Aggressive treatment best for older hypertensives?
Data show effectiveness four times greater
It appears that the very group of patients that physicians often are reluctant to treat for high blood pressure — older adults with multiple risk factors for cardiovascular disease — have the most to gain from aggressive treatment. Researchers from Wake Forest University Baptist Medical Center in Winston-Salem, NC, and colleagues found that treating these high-risk older adults was four times more effective at preventing heart attacks, strokes, and heart failure than treating those with lower levels of risk.1
"This is a real breakthrough in geriatric medicine because high blood pressure is one of the most prevalent and least adequately treated cardiovascular conditions in older people," notes Marco Pahor, MD, professor of geriatrics at Wake Forest, and one of the paper’s co-authors.
Data substantial
The researchers used a risk assessment tool developed by the American Heart Association in Dallas to classify the risk of future heart attacks, stroke, and heart failure in 4,453 adults over the age of 60 who participated in the Systolic Hypertension in the Elderly Program (SHEP), a study conducted in 1991 by the National Heart, Lung and Blood Institute and the National Institute on Aging. Participants had systolic blood pressure readings of at least 160 mm Hg.
That study tested whether treatment of isolated systolic hypertension in older persons prevents stroke. The first-step therapy was chlorthalidone (12.5 mg/d). The second-step therapy involved the addition of atenolol (25 mg/d), or reserpine (0.05 mg/d) if atenolol was not tolerated. Drug treatment in the placebo and active treatment groups was increased by doubling the dosage or adding a second-step drug until the BP goal (decreasing systolic BP to <160 mm Hg or by at least 20 mm Hg) was reached.
"What we did was re-analyze the data of this trial and the effects of treatment according to levels of risk, to see if it was effective when the patients had more risk levels," explains Pahor. His group’s analysis focused on four types of events: First-occurring major cardiovascular event, including stroke, MI or heart failure; first-occurring MI; first-occurring stroke; and first clinical diagnosis of congestive heart failure. "What we found was that the treatment was actually more effective and more efficient among those patients with more risk factors. The absolute risk of a cardiovascular event was higher, but the effect of the treatment was better," he explains. "This gives us the empirical evidence that we should treat those people even more aggressively."
These findings have great significance, says Pahor, because of the number of people they potentially could help. "Between 50% and 70% of those people over 60 have hypertension, so it’s a condition that’s very frequently seen," he notes. "In the U.S., there are about 18 million older adults with high blood pressure. Of those, only 3 million are adequately treated and 15 million are not."
Why is this population not being treated adequately? "A small proportion of those who have hypertension are unaware that they do, but many are aware but are not treated," Pahor observes. "Frequently, physicians believe that when an older person has higher than normal blood pressure this is related to age, but we have several trials that show they should be treated as aggressively as younger people and it will do no harm. Still, there’s a concept among physicians that they can’t tolerate the medications."
Also, says Pahor, if these patients have several different conditions — i.e., they have diabetes, high cholesterol, or a previous stroke or heart attack — physicians are concerned that if they treat them too aggressively they will do more harm than good — that they are more likely to experience adverse effects from the treatment.
Quality managers should review these findings carefully, he advises, and be aware of what they do and do not show. "What we have found that applies to older people is well-known in younger people, so we should treat both groups the same," he says. "What we have not addressed is to what extent they should be treated. If they are not treated at all, we know their outcomes are much worse — but we could not assess, for example, what would happen if their blood pressure was lowered even more aggressively."
The key, he says, is to make sure that any patient who has high blood pressure receives adequate treatment. That standard was outlined in the Archives of Internal Medicine (1997; 157:2,413-2,446), by the Joint National Committee. "It has been endorsed by both the American Heart Association and the National Heart, Lung and Blood Institute," Pahor concludes.
Reference
1. Ferrucci L, Furberg CD, Penninx BWJH, et al. Treatment of isolated systolic hypertension is most effective in older patients with high-risk profile. Circulation 2001; 104:1923.
Need more information?
For more information, contact: Marco Pahor, MD, Professor of Geriatrics, Wake Forest University School of Medicine, Department of Internal Medicine, One Medical Center Blvd., Winston-Salem, NC 27157. Telephone: (336) 713-8520.
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