Blood pressure control of people 80 years and older, especially women, must be made a national priority

May 19 2004

“The current rates of blood pressure control in the elderly are unacceptably low,” says Donald M. Lloyd-Jones, MD, of Northwestern’s Feinberg School of Medicine, Chicago. “The elderly are the fastest growing segment of the US population and they have the highest prevalence of hypertension. Yet, clinicians seem to be reluctant to treat older patients aggressively, perhaps because of perceived lower benefits or possible increased risk of side effects.”

Dr. Lloyd-Jones and colleagues from the National Heart, Lung, and Blood Institute’s Framingham Heart Study pooled 14,087 examinations of participants in the Framingham Heart Study from 1990-1999.

The Framingham Heart Study, started in 1948 in Framingham, MA, is the longest-running prospective epidemiological study of heart disease. Researchers are now enrolling the grandchildren of the study's original participants.

There were 2,234 individual men and 2,958 women in the current study. Participants were stratified by age – less than 60, 60-79 and 80 and older.

“As expected, the prevalence of hypertension increased markedly with advancing age,” Dr. Lloyd-Jones said. In the less than 60 age group, 26.9% had high blood pressure; in the 60-79 group, 58.9% had high blood pressure and 70.9% had high blood pressure in the 80 and older group.

“The overall prevalence of treatment was 65.8%,” he said. “Treatment rates increased substantially from the younger to old age group (57.2% to 71.6%) with no further increase in the 80 and greater ‘old-old’ group (72.9%),” he explained. “However, the number of antihypertensive medications used was similar across all age groups, with two-thirds of treated hypertensives using only one medication, 25% using two and fewer than 10% using three medications.”

Dr. Lloyd-Jones noted that the use of thiazide diuretics increased steadily with advancing age, but remained suboptimal. In the age 80 and older group, only 21.8% of men and 32.2% of women with hypertension were using thiazide diuretics for therapy, “despite the fact that thiazides have been shown to be extremely effective in older hypertensive patients.”

Dr. Lloyd-Jones said among hypertensive individuals in the 1990s, the overall prevalence of blood pressure control (less than 140 mm Hg systolic and 90 mm Hg diastolic) was 33.7%. Control rates declined with advancing age, with a more dramatic decline in women. Among those 80 and older with hypertension, only 32% of men and 24% of women had their blood pressure under control.

The investigators also showed that the risks associated with hypertension for the development of cardiovascular disease, major coronary events and congestive heart failure were substantially higher in the oldest age group compared with younger people with high blood pressure.

“There are several major public health implications to be drawn from the study,” Dr. Lloyd-Jones concluded. “The elderly have the highest prevalence of hypertension and the risks associated with hypertension increase with advancing age.

“Treatment principles should be the same for all age groups,” he said. “Lower initial doses of medications may be needed to avoid side effects in older patients, but standard doses and multiple drugs may be required to reach appropriate blood pressure targets.

“That means physicians should start low, and add more medications as necessary to help their patients reach their blood pressure goals,” Dr. Lloyd-Jones said. “Poor control is due in part to an inadequate number of medications and, perhaps, to poor selection of drug classes.”

The American Society of Hypertension (ASH) is the largest US organization devoted exclusively to hypertension and related cardiovascular diseases. ASH is committed to alerting physicians, allied health professionals and the public about new medical options, facts, research findings and treatment choices designed to reduce the risk of cardiovascular disease. http://www.ash-us.org/