Hypertension in the Elderly

Cardiovascular disease in the elderly

Cardiovascular disease is the major cause of death and disability in the elderly. Atherosclerotic coronary heart disease is the most prevalent problem, followed by hypertensive cardiovascular disease. Calcific aortic stenosis is the most common haemodynamically important valvular lesion; surgical correction significantly improves the prognosis. Pulmonary embolism occurs frequently, related to immobilization and co-morbidity. Congestive heart failure is both under-diagnosed and over-diagnosed. Complete heart block and sick sinus syndrome increase with age; appropriate pacemaker therapy can improve the length and quality of life. Clinical evaluation of elderly patients is often hampered by multiple co-existing disease involving other organ systems, problems in reporting symptoms, and associated functional and structural changes of ageing that may mimic or mask cardiovascular disease. Presentations of cardiac illness often differ from those in a younger population. Most of the available data on therapy and prognosis do not apply to contemporary practice, so that clinical decisions are often extrapolated from information acquired in younger patients. Elderly patients are at high risk of complications of most diagnostic and therapeutic procedures, more related to co-morbidity than to age; they have more frequent and serious adverse drug reactions, due both to co-morbidity and to multiple medications. Age as such should not constitute a barrier to cardiac care; in the USA at least one-third of all cardiovascular procedures are performed in elderly patients. The goals of therapy are improvement in function and postponement of debilitating illness, enabling an extended active independent lifestyle.

Efficacy and safety of rilmenidine in elderly patients--comparison with hydrochlorothiazide. The Belgian Multicentre Study Group

The aim of this trial was to study the treatment of hypertension in the elderly, comparing a new oxazoline antihypertensive agent, rilmenidine, with the diuretic hydrochlorothiazide (HCZ). After 2 weeks on placebo, 88 elderly patients (mean age 75 years; 65 women), corresponding to strict inclusion criteria, were randomized to 8 weeks double-blind monotherapy with rilmenidine 1-2 mg/day (n = 46) or HCZ 25-50 mg/day (n = 42), with administration of potassium supplements as required. Particular emphasis was placed on the evaluation of safety: blood screens were repeated after 2, 4, and 8 weeks of treatment and symptoms were systematically evaluated every 2 weeks. The rilmenidine and HCZ groups were comparable at randomization, with baseline supine systolic/diastolic blood pressures of 167/101 mm Hg and 172/101 mm Hg, respectively. Both drugs induced a significant decrease in blood pressure: at 8 weeks, supine blood pressure had decreased to 154/89 mm Hg and to 155/87 mm Hg in the rilmenidine and HCZ groups, respectively (difference not significant between groups). Changes in heart rate did not differ significantly between groups (-3 bpm at 8 weeks). Drug-related symptoms were rare and the incidence was similar in both groups. Weight decreased significantly in the HCZ group by 1 kg (p < 0.001) and did not change in the rilmenidine group. After 8 weeks of monotherapy, expected variations in serum biochemistry were detected in the HCZ group, resulting in a significant difference in comparison with the rilmenidine group: serum potassium and chloride decreased significantly and uric acid levels increased significantly in the HCZ group.(ABSTRACT TRUNCATED AT 250 WORDS)

Extent of beta 1- and beta 2-receptor occupancy in plasma assesses the antagonist activity of metoprolol, pindolol, and propranolol in the elderly

We estimated antagonist activity of metoprolol, pindolol, and propranolol in elderly cardiovascular patients by determining the extent to which the drugs occupied rabbit lung beta 1- and rat reticulocyte beta 2-adrenoceptors in plasma samples during drug treatment. The randomized, double-blind, crossover study was carried out by administering twice daily 100 mg metoprolol, 5 mg pindolol, and 80 mg propranolol for 7 days to 20 hypertensive subjects with a mean age of about 70 years. A 2-week interval was kept between administration of the different regimens. Receptor occupancy was measured at 1 hour before and 2 hours after administration of the last dose of each regimen by adding rabbit lung beta 1- and rat reticulocyte beta 2-receptors to plasma samples and by labeling the receptors with a radiolabeled beta-antagonist, (-)-[3H]CGP-12177. The results and conclusions were the following: (a) The extent to which metoprolol, pindolol, and propranolol occupied rabbit lung beta 1- and rat reticulocyte beta 2-adrenoceptors in plasma samples estimated accurately the intensity of beta-receptor antagonism in the patients who did not tolerate physiological and pharmacological tests measuring the degree of beta 1- and beta 2-adrenoceptor blockade. (b) The mean beta 1- and beta 2-receptor occupancy of pindolol and propranolol varied between 76% and 99% during the treatments. The mean beta 1-receptor occupancy of the metoprolol regimen varied between 54% and 92%, and its beta 2-receptor occupancy varied between 6% and 38%. Thus the antagonist activity of the metoprolol regimen differed significantly from that of the other regimens (ANOVA for repeated measures, p < 0.05 and 0.001, for the beta 1- and beta 2-occupancy, respectively). (c) The extent of beta 1- and beta 2-receptor occupancy in plasma samples was in conformity with the literature on the intensity, selectivity, and duration of beta-blockade after similar drug doses. (d) The data on the receptor occupancy of beta-blocking drugs in plasma samples appear to be valuable in analyzing their effects, and it may be a method for optimizing drug therapy for aged cardiovascular patients.

A review of persistent, low-grade lead challenge: neurological and cardiovascular consequences

Although acute toxicity following heavy intake of lead (Pb) is a well-established clinical entity, the harmful effects of persistent, low-dose challenge, a situation commonly found among the general population, is uncertain. The major dangers of persistent, low-dose challenge that have been hypothesized are controversial: first, mentation and behavioral perturbations and second, development of hypertension with its consequences on the cardiovascular system. Accordingly, one cannot exclude some contributions from persistent Pb exposure to chronic disease and the aging process. Despite these potential adversities, many sources for Pb contact still remain with us. Current estimates are that 10-50% of American children (over 3-4 million) harbor unsafe levels according to present-day standards. Therefore, it is reasonable to conclude that more work is needed in this area. Clearcut evidence concerning the deleterious influence of Pb on the nervous and/or cardiovascular-renal systems would lead to greater attempt to lessen exposure, to ameliorate symptomatology by providing supplemental agents which obviate the unwanted effects of Pb (iron, calcium, zinc), and to consider therapy with binding agents, like CaNa2EDTA, in the afflicted.

Non-steroidal anti-inflammatory drugs and hypertension in the elderly: a community-based cross-sectional study

1. Whether non-steroidal anti-inflammatory drug (NSAID) usage in the elderly elevates blood pressure or antagonises the blood pressure-lowering effect of antihypertensive medication is presently unknown. The primary aims of this study were to estimate the prevalence of NSAID usage, to evaluate the prescription of NSAIDs for arthritis and to determine whether NSAID usage was an independent predictor of hypertension in a large elderly community. 2. All non-institutionalised elderly (> 60 years) residents of Dubbo, NSW who attended for a baseline assessment were enrolled (1237 males, 1568 females). A questionnaire was administered and blood pressure was measured according to the Prineas protocol. The frequency of NSAID usage was determined, with stratification by age, sex, blood pressure group and history of arthritis. 3. NSAID usage was 26% overall (females 28%, males 23%), increased with age and was higher in females than males for every age group studied. Amongst patients with a past history of 'arthritis', 45% were using NSAIDs. Twelve percent were taking NSAIDs and antihypertensive medication concurrently, constituting the population at risk of an adverse drug-drug interaction. Employing a multiple logistic regression model which adjusted for several confounders in the cross-sectional analysis, NSAID usage significantly predicted the presence of hypertension (odds ratio: 1.4, 95% confidence interval: 1.1-1.7) with an attributable risk of 29%. 4. Amongst non-institutionalised elderly persons, NSAID usage may be an independent risk factor for hypertension. Considering the substantial consumption of NSAIDs by elderly patients, physicians should review their NSAID prescribing patterns for this community group.

Renal function in the elderly: results from the European Working Party on High Blood Pressure in the Elderly trial

Effects of antihypertensive treatment on renal function were analyzed in data from a prospective, double-blind investigation of 840 patients randomly assigned to placebo or to active treatment with a combination of triamterene and hydrochlorothiazide. Baseline serum creatinine levels were significantly and positively correlated to age, gender (higher in men), systolic blood pressure, and history of cardiovascular complications. During a five-year follow-up period, serum creatinine levels increased significantly in treated patients but not in placebo patients. Five patients died of renal causes (one in the placebo group, four in the treated group), and five patients dropped out of the study because of an increase in serum creatinine of more than 100% (four received active treatment). The incidence of renal complications in the hypertensive elderly is small. The current data do not support the hypothesis that renal deterioration can be prevented by antihypertensive treatment.

Subjective symptoms and pharmacokinetics/dynamics of metoprolol CR in elderly subjects--a comparison with atenolol

In a double-blind, randomised, cross-over study, the pharmacokinetic/dynamic effects and subjective symptoms of a new controlled-release (CR) formulation of metoprolol (50 and 100 mg) have been compared with atenolol (50 mg) and placebo in 20 elderly healthy subjects. The metoprolol CR formulation displayed an even plasma concentration-time profile over the dosage interval while atenolol produced a peak at 2-4 h. All three active treatments produced significant beta 1-blockade at 24 h compared to placebo. Four hours after dose intake, the degree of beta 1-blockade was significantly greater with conventional atenolol 50 mg than with either dose of metoprolol CR. Subjective well-being was examined with a self-administered questionnaire (MSE-profile), including three dimensions: Contentment, Vitality and Sleep. No significant differences were detected between placebo and either dose of metoprolol CR. At 2 h, following atenolol, a deterioration in Vitality was observed compared to placebo and metoprolol CR 100 mg. At the end of the dosage interval there was no longer any significant difference between the treatments. Perceived leg fatigue during exercise, evaluated 4 h after dosing, was more pronounced during treatment with atenolol than metoprolol CR 50 mg. The results suggest that the metoprolol CR formulation was not associated with significant effects on subjective well-being, whereas atenolol caused a deterioration at the time of the peak plasma concentration of the drug.

The efficacy of low dose metoprolol CR/ZOK in mild hypertension and in elderly patients with mild to moderate hypertension

In two separate but similarly designed placebo-controlled studies, the efficacy of metoprolol CR/ZOK 50 mg once daily was evaluated in 64 patients (mean age 53 years) with mild hypertension (Study I) and in 34 elderly patients (mean age 68 years) with mild to moderate hypertension (Study II). Both studies were of randomized, double-blind, parallel-group design, the entry criteria for diastolic blood pressure being greater than or equal to 90 less than 105 mm Hg in Study I and greater than or equal to 95 less than 110 mm Hg in Study II. Study I: The impact of metoprolol CR/ZOK 50 mg once daily for 4 weeks compared with placebo 24 hours post dosing was to produce a significant reduction in supine (P = .0001), and standing (P less than .0001) systolic blood pressures and the standing diastolic pressure (P = .035). The supine diastolic pressure was lower after metoprolol CR/ZOK but not significantly so. Study II: Metoprolol CR/ZOK 50 mg daily given to elderly hypertensives when compared with placebo 24 hours post dosing produced a significant fall in supine (P = .022) and standing (P = .022) diastolic pressure. Systolic pressure and heart rate were not significantly reduced. One patient in Study II had a nonfatal myocardial infarct whilst receiving placebo. There were no other serious adverse effects in either study and no patients were withdrawn from the trial because of drug related unwanted events. The studies indicate that 50 mg metoprolol CR/ZOK may be an effective antihypertensive agent which may prove useful in the treatment of mild to moderate hypertension, particularly in the elderly.

Incidence of hypertension in an ambulatory elderly population

Investigations of the natural history of blood pressure have generally evaluated mean systolic and diastolic pressure changes. While information, this information is not directly applicable to clinical practice settings, in which patients are usually classified as normotensive or hypertensive. We measured the actual incidence of hypertension, using two different definitions, in an ambulatory elderly population of 2,584 individuals over an 8-year period. Using the less stringent blood pressure definition (systolic blood pressure greater than 140 mmHg and diastolic blood pressure greater than or equal to 90 mmHg), 884 (34.2%) participants were normotensive and 1,700 (65.8%) were hypertensive at an initial screening. The average annual incidence of hypertension over the subsequent eight years was 13.2%, and life tables demonstrated a gradual risk of developing hypertension. The development of hypertension was not associated with gender or age; while older age groups had a greater chance of developing hypertension than younger, the difference did not reach statistical significance.

Isolated systolic hypertension in the elderly: pathophysiology and treatment

Isolated systolic hypertension (ISH) is a common clinical finding in the elderly population and appears to be a risk factor for cardiovascular morbidity and mortality. It appears feasible and safe to treat patients with various antihypertensive drugs; however, the morbidity and mortality benefits still need to be determined.

Age-related changes in blood pressure

This report is based on three different representative population samples of a total of 1304 men (50-79 years old) and 1246 women (38-79 years old) observed for up to 12 years. Subjects' consumption of antihypertensive drugs and blood pressure levels in subjects with and without such treatment are presented. The prevalence of treatment with antihypertensive drugs (including beta-blockers and diuretics for other indications) increased from 2% at age 50 years to 37% at 79 years of age among the men and from 1% at 38 years to 61% at 79 years of age among the women. The mean systolic/diastolic blood pressure in untreated subjects increased from 138/91 mm Hg at age 50 years to 159/91 mm Hg at age 70 years in the men and from 123/79 mm Hg at age 38 years to 168/93 mm Hg at age 70 years in the women. At age 79 years the mean systolic/diastolic blood pressure was 155/83 mm Hg in the men and 161/85 mm Hg in the women. In a longitudinal follow-up of reexamined subjects, there was an increase in systolic blood pressure levels up to age 75 years and a reduction in diastolic blood pressure after age 75 years in both sexes.

Swedish trial in old patients with hypertension. A prospective multicentre study in Swedish primary health care

The Swedish trial in old patients with hypertension was initiated by the Swedish League against Hypertension. It will be conducted as a prospective multicentre study in Swedish primary health care, and will comprise approximately 2 000 patients on active treatment and 2 000 on placebo to be studied for three years. The primary goal with this study is to investigate whether pharmacological treatment of hypertension in men and women aged 70-84 years will reduce the incidence of fatal and nonfatal cardiac and cerebrovascular disease. Before starting the main trial a pilot study comprising 400 patients will be carried out during one year to evaluate all logistical aspects of the study. This pilot study commenced in October 1985.

Osler's maneuver, pseudohypertension, and true hypertension in the elderly

Up to half of the geriatric population has been reported to have arterial hypertension and, therefore, an augmented risk of heart attack, stroke, congestive heart failure, and sudden death. Recent studies indicate that mechanisms serving to elevate arterial pressure in the elderly diametrically differ from those in younger patients with similar elevation of arterial pressure. Elderly hypertensive patients have a low cardiac output, elevated vascular resistance, impaired tissue flow, and increased arterial stiffness. Arterial stiffness, if marked, can give rise to pseudohypertension--an entity often responsible for inappropriate diagnosis and inappropriate therapy in the geriatric population. Pseudohypertension can be suspected from a simple bedside maneuver that was hinted at by Sir William Osler almost a century ago. Arterial hypertension seems to accelerate the physiologic process of aging in the cardiovascular system and threatens, therefore, to set the biologic clock at a faster pace. Hopefully, antihypertensive agents more closely tailored to underlying mechanisms of pressure elevation will reverse hypertensive damage to target organs and thereby reset the aging process of the cardiovascular system at a slower pace.