Pharmacotherapy for hypertension in the elderly

Mulrow C, Lau J, Cornell J, Brand M

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Summary

Medications to treat high blood pressure are effective in preventing serious complications, such as stroke or heart attack, in elderly people.
Hypertension (high blood pressure) is common among elderly people and increases the risk of serious problems such as heart disease and stroke. Several medications are used to try to lower blood pressure and reduce the risk of complications, but relatively few studies have examined treatments for hypertension in people over 60 years of age. The review found that medications to lower blood pressure were highly effective in preventing complications such as stroke and heart attack in elderly people. However, effects of treatment in very old people or people with other problems like diabetes are not clear. More research is needed.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 3, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Mulrow C, Lau J, Cornell J, Brand M. Pharmacotherapy for hypertension in the elderly. Cochrane Database of Systematic Reviews 1997, Issue 4. Art. No.: CD000028. DOI: 10.1002/14651858.CD000028

This version first published online: July 21. 1997
Date of last substantive update: December 01. 1997

Abstract

Background

Elderly persons have higher prevalences of hypertension than younger and middle-aged persons and elders with hypertension have a much higher risk of cardiovascular morbidity and mortality than middle-aged persons with hypertension. Despite the higher prevalence and risk in older persons, most early randomized controlled trials evaluating antihypertensive drug therapy were conducted in middle-aged persons. Since 1985, multiple large trials have been published, and several meta-analyses have summarized their results (Davidson 1987, Staessen 1988, Staessen 1990a, Staessen 1990b, Leonetti 1992, Thijs 1992, Celis 1993, MacMahon 1993, Thijs 1994, Pearce 1995). The purpose of this systematic review is to build on these prior published meta-analyses and provide a comprehensive overview of available trial evidence regarding long-term benefits and harms of antihypertensive drug therapy in elders.

Objectives

To quantify the long-term effects of antihypertensive drug therapy on morbidity and mortality in the elderly. To characterize co morbid risk profiles of trial participants.

Search strategy

Electronic search of WHO-ISH Collaboration register (August 1997), The Cochrane Library (1997; Issue 1), MEDLINE (1966 to April 1997) and two Japanese databases (1973-1995); references from reviews, trials and 10 previously published meta-analyses; and experts.

Selection criteria

Randomized controlled trials of at least one year duration in hypertensive elders (at least 60 years old) assessing antihypertensive drug therapy and providing morbidity and mortality data.

Data collection and analysis

At least two independent reviewers abstracted data on morbidity and mortality results and trial characteristics. The following outcomes were assessed: total mortality; coronary heart disease (CHD) mortality; combined CHD morbidity and mortality; cerebrovascular mortality; combined cerebrovascular morbidity and mortality; cardiovascular mortality; combined cardiovascular morbidity and mortality; and drop outs due to side effects of treatment.

Main results

Fifteen trials including 21,908 elderly subjects were identified. The average prevalence of cardiovascular risk factors, cardiovascular disease, and competing co morbid diseases was lower among trial participants than the general population of hypertensive elderly persons. Most subjects were 60 to 80 years old. Most trials were conducted in Western, industrialized countries and evaluated diuretic and beta-blocker therapies. Event rates per 1000 participants over approximately 5 years indicated that antihypertensive drug therapy was beneficial. Cardiovascular morbidity and mortality was reduced from 177 to 126 events (95% CI of the difference 31 to 73). Cardiovascular mortality was reduced from 69 to 50 deaths (95% CI of the difference 9 to 31). Total mortality was reduced from 129 to 111 deaths (95% CI of difference 4 to 28). The data from the three trials restricted to persons with isolated systolic hypertension indicated a significant benefit: cardiovascular morbidity and mortality over approximately 5 years was reduced from 157 to 104 events per 1000 participants (95% CI of the difference 12 to 89). Numbers of participants who dropped out of trials secondary to adverse drug effects were often not reported. The four trials that did report this data showed a wide variation in drop out rates ranging from no significant differences between treatment and control groups to as many as one out of four patients dropping out due to side effects of treatment.

Authors' conclusions

Randomized controlled trials establish that treating healthy older persons with hypertension is highly efficacious. Benefits of treatment with low dose diuretics or beta-blockers are clear for persons in their 60s to 70s with either diastolic or systolic hypertension. Differential treatment effects based on patient risk factors, pre-existing cardiovascular disease and competing co-morbidities could not be established from the published trial data.

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