Treating hypertension and prehypertension in older people: when, whom and how

Abstract

Prehypertension should be treated with lifestyle measures and not with antihypertensive drug therapy in older adults. Lifestyle measures should be encouraged both to retard development of hypertension and as adjunctive therapy in those with hypertension. A meta-analysis of 11 randomized controlled trials of 40,325 older persons showed that antihypertensive drug therapy significantly reduced all-cause mortality 13% (7-19%), cardiovascular death 18% (7-27%), cardiovascular events 21% (13-27%), stroke 30% (23-37%), and fatal stroke by 33% (9-50%) (Ostrowski et al., 2014 [32]). The American College of Cardiology/American Heart Association 2011 expert consensus document on hypertension in the elderly recommended that the systolic blood pressure be lowered to <140 mm Hg in older persons younger than 80 years and to 140-145 mm Hg if tolerated in adults aged 80 years and older. A meta-analysis of 147 randomized trials including 464,000 persons with hypertension showed that except for the extra protective effect of beta blockers given after myocardial infarction and a minor additional effect of calcium channel blockers in preventing stroke, the use of beta blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), diuretics, and calcium channel blockers cause a similar reduction in coronary events and stroke for a given decrease in blood pressure. The choice of specific antihypertensive drugs such as diuretics, ACE inhibitors, ARBs, beta blockers, or calcium channel blockers depends on efficacy, tolerability, presence of specific comorbidities and cost.

Keywords: Antihypertensive drugs; Cardiovascular events; Hypertension; Lifestyle measures; Prehypertension; Stroke.