Age-related issues in the treatment of hypertension

A retrospective electronic chart review of blood pressure changes in elderly patients treated with amlodipine or an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker

BACKGROUND

Despite the high costs of managing hypertension, pharmacologic intervention is cost-effective, particularly in patients at highest risk for cardiovascular events. The prevalence of hypertension in the elderly and the age-associated risks of coronary artery disease and stroke suggest that early identification and aggressive treatment should be priorities in this population.

OBJECTIVE

The aim of this study was to compare the effect of amlodipine and angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) in the treatment of essential hypertension in elderly patients (>60 years) in an actual practice setting.

METHODS

This was a retrospective cohort analysis using electronic medical records stored in the Physicians Data Corporation cardiology database. Patients aged >60 years who received care from a cardiologist and who had a recorded diagnosis of hypertension during 1997 or 1998 were identified. For inclusion, patients had to have received an initial prescription for amlodipine, an ACE inhibitor, or an ARB at the index visit. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) readings from the index visit and > or =1 subsequent visit (<180 days after the index visit) were assessed.

RESULTS

A total of 192 patients (56.3% male; mean age, 71.9 years) met the inclusion criteria. Amlodipine-treated patients experienced a mean decrease in SBP of 26.7 mm Hg, compared with 18.8 mm Hg in patients receiving an ARB and 15.8 mm Hg for patients receiving an ACE inhibitor (P = 0.008, amlodipine vs ACE inhibitor). DBP decreased 8.8 mm Hg with amlodipine, 8.7 mm Hg with an ARB, and 6.2 mm Hg with an ACE inhibitor. After adjusting for age, sex, and disease severity, amlodipine-treated patients were -4 times as likely to move to a better blood pressure stage than patients treated with an ARB or an ACE inhibitor (odds ratio, ARB vs amlodipine: 0.245; 95% CI, 0.080-0.753; odds ratio, ACE inhibitor vs amlodipine: 0.234; 95% CI, 0.072-0.761).

CONCLUSION

Results of this study indicate that in patients aged >60 years, amlodipine may be an effective therapy for hypertension.

Controlling isolated systolic hypertension. No time to be complacent

Isolated systolic hypertension (ISH) is the most common form of hypertension in the elderly. It is an even better predictor of morbidity and mortality than is diastolic blood pressure. Several large trials have documented a clear benefit to treating ISH. Therapy should be initiated only after careful evaluation of the patient's overall medical status, because the elderly are at increased risk of adverse effects from medications. Pharmacologic therapy should be started at a low dose and increased slowly, if necessary. If hypertension is still present after the addition of two or three medications, a cause other than essential hypertension should be considered, such as white coat hypertension, secondary hypertension, or pseudohypertension.