies that community control of hypertension, particularly in older groups, may have limits that cannot be overcome by simple strategies or maximal drug dosing. The basis for these limits is not clear, but the nature of this clinic’s experience includes both physician choice and patient acceptance.
Community surveys have shown that the component of blood pressure control least often achieved in treatment of older patients, particularly women, is reduction of systolic pressure to <140 mm Hg.6 In the Systolic Hypertension in the Elderly Program Trial, which established the benefit of drug treatment for systolic hypertension in this age group, the 5-year average systolic blood pressure was 155 mm Hg for the placebo group and 143 mm Hg, 12 mm Hg lower, for the drug-treated group. Thus, unequivocal prevention of cardiovascular disease was achieved by reduction of blood pressure, yet more than half of those treated failed to reach goal pressure. A similar pattern was observed in the Systolic Hypertension in Europe Trial, where the goal systolic pressure was 150 mm Hg and the average on treatment systolic pressure was slightly above this target; 43% met the goal. Because these represent the best evidence from trial conditions, 1 careful analysis of the rationale for treatment of systolic hypertension in older groups has concluded that providers and patients have some latitude in choosing the most appropriate goal for on-treatment systolic pressure so that a uniform target of <140 mm Hg is not suitable for all comers.7
The benefit of drug treatment for hypertension lies not in whether a guideline-based goal blood pressure is achieved but whether treatment has sufficiently reduced usual pressure to prevent future disease.8 Thus, a reduction in pretreatment systolic pressure from 142 mm Hg to on-treatment pressure of 138 mm Hg (at goal) has far less benefit compared with a reduction from 160 mm Hg to 145 mm Hg (not at goal). By focusing only on "control" of blood pressure as above or below the set goal, the approach used by Bailey et al5 fails to capture the actual benefit of treatment that is achievable for the older patients, because we are not provided with the reductions in pressure that drug treatment elicited. However, the value in looking at control of hypertension in this report gives a needed insight into the real world limits of trying to force a fixed goal for treatment on a group of skilled providers and, presumably and probably, willing patients.
Is lower always better for blood pressure in the elderly? This question has been raised in assessing treatment of older patients in the US Veterans’ Administration4 and in follow-up of older groups surviving well beyond 85 years of age.9 These studies suggest that the optimal systolic pressure of these older groups may be >140 mm Hg systolic pressure but do not provide a clear-cut explanation. Certainly older patients often have orthostatic hypotension that may be ignored in treating higher pressures based only on measurements made when seated.10 In attempting to lower systolic pressure, diastolic pressure will fall with risk of the J-curve effect, perhaps more pronounced in the old-old as well.11 Frailty in older patients might exclude some individuals for inclusion in clinical trials but may not be fully recognized in focusing treatment on hypertension.12 Perhaps some of these issues were taken into account by the physicians treating hypertension in the Mayo Clinics and account for the patterns found in this report.5
Those of us who treat high blood pressure in the elderly often ponder the complexities of reconciling lower blood pressure with quality of life and risk of preventable cardiovascular disease. We need more evidence and nuanced expert opinion in giving age its due for the formulation and dissemination of improved guidelines to increase true patient-centered management of high blood pressure in older individuals.
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Acknowledgments |
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Disclosures
None.
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Footnotes |
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The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
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References |
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Related Article:
Hypertension 2008 51: 841-847.
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