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The new guidelines are based on data from 2 trials that focused specifically on treating elderly patients for hypertension, which hadn't been done before.
Controlling hypertension in the elderly (≥65 years of age) is an important issue to address as the U.S. population ages because most older people are affected by the condition. Hypertension is more common in the elderly due to changes of arterial structure and function that accompany aging.
Blood vessels lose elasticity, resulting in increased systolic blood pressure, decreased organ perfusion, and increased myocardial oxygen demand. These problems are magnified in patients with coronary stenosis or excessive drug-induced diastolic blood pressure (DBP) reduction. Autonomic dysregulation contributes to orthostatic hypotension and hypertension, putting patients at risk for problems such as falls, coronary artery disease, and cerebrovascular disease.
New treatment guidelines
Treatment goals for the elderly are as follows:
1. Goal is not achieved despite taking a regimen of 4 well-selected and appropriately dosed drugs;
2. Prescribed therapy is causing unacceptable side effects;
3. The DBP is being reduced to a potentially dangerous level of <65 mm Hg.
These recommendations were made largely based on data from 2 trials: the Hypertension in the Very Elderly Trial (HYVET) and the Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial.
Dr. Saseen referred to the HYVET trial as "landmark" because it is the first trial that included only patients greater than 80 years of age. The study compared antihypertensive therapy (indapamide SR plus perindopril) to placebo. The target blood pressure in the trial was 150/80 mm Hg. Death from any cause was reduced by 21% in the treatment group, and the study was stopped early due to overwhelmingly positive cardiovascular benefits of treatment.
The ACCOMPLISH trial compared treatment with benazepril and amlodipine to benazepril and hydrochlorothiazide (HCTZ) in patients who were at high risk for cardiovascular events. Approximately 40% of subjects were greater than 70 years old. The combination of benazepril and amlodipine regimen resulted in fewer cardiovascular events and was stopped early.
A conservative approach
Lifestyle modifications are still considered part of first-line therapy, but not as solo treatment, according to Dr. Saseen. The guidelines state that first-line treatment may include an angiotensin-converting-enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), a calcium channel blocker, a beta-blocker, or diuretic. Beta-blockers should not be used as first-line therapy without a compelling indication to do so.
In general, drugs should be initiated 1 at a time and increased to their maximum tolerated dose before adding a second agent. However, if the patient is at least 20 mm Hg away from his or her blood pressure target, 2 drugs may be started concurrently. Dr. Saseen pointed out that clinicians need to be aware of the risk of orthostatic hypotension with this approach, especially in patients who have isolated systolic hypertension.
Goals differ from JNC7
The AHA treatment goals for the elderly differ from JNC7, which advises treating older patients to obtain the same goals as the general population.
Dr. Saseen acknowledged that this population "poses many challenges" and that these recommendations are controversial because data have been extrapolated from other populations in some cases. He said, "All patients over 80 years of age should have regular monitoring for adverse effects because they are most at risk."