Does White Coat Hypertension Require Treatment Over Age 80?

Twelve hot questions in the management of hypertension in patients aged 80+ years and their answers with the help of the 2023 European Society of Hypertension Guidelines

Arterial hypertension is a major risk factor for cardiovascular morbidity and mortality, and highly prevalent in older age, underscoring the importance of its appropriate management. The population is ageing at an increasing rate, with those aged 80+ years being the fastest growing population characterized by high heterogeneity in terms of functionality and autonomy. The prevalence of hypertension rises with increasing age, due to a significant increase in SBP largely as a result of age-related stiffening of the aorta and other large arteries, affecting almost 80% of those aged 80+ years. Appropriate management of blood pressure in this population is a priority for clinicians. Frailty is a condition characterized by marked vulnerability to adverse health outcomes and is common among older adults including those with hypertension. Hypertension increases frailty level and at the same time, individuals with increasing frailty present with more drug-related adverse effects meaning they are less tolerant to blood pressure lowering by medication. Thus, frailty is a factor that should be integrated when treating hypertension in this population. The European Society of Hypertension 2023 Guidelines on the management of Hypertension are the first international guidelines to integrate the concept of adapting blood pressure management in older adults according to their frailty/functionality level, and to propose practical tools for the application of this concept in the daily practice of physicians and other healthcare professionals. The present article prepared by the European Society of Hypertension Working Group on Hypertension in Older Adults aims to further address some important aspects mentioned concisely in the 2023 European Society of Hypertension guidelines, in order to help physicians and other healthcare professionals including those practicing in primary care. To this end, this study discusses 12 'hot questions' which are answered with the help of the 2023 European Society of Hypertension Guidelines. We hope the present article and Working Group's actions will contribute to understanding and applying the ideal management of hypertension in this most vulnerable population.

[Ambulatory blood pressure monitoring, adult and pediatric population. A narrative review]

Hypertension has become a central risk factor for the development of cardiovascular disease, underscoring the importance of its accurate diagnosis. Numerous studies have established a close relationship between elevated systolic (SBP) and diastolic (DBP) blood pressure and an increased risk of cardiovascular event (CVE). Traditionally, blood pressure (BP) measurements performed in clinical settings have been the main method for diagnosing and assessing hypertension. However, in recent years, it has been recognized that BP measurements obtained outside the clinical setting, using self-monitoring blood pressure (SMBP) and ambulatory blood pressure monitoring (ABPM), offer a more realistic perspective of patients' daily lives and therefore provide more reliable results. Given the evolution of medical devices, diagnostic criteria, and the increasing relevance of certain components of ABPM in the prediction of adverse cardiovascular outcomes, a comprehensive update that is practical for daily clinical practice is required. The main objective of this article is to provide an updated review of ABPM, focusing on its importance in the evaluation of hypertension and its impact on public health in Colombia. In addition, it will discuss the implications of changes in diagnostic thresholds and provide concrete recommendations for the effective implementation of ABPM in clinical practice, allowing health professionals to make informed decisions and improve the care of their patients.

Effects of Nondipping Blood Pressure Changes: A Nephrologist Prospect

Blood pressure (BP) variations depend on various internal, environmental, and behavioral factors. BP fluctuations occur both in normotensive and hypertensive people. Although it fluctuates over the 24-hr day and night, the morning BP increases after waking up and declines throughout sleep. It is typical for BP to decrease by 10% to 20%, while sleeping, known as dipping BP. However, if there is no decrease in nighttime mean systolic BP or a drop of less than 10 mmHg, it is called nondipping BP. Conversely, reverse dipping BP means an increase in mean systolic BP instead of a drop during the night. Reverse dipping is observed in hypertension (HTN), diabetes mellitus (DM), chronic kidney disease (CKD), and obstructive sleep apnea (OSA) syndrome. The introduction of ambulatory BP monitoring (ABPM) led to the emergence of identifying normal and elevated BP patterns. Non-dipping BP increases the risk of cardiovascular system (CVS) complications such as left ventricular hypertrophy, proteinuria, glomerular filtration rate (GFR) reduction, and CKD progression. A loss or blunting of the normal BP profile is recognized as a deleterious variant, and restoring abnormal BP patterns has been reported to significantly impact end-organ damage, morbidity, and mortality. In this non-systematic clinically-oriented, comprehensive review, we aim to update the BP variables and the pathophysiology of nondipping BP and point out the areas which need more investigation from a nephrology perspective because the nondipping BP increases the risk of proteinuria, GFR reduction, and CKD progression. A literature search of PubMed, Google, EMBASE, and Google Scholar was conducted. Checks of selected papers and relevant reviews complemented the electronic search. With improved BP measurement methods, the physiology of BP profile variations is readily detectable during the day and night. A nondipping BP profile is a distinct BP pattern that may have significant end-organ damage effects and therapeutic importance for nephrologists. The pathophysiology of the nondipping BP variant must be clarified to prevent complications, and further investigations are required. Furthermore, there is debate about the best BP index to utilize: systolic BP, diastolic BP, mean arterial pressure, or a mixture of all. All these areas are important and need new research projects.

Possible cardiovascular risks of white coat hypertension: updated

White-coat hypertension (WCH) has been defined as an increased blood pressure (BP) in the doctor's office and a normal BP outside the office by 24 hr ambulatory BP monitoring (ABPM) or home BP measurement. It is generated by fear and anxiety of whether an abnormal value could be found and indicate the existence of hypertension. When first described, it was defined as a neuro-defense reaction related to the presence of the doctor in their office or clinic and associated with an increase in heart rate. Initially it was considered a benign condition, not associated with the hypertension mediated organ damage (HMOD) and not requiring treatment. However, recent studies have shown that WCH is not a benign condition and is associated with HMOD and cardiovascular (CV) events (CVE). According to recent ACC/AHA guidelines, the outside of office normal BP should be < 130/80 mmHg and according to the ESC/ESH guidelines, the outside of office normal BP should be < 135/85 mmHg. The prevalence of WCH varies by different studies from 15% to 40% and up to 50% in older subjects. Currently, the management of WCH if not associated with CV risk factors should be conservative with healthy lