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Pengendalian terpadu tekanan darah

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Optimal manajemen hipertensi

pada pasien usia lanjut

Maria Czarina Acelajado

vaskular biologi dan hipertensi
Program, Divisi penyakit
kardiovaskular, University of
Alabama di Birmingham,
Birmingham, AL, Amerika Serikat

Tekanan darah tinggi adalah faktor risiko modiable Umum dan penting untuk
Abstrak:
jantung dan penyakit ginjal. Prevalensi hipertensi, khususnya terisolasi sistolik hipertensi,
meningkatkan maju dengan usia, dan ini adalah sebagian disebabkan oleh perubahan terkait
umur dalam pohon arteri, yang mengarah ke peningkatan dalam arteri kaku. Perubahan gaya
hidup terapeutik, asupan natrium berkurang Diet, berat badan, aktivitas aerobik rutin dan
moderasi konsumsi alkohol, telah ditunjukkan untuk benet pasien lanjut usia dengan tekanan
darah tinggi. Menurunkan tekanan darah (BP) menggunakan agen farmakologis mengurangi
risiko kardiovaskular morbiditas dan mortalitas, dengan tidak ada perbedaan dalam
pengurangan risiko pada pasien usia lanjut dibandingkan dengan hypertensives muda. Pedoman
merekomendasikan tujuan BP
140/90 pada pasien hipertensi tanpa memandang usia dan130/80 di
pasien dengan diabetes termasuk atau penyakit ginjal, dan menurunkan BP lebih lanjut belum
menunjukkan untuk berunding benet tambahan apapun. Selain itu, pilihan antihipertensi
tidak tampaknya menjadi sama pentingnya dengan tingkat menurunkan BP. Pertimbangan
khusus dalam perawatan pasien lansia hipertensi meliputi kerusakan kognitif, demensia,
hipotensi orthostatic dan Polifarmasi.
hipertensi, orang tua, pengobatan, tekanan darah
Kata kunci:

Hipertensi mempengaruhi 26.4% dari populasi dunia, mempengaruhi sekitar 972 juta
orang di seluruh dunia, dan pasien dengan tekanan darah tinggi (BP) diproyeksikan
terdiri dari 29. 2% dari populasi dunia pada tahun 2025.
Prevalensi hipertensi
1

Surat-menyurat: Maria Czarina

Acelajado
vaskular biologi dan hipertensi
Program, University of Alabama di
Birmingham, CH19, 115 kamar, 1530
3rd Avenue South, Birmingham,
AL 35294-2041, AMERIKA SERIKAT
Tel 1 205 934 9281
Faks 1 205 934 1302
email czarina.acelajado@ccc.uab.edu

meningkat dengan usia lanjut, sedemikian rupa sehingga sebanyak setengah dari
individu berusia antara 60 dan 69 tahun yang hipertensi, dan hal ini meningkatkan
sampai 60%-70%
dalam orang-orang di atas usia 70. Lebih lanjut, resiko menderita
1
tekanan darah tinggi dalam normotensive
individu-individu yang berusia antara 55 sampai 65 90%.
tahun2adalah
Tekanan darah tinggi adalah faktor risiko modiable penting untuk kardiovaskular dan
penyakit ginjal. Ketinggian di BP luar 115/75 mmHg meningkatkan risiko kematian
dari penyakit jantung iskemik (IHD) dan stroke dalam mode linier log, sehingga
risiko kematian dari IHD atau stroke adalah dua kali lipat untuk setiap peningkatan
20/10 3mmHg BP. Setelah usia 50, sistolik BP (SBP) lebih penting daripada diastolik
BP
(DBP) dalam memprediksi hasil kardiovaskular yang merugikan. Hal ini disebabkan
usia - terkait peningkatan SBP, sedangkan DBP cenderung menurun setelah 60
tahun, seperti bahwa sebagian besar lansia individu telah mengisolasi sistolik
hipertensi (ISH) dan tekanan Nadi
meningkat (PP). Risiko untuk kematian semua
4
sebab dan kardiovaskular
berkorelasi positif dengan peningkatan SBP dan PP pada pasien usia lanjut dan
terbalik berkorelasi5,6untuk DBP.

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Fenomena ini meningkat SBP dan PP di hypertensives
tua sebagian dijelaskan oleh peningkatan arteri kaku dengan
usia lanjut. Perubahan-perubahan struktural di media arteri,
yang meliputi penurunan jumlah sel otot polos pembuluh
darah yang digabungkan dengan peningkatan kolagen
konten di dinding pembuluh, endapan kalsium, dan
gangguan bers elastis, mengakibatkan kapal sangat kaku
dengan penurunan kapasitansi dan hilangnya mundur.
Perluasan terbatas
7

individu (tapi ini tidak dapat terelakan), dan ini diucapkan

dalam orang-orang dengan hipertensi dan aterosklerosis dan
perokok. Dengan demikian, insiden CKD meningkat
dengan usia lanjut, dimana rasio peluang untuk
pengembangan CKD adalah 1,58 dan 5,53 orang berusia
40-59 tahun dan orang-orang berusia 60 tahun dan lebih tua,
15
masing-masing. Pada
pasien usia lanjut dengan ISH, SBP
adalah
kuat dan mandiri prediktor penurunan ginjal func-tion.
Pada16saat ini, estimasi GFR menggunakan Modied

pohon arteri kaku (yang paling ditandai pada tingkat arteri

Diet penyakit ginjal rumus atau Cockcroft-Gault equa-tion
elastis besar) mengarah ke peningkatan puncak BP,
menyediakan alat pengukur yang lebih baik dari fungsi ginjal
sedangkan mundur terbatas mengakibatkan penurunan DBP. daripada kreatinin serum sendirian dan sebaiknya
Perubahan ini juga mengakibatkan peningkatan pulsa
dipasangkan dengan urine
untuk memeriksa albuminuria.
17
kecepatan gelombang (PWV), dimana pulsa gelombang
Hal ini penting untuk layar untuk CKD,
Jika ada, karena hal ini memiliki implikasi dalam hal
yang dihasilkan oleh kontraksi jantung disebarkan cepat
pilihan agen anti hipertensi dan BP tujuan.
sepanjang arteri kaku. Peningkatan PWV telah terbukti
secara mandiri memprediksi angka kematian kardiovaskuler
Pada orang tua, stenosis arteri ginjal adalah sering
dan mor-bidity pada pasien dengan usia dengan
tekanan
8
karena aterosklerosis. Sekitar 7% dari individu-individu
darah tinggi. Sebagai akibat wajar,
peningkatan PWV di usia pertengahan (berarti 53
berusia 17 tahun) adalahyang berusia di atas 65 tahun memiliki beberapa tingkat
arteri ginjal penyempitan, dan 60% pasien hipertensi atau
independen prediktor longitudinal peningkatan SBP setelah bukti lain yang menurunkan penyakit (penyakit arteri
9
tindak lanjut berarti 4,3 tahun.
koroner atau penyakit arteri perifer). Stenosis arteri ginjal
18
harus dicurigai
dalam
pasien usia lanjut yang menyajikan dengan onset baru atau
Diagnosis
Pedoman Nasional dene hipertensi dan merekomendasikan dipercepat hipertensi (dengan memburuknya BP kontrol),
pada pasien dengan hipertensi resisten (yang membutuhkan
inisiasi pengobatan anti hipertensi ketika BP melebihi
140/90 mmHg. Orang dengan diabetes, penyakit ginjal atau tiga atau lebih medica-tions untuk membawa BP untuk
tujuan), pada pasien dengan asimetris ginjal pada pencitraan
penyakit kardiovaskular, pengobatan anti hipertensi adalah
(perbedaan yang lebih besar dari 1,5 cm), dan orang-orang
recom-diperbaiki jika BP melebihi mmHg 130/85.
10-14
yang hadir dengan ash edema paru atau gagal ginjal akut
Ofce BP
metode biasa untuk BP pengukuran, dan ini adalah ideal per setelah memulai sistem renin-angiotensin blocker terapi
- dibentuk pada pasien duduk dengan lengan didukung pada (mengkonversi angiotensin [AS] inhibitor enzimreseptor
angiotensin blocker [ARB], atau langsung renin inhibitor).
tingkat jantung. Rata-rata dua BP bacaan dari lengan sama
Teknik yang digunakan untuk mengevaluasi pencitraan
lebih dipilih, yang diambil setelah setidaknya 5 menit
19
istirahat.
Setelah diagnosis hipertensi conrmed, evaluasi
patensi arteri ginjal mencakup ginjal USG Doppler,
sekarang diarahkan pada menilai gaya hidup, mencari
computed tomography angiography, dan resonansi magnetik
faktor-faktor risiko kardiovaskular, mengidentifikasi
angiografi dan digunakan sebagai tes skrining. Standar emas
penyebab hipertensi sekunder, serta mencari bukti kerusakan organ
untuktarget.
diagnosis tetap angiografi arteri ginjal. Perawatan
termasuk modication faktor risiko kardiovaskular, terapi
antihy-pertensive, dan pada pasien yang memenuhi syarat,
revaskularisasi, tapi ini tidak konsisten telah ditunjukkan
untuk menormalkan BP pada pasien hipertensi.
Penyebab sekunder
Di lebih dari 90% dari pasien hipertensi, ada tidak ada sebab
identiable BP tinggi (hipertensi primer atau penting).
Dalam sisa, ditinggikan BP disebabkan sebagian atau
seluruhnya untuk menyebabkan specic, yang mungkin
berpotensi reversibel. Penyebab umum sekunder hipertensi
pada orang tua mencakup penyakit ginjal kronis (CKD) dan
stenosis arteri ginjal. Penyebab lain meliputi apnea tidur
obstruktif, utama aldosteronism, penyakit Cushing,
pheochromocytoma, hiper-parathyroidism, coarctation aorta
dan tumor intrakranial.
CKD dapat menyebabkan atau akibat dari hipertensi.
Penurunan tingkat ltration glomerulus (GFR) dengan
penuaan terjadi di sebagian
146

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Pengobatan
Perubahan gaya hidup
Modications gaya hidup yang penting untuk membantu
menurunkan BP di hiper - tensive pasien termasuk
pengurangan natrium Diet, berat badan dan pemeliharaan
berat badan ideal, aktivitas aerobik rutin dan moderasi
minum alkohol (Tabel 1). Uji intervensi farmakologis bebas
di tua (nada) acak 975 pasien berusia 60-80 tahun dengan
hipertensi
(TD
145/85 mmHg saat mengambil satu antihipertensi

Tekanan darah terpadu kontrol 2010:3

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Optimal manajemen hipertensi
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Tabel 1
Derajat pengurangan BP dicapai dengan modifikasi gaya hidup dalam
natrium sangat mengurangi asupan dan berat badan (melalui
pasien lanjut usia dengan tekanan darah tinggi
diet dan peningkatan aktivitas fisik), mengakibatkan
Intervensi

Definisi

pengurangan secara klinis penting yang membutuhkan

Tingkat SBP DBP
pengurangan (mmHg)obat-obat anti hipertensi pada pasien lansia hipertensi.

Diet natrium
pembatasan
Meningkatkan fisik
kegiatan

Batas asupan natrium

3.47.2/1.93.2
untuk80 mmol/hari
Aktivitas aerobik yang abadi8.5 5.1
30 min, dilakukan tiga kali
mingguan
pengurangan berat badan
berat badan 4.5 kg
4/1.1
Membatasi alkohol Batas asupan alkohol
1.2 0.7
asupan
untuk2 minuman/hari

untuk

Selain pengurangan natrium, diet kaya buah-buahan,

sayuran, dan produk susu rendah lemak, cho-lesterol
terbatas dengan lemak jenuh, dianjurkan untuk pasien
hipertensi (diet Diet pendekatan untuk menghentikan
hipertensi atau DASH), kecuali orang-orang dengan CKD,
yang meningkatkan kalium dan protein mungkin berbahaya.
21 modication
Makanan
adalah penting nonpharmacological interven-tion mengurangi BP pada pasien lanjut usia dengan tekanan darah tinggi.

Catatan:
Hak cipta 2009. Direproduksi dengan izin dari elsevier. Acelajado
41
Clin Geriatr Med.
MC, jadi Oparil. Hipertensi pada orang tua.
2009; 25: 391-492.

Pada pasien lansia hipertensi, rutin aerobik, terdiri dari

minimal 30 menit interval pelatihan di treadmill dilakukan
obat) untuk pengurangan natrium, berat badan, kombinasi
tiga kali seminggu, telah terbukti baik ditoleransi dan
keduanya, atau perawatan biasa untuk para peserta yang
benecial. Kepatuhan terhadap
latihan 12-minggu
gemuk dan natrium pengurangan dan perawatan 20biasa
pada
peserta menghadiri
22
sesi kelompok intervensi, dan 90 hari setelah sesi posisi mereka, pasien sudah disapih dari obat anti
pasien
nonobese.
Studi
hipertensi mereka, dengan tujuan menghentikan obat sama sekali. Endpoint utama yang nding dari ditinggikan BP (SBP
program studi ini diturunkan SBP oleh 8.5 mmHg, DBP
oleh 5.1 mmHg, dan PP oleh 3.2 mmHg dari baseline pada
24 jam Ambulatori BP pemantauan pada pasien hipertensi
tua pada rejimen obat anti hipertensi stabil. Efek ini tidak
dilihat dalam kelompok kontrol, yang menetap, di antaranya
190 mmHg atau DBP
110 mmHg di nilai BP adalah serupa pada awal dan setelah 12 minggu
tindak lanjut. Lebih lanjut, ada ditandai perbaikan kinerja
Satu studi banding; atau berarti SBP 170 mmHg atau berarti DBP
fisik dalam kelompok latihan dibandingkan dengan
100 mmHg atas dua kunjungan berurutan; atau berarti SBP
150 mmHg atau berarti DBP 90 mmHg lebih dari tiga berurutan kelompok yang menetap, yang diukur dengan pergeseran
rightward dalam laktat dan denyut jantung kurva setelah 12
Kunjungan) pada satu atau lebih studi banding setelah
minggu. Satu pasien drop out dari studi karena sakit lutut,
penghentian obat atau penyapihan, kebutuhan untuk
dan lain mengembangkan akut kolesistitis setelah 4 minggu;
reinstitute antihipertensi terapi, serta peristiwa
Sebaliknya, kejadian buruk tidak parah diperhatikan selama
kardiovaskular (serangan jantung, stroke, jantung kongestif, studi. Pada pasien hipertensi tua tanpa contraindi-kation,
angioplasti atau operasi bypass koroner), dan kematian.
aktivitas fisik secara teratur adalah benecial dan aman dan
Para peserta obesitas dalam nada yang diacak untuk
berat badan dan kombinasi lengan diberi
tujuan penurunan berat4.5
badan
kg, dari
menggunakan kombinasi diet dan
meningkatkan aktivitas fisik. Penurunan berat badan rata-rata antara
peserta di lengan kehilangan berat badan adalah 3,5 kg, dan 47%
mencapai tujuan dari 4.5 kg setelah 9 bulan. Ini menghasilkan
di 39% dari subyek dalam berat kehilangan lengan tidak
mengalami kenaikan BP atau kebutuhan untuk reinstitute
obat penurun BP selama 30 bulan setelah menghentikan
obat antihipertensi. Pada pasien yang diacak untuk natrium
reduc-tion dan kombinasi lengan, hanya 36% mencapai
tujuan mengurangi asupan natrium untuk
80 mmol/hari (1.8 g/hari). Dalam
Terlepas dari ini, 72% dari orang-orang yang ditugaskan ke diet
rendah sodium telah mereka140/90
BP yang
dikendalikan
untuk
mmHg,
dan 38%
dari ini
tetap dari obat anti hipertensi selama 30 bulan.
Berarti nilai SBP dan DBP sebelum inisiasi obat anti
hipertensi penarikan yang lebih rendah pada semua
kelompok intervensi dibandingkan dengan perawatan biasa
signicantly. NADA menunjukkan bahwa
nonpharmacological intervensi untuk menurunkan BP,

harus didorong.

Perawatan farmakologis
Manfaat dari pengobatan farmakologis
hipertensi pada orang tua
Pada pasien lansia hipertensi, menurunkan BP mengurangi
risiko kardiovaskular morbiditas dan mortalitas. Benets
dicapai dengan BP pengurangan pada orang tua mirip
dengan yang di Hipertensi pasien yang lebih muda. Tekanan
darah menurunkan pengobatan Trialists' kolaborasi
menggenang data dari uji 31, melibatkan individu 190,606,
yang dibandingkan pengobatan antihy-pertensive aktif
plasebo atau kurang intensif rejimen, serta uji yang
dibandingkan rejimen antihipertensi berbeda.
Hal ini menunjukkan bahwa ada tidak ada
perbedaan
dalam 23(fatal dan mematikan stroke,
insiden hasil
kardiovaskular
penyakit jantung koroner, dan gagal jantung) pada pasien
yang berusia 65 tahun dan lebih tua dibandingkan dengan
hipertensi individu

Tekanan darah terpadu kontrol 2010:3

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aged under than 65 years. Further, there was no difference in

the risk reduction achieved between the two age groups per
unit reduction in BP. There was also no interaction between
age and the effects of treatment on the primary outcome for
any antihypertensive regimen compared to control.

patients from the SYST-EUR Study (where median

follow-up was 6.1 years), those who had received active
treatment during the double-blind phase of the trial had 28%
less incidence of stroke and 15% less cardiovascular
complications compared to those patients who were randomized to receive place

Individual trials quantify the magnitude of risk reduction achieved with BP lowering. The Systolic Hypertension in the Elderly Program (SHEP) evaluated the ability
of chlorthalidone with or without atenolol versus placebo
in reducing the risk of fatal and nonfatal stroke in elderly
patients (
$ 60 years old) with ISH. Compared to placebo,
24
active treatment reduced the risk of stroke by 36% after an
average of 4.5 years of follow-up (P = 0.0003). The Systolic
Hypertension in Europe trial (SYST-EUR) was done on
4695 patients who were $60 years old with ISH (SBP on
study entry .160 mmHg).25The study participants were

during that period (P = 0.01 and P = 0.03, respectively).27

Given the high incidence of ISH in the elderly population,
early recognition and initiation of therapy are important.

randomized to receive either nitrendipine 1040 mg/day with

the possible addition of enalapril 520 mg/day and
hydrochlo- rothiazide 12.525 mg/day or matching placebos.
SYST-EUR showed that active treatment reduced the rate
endpoints (fatal and nonfatal stroke) by 42% (P = 0.003)
and all fatal and nonfatal cardiovascular endpoints (stroke,
retinopathy, myocardial infarction, congestive heart failure,
and renal insufciency) by 31% (P , 0.001) compared to
placebo after a mean follow-up of 2 years. A similar study, the
Systolic Hypertension in China trial (SYST-CHINA), which
randomized 2394 hypertensive patients aged 60 or older, demonstrated that active treatment (nitrendipine 1040 mg/day,
with the addition of captopril 12.550 mg/day or hydrochlorothiazide 12.525 mg/day or both, is administered to achieve
an SBP goal of ,150 mmHg) reduced the incidence of total
strokes by 38% (P = 0.01), stroke deaths by 58% (P = 0.02),
cardiovascular mortality by 39% (P = 0.03), and all fatal and
nonfatal cardiovascular endpoints (similar to the SYST-EUR
trial) by 37% (P = 0.004) compared to placebo.26
A meta-analysis of eight trials on elderly hypertensive
patients has shown that antihypertensive treatment reduced
total mortality by 13% (P = 0.02), cardiovascular deaths by
18%, stroke by 30%, and coronary events by 23% compared
to control (placebo or a less intensive antihypertensive
regimen). 6 The absolute benet was found to be higher in
men, in patients who were 70 years old, and in those with

previous cardiovascular disease
or higher PP. These
data provide strong support that BP lowering in the elderly
sig- nicantly reduces cardiovascular risk.

Lastly, the benet of hypertension treatment has been

shown to persist long after the termination of studies. In
the 14-year follow-up of SHEP participants, those who had
received active treatment with chlorthalidone with or without
atenolol during the trial had fewer deaths from cardiovascular causes (P = 0.016), without a signicant difference
in all-cause mortality or stroke deaths compared to those
randomized to placebo. Further, those who had sustained 28
a stroke during the trial had a worse prognosis compared to
those who were stroke free, and the predictors of death
included SBP, diabetes, and smoking, which are modiable.
highlights the fact that in elderly hypertensive patients
ofThis
primary
who had a stroke, control of modiable cardiovascular risk
factors may help decrease the long-term risk of death.

Goal of antihypertensive therapy

The guidelines in the management of hypertension recommend a BP goal of ,140/90 mmHg in hypertensive patients
and ,130/80 in patients with diabetes and kidney diseases,
irrespective of age.1014 While at best prudent, it is not backed
by solid evidence showing that treating hypertension to these
BP goals provides additional cardiovascular risk reduction.
Major placebo-controlled trials involving elderly
hypertensive patients enrolled individuals with.a baseline SBP 160 mmHg,
and the treatment goal was 150 mmHg in most studies. In a
 1111 nondiabetic hypertensive
prospective study done in Italy,
patients (mean age 67) were randomized to receive open-label
antihypertensive treatment to lower SBP to ,140 mmHg in
one group and ,130 mmHg in another.29The primary endpoint was the incidence of left ventricular hypertrophy after
2 years of follow-up. The study showed that patients who
were randomized to SBP lowering to ,130 mmHg had less
incidence of left ventricular hypertrophy compared to those
randomized to the SBP goal of, 140 mmHg (11.4% and 17%,
respectively, P = 0.013). The difference in SBP achieved after
the 2-year follow-up between the two groups, however, was
only 3.8 mmHg, so the effect of choice of antihypertensive
medication may have inuenced the results.

Early treatment of hypertension in elderly patients

as opposed to delayed treatment also produces greater
In the Action to Control Cardiovascular Risk in Diabetes
cardio- vascular risk lowering. In the open-label follow-up of 3517
Blood Pressure trial (ACCORD BP), 4733 middle-aged and

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Optimal management of hypertension

elderly participants (mean age 62 years) with type 2 diabetes that are attributable to antihypertensive therapy, which
mellitus and established cardiovascular disease, evidence of
include hypotension, syncope, bradycardia, and arrhythmia,
target organ damage, or at least two cardiovascular risk factors as well as hypokalemia and elevations in serum creatinine.
On the other hand, there was a signicant reduction in the
were randomly assigned in a 2 2 factorial design to intensive incidence of total stroke and nonfatal stroke (which are two
(SBP , 120 mmHg) versus standard (SBP , 140 mmHg) of several prespecied secondary outcomes) in the intensive
BP con- trol compared to standard BP control. The
BP control.30Antihypertensive medications were given openACCORD Study, however, is limited by the low occurrence
label, and the study did not specify the drug class that would
of cardiovascular events during the study duration in the
be used for lowering BP in both groups. After a mean
standard control group, which may have minimized a
follow-up of 4.7 years, the BP decreased from a mean of
probable difference in outcomes, if any, between the two
139/76 mmHg in both groups to 119/64 mmHg in the
groups. Nevertheless, the ACCORD results, while showing that SBP loweri
intensive BP-lowering group and 133/70 mmHg in the
standard control group, which resulted in a 14/6 mmHg
difference between the two groups (Figure 1). As expected,
,120 mmHg
those in the intensive BP-lowering group were on greater
reduces the risk for stroke, did not support further
numbers of antihypertensive agents. There was no signicant
lower- ing of SBP beyond 140 mmHg in improving
difference between the two groups in the incidence of major
cardiovascular outcomes in middle-aged and elderly
cardiovascular events, which include the composite of
hypertensive patients with diabetes and may in fact lead to
nonfatal myocardial infarction, nonfatal stroke, and
a higher incidence of adverse effects related to treatment.
cardiovascular death. Moreover, there was a higher incidence of adverse
events
treatmentelderly
group patients and
Whether
thisin
is the
trueintensive
for nondiabetic
older patients with kidney disease is still controversial.

Primary outcome

Proportion with event

1.0

0.2

0.8

1.0

Standard

0.1

Intensive

0.6
0.0
0 1 2 3 4 5 6 7 8

0.4

Nonfatal stoke

Proportion with event

P= 0.20

0.2
0.0
0

0.2

0.8

0.1
0.0
0 1 2 3 4 5 6 7 8

0.4

P= 0.03

0.2
0.0

Years

2362 2273 2182 2117 1770 1080

298
2371 2274 2196 2120 1793 1127 358

175 80
195 108

Proportion with event

No. at risk
Intensive
Standard

Nonfatal myocardial infarction

1.0

Standard
Intensive

0.6
0.0
0 1 2 3 4 5 6 7 8
P= 0.25

0.2
0.0
0

2362 2291 2223 2174 1841 1128

313
2371 2287 2235 2186 1879 1196 382

1.0

0.1

0.4

0.2

0.8

0.1

Standard

0.6

Intensive

0.0

0 1 2 3 4 5 6 7 8

0.4

P= 0.74

0.2
0.0

Years

No. at risk
2362 2278 2190 2133 1787 1087
Intensive
Standard 2371 2278 2208 2141 1818 1145

186 88
215 114

Death from cardiovascular disease

0.2

0.8

Years

Proportion with event

No. at risk
Intensive
Standard

Standard

Intensive

0.6

Years
299
365

177 82
201 112

No. at risk
Intensive
Standard

2362 2304 2252 2201 1870 1143

317
2371 2313 2268 2218 1922 1220 393

188 91
221 118

Figure 1
Comparison of intensive versus standard BP lowering on the composite of nonfatal stroke, nonfatal myocardial infarction, and death from cardiovascular disease
(primary outcome). Copyright 2010. Adapted with permission from Massachusetts Medical Society. All rights reserved. Cushman wC, evans Gw, Byington RP, et al., for
30
N Engl J Med
the ACCORD Study Group. effects of intensive blood pressure control in type 2 diabetes mellitus.
. 2010;362:15751585.

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Choice of antihypertensive agents

The presence of comorbidities, history of adverse reactions
to medications, cost, ease of dosage, and patient preference
inuence the choice of antihypertensive agents in elderly
patients. A large meta-analysis has shown that the choice
of antihypertensive agent does not inuence outcomes,
ie, the benefit derived from BP reduction is similar in
magnitude and independent of the antihypertensive agent
used to create such effect, regardless of the patients age.

Most hypertensive patients would need two or

more antihypertensive agents to bring the BP to goal.
Combination therapy using agents with complementary
mechanisms of action is favorable because it allows the
use of antihyperten- sive medications at lower doses than
if the medication was used singly, thereby also
minimizing the incidence of adverse effects. Further, the
use of combination therapy at the outset, particularly in
high-risk patients, reduces cardiovascular risk by giving early BP control. F

23

11

Data comparing diuretics or beta blockers (BB) versus ACE are preferred by most physicians and are recommended by
inhibitors or calcium channel blockers (CCB), as well as
certain guidelines as they may lower overall cost and
ACE inhibitors versus CCB, show that there was no
improve adherence to treatment.
31
difference in the proportional reduction of cardiovascular
risk between the different antihypertensive regimens in patients 65Acceptable
years of antihypertensive drug combinations include a
reninangiotensin system blocker and a diuretic or CCB, as
.
age (Figure 2). Diuretics, ACE inhibitors, ARB, BB, CCB, well as BB and a diuretic. Several trials have demonstrated
the benet of these combinations in reducing cardiovascular
and aldosterone antagonists, either singly or in
risk in elderly patients with hypertension. For example, in
combination, are all acceptable options as initial
SHEP, chlorthalidone with atenolol reduced the risk for
antihypertensive agents in elderly patients. Guidelines
fatal and nonfatal stroke compared to placebo. SYST-EUR (where as
in managing hypertensive patients specify particular
agents to use in certain disease conditions, such as
coronary artery disease, renal disease, and diabetes, where
the preferred agent has been found, in clinical trials, to
have favorable effects in specic clinical settings.

Risk ratio
Age > 65
A

1.01 (0.95 1.06)

1.02 (0.97 1.06)

24

much as 80% of the study participants were on combination

antihypertensive therapy during the rst year of the trial) and
SYST-CHINA showed that CCB-based therapy combined
with an ACE inhibitor and a thiazide diuretic reduced the
incidence of fatal and nonfatal cardiovascular events,
particu- larly fatal and nonfatal stroke, and the composite of
fatal and nonfatal cardiovascular endpoints.
25,26
Other large outcome
trials, which did not exclusively involve elderly
patients, have also shown that combination
antihypertensive therapy is benecial. The
Anglo-Scandinavian Cardiac Outcomes TrialBlood
Pressure Lowering Arm, conducted in 19,257 high-risk
hypertensive patients (mean age 63 ) and comparing
amlodipine with or without perindopril versus atenolol with
or without bendroumethiazide, found that the
treatment based on amlodipine was superior in preventing
a compos- ite of cardiovascular mortality, myocardial infarction, and stroke
32

Cardiovascular Events thru Combination Therapy in

Patients Living with Systolic Hypertension
(ACCOMPLISH) trial, which had a predominantly elderly
patient population (mean age 68), demonstrated that an
ACE inhibitorCCB combina- tion (benazepril and
0
.
1.0 5
2
. amlodipine) 0was effective in preventing a composite of fatal
Favors first
Favors second
and nonfatal cardiovascular endpoints and was superior
listed
listed
(19.6% less events) to a combination of an ACE inhibitor
and a diuretic (benazepril and hydrochloro- thiazide) in spite
Figure 2
Comparison of different BP-lowering regimens in reducing cardiovascular
.65 years old.A) Angiotensin-converting enzyme of a similar degree of BP reduction in both groups. The last two studies imply
risk in hypertensive patients
C

0.98 (0.92 1.05)

inhibitor versus diuretic or beta blocker.

B) Calcium antagonist versus diuretic or
beta blocker.C ) Angiotensin-converting enzyme inhibitor versus calcium antagonist.
33
Copyright 2008. Adapted with permission from BMJ Publishing Group Ltd.
Turnbull F, for the Blood Pressure Lowering Treatment Trialists
lowering is not entirely
Collaboration. effects of different regimens to lower blood pressure on major cardiovascular events in older
BMJ. 2008;336:11211123.
and younger adults: meta-analysis of randomised trials.
23

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dependent on BP lowering in some

antihypertensive treatment trials.

