Hypertension in the very elderly: to treat or not to treat?

Abstract

Introduction: Hypertension is the most prevalent cardiovascular risk factor. A decrease in blood pressure (BP) in hypertensive patients below the age of 65 reduces the risk of cardiovascular events and death. There are few studies of the reduction of risk in the very elderly (above 80 years of age). Objectives: To review the evidence for the reduction of risk of major cardiovascular events and mortality in very elderly patients with anti-hypertensive treatment. Data source: National Guideline Clearinghouse, Guideline Finder, Canadian Medical Association, The Cochrane Database, DARE, Bandolier, MEDLINE/PubMed e Índex de Revistas Médicas Portuguesas. Methods: A search was conducted on MEDLINE and evidence-based medical sites for articles published between January 2004 and August 2014 in English, Spanish or Portuguese using the keywords ‘Hypertension/therapy’ AND ‘Aged, 80 and over’. Results: Eight articles met the inclusion criteria. In the guidelines found, antihypertensive treatment reduced the incidence of stroke and cardiovascular morbidity and increased mortality from other causes (Strength of Recommendation C). For patients in good physical and psychological condition, BP values should be around 140-150mmHg (Strength of Recommendation B). Otherwise, treatment should be individualized and monitored clinically (Strength of Recommendation C). One meta-analysis found a reduction in the risk of stroke, cardiovascular events and heart failure (LE 2). Clinical trials show benefit in controlling BP to 150/80mmHg (LE 1). Lower values are associated with greater risk of death and heart failure (LE 2). Conclusion: The overall benefit of treatment of elevated blood pressure in very elderly is questionable. Although it is associated with a reduction in the risk of cardiovascular events, all-cause mortality, and cause-specific mortality, the results are mixed (Strength of Recommendation B). The reduction of all-cause mortality was achieved in studies with lower reductions of blood pressure and less intensive therapies (Strength of Recommendation B).