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Treating the very elderly

In the past, treatment of BP in the very elderly was controversial. This subgroup of patients is usually excluded
from clinical trials, and the data available to demonstrate
treatment benets were limited and inconclusive. Further,
the benets of antihypertensive therapy could be potentially
offset by complications of treatment, which are seen
as occurring more commonly in the elderly, such as
dementia, orthostatic hypotension, heart failure, and
electrolyte abnor- malities. This clinical uncertainty with
regards to the relative benets and risks associated with
antihypertensive therapy in patients
.80 years old was addressed by the Hypertension in the Very Elderly Trial (HYVET). HYVET enrolled
3845 hypertensive patients who were .80 years old with a

Optimal management of hypertension

adjustments, and obtaining a standing BP when increasing

medication doses in symptomatic patients are part of a good
practice. In addition, elderly patients frequently take
multiple medications for other comorbid conditions, so the
possibil- ity of drug interactions is high. This is particularly
true for nonsteroidal anti-inammatory drugs, which may
interfere with the actions of antihypertensive medications,
and may lead to poor BP control. Polypharmacy may also lead to
37

poor compliance in elderly patients, so simplication of the

drug regimen is encouraged.
Cognitive impairment is common in the elderly population. Hypertension has been implicated in the pathogenesis of cognitive impairment and dementia in the elderly.
Elevated BP during middle age predicts the development of
dementia with aging. Further, a high SBP (
38
.180 mmHg)
and a low DBP (,70 mmHg) increase the risk of dementia
in older adults. Antihypertensive treatment lowers this
39
risk as shown in SYST-EUR, where active treatment
is associated with a 65% lower risk of dementia
compared
40 to placebo.
In treating hypertensive patients with cognitive

baseline SBP .
160 mmHg and randomized them to receive
indapamide or placebo. Perindopril or placebo was added
34
on later if the BP was still above goal (,150/80 mmHg). The
results show that active treatment was associated with a 30%
reduction in fatal or nonfatal stroke (P = 0.06), a 39% reduction in stroke deaths (P = 0.06), a 21% decrease in all-cause
mortality (P = 0.02), and a 23% decline in cardiovascular impairment, simplifying the treatment regimen,
death after a median follow-up of 1.8 years. Further, there regular follow-ups, and involving caregivers are all part
of optimal BP management.
was a 64% reduction of heart failure (P , 0.001). This was
achieved without an excess of adverse events in the active
treatment arm compared to placebo. The incidence of potas- Summary
sium abnormalities or increase in serum creatinine, uric
Hypertension is a common and very important modiable
acid, or glucose was similar in the active and placebo
risk factor for cardiovascular morbidity and mortality. The
treatment arms. Orthostatic hypotension occurred in
prevalence of hypertension increases with advancing age,
12% of study participants in the pilot trial, but the authors
and this is accounted for partly by age-related changes in
counter that this higher than expected number could be due
the arterial tree. Initiating antihypertensive treatment is
to selection bias as those with SBP 140 mmHg were excluded recomfrom themended when BP exceeds 140/90 mmHg (130/85
mmHg in those with diabetes, kidney disease, and
.
cardiovascular disease). Therapeutic lifestyle changes
35
analysis. This trial gave conclusive evidence that even in
should be encour- aged in elderly hypertensive patients
the very elderly (.80 years old), treatment of hypertension and include dietary sodium restriction, increased physical
reduces cardiovascular risk signicantly. A caveat, however, activity, weight loss and maintenance of ideal body
is that HYVET excluded nursing home residents, patients weight, and moderation of alcohol consumption. In the
elderly, pharmacological treatment of hypertension
with dementia, and those with kidney disease or heart
provides signicant reductions in cardiovascular risk. The
fail- ure, which comprise a signicant subset in this age
degree of BP reduction achieved appears to be more
group; hence, these results may not be generalized to all
important than the choice of antihyper- tensive agent, and
elderly patients
.80 years of age.
this is true for younger and older patients. Combination
antihypertensive therapy is usually indicated in elderly
Other considerations in the treatment hypertensive patients, and acceptable regimens include a
reninangiotensin system blocker and a diuretic or a CCB.
of elderly hypertensive patients
Treatment of hypertension in elderly patients is
The treatment of elderly hypertensive patients is compliconfounded by a greater tendency to develop
cated by many factors. Orthostatic hypotension, dened as a
orthostatic hypotension, polypharmacy, and a higher incidence of c
supine-to-standing BP difference of 20/10 mmHg, occurs
more commonly in the elderly, owing to a blunted baroreex response that occurs with standing.36 Initiating antihypertensive medications at low doses and making gradual

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Disclosure

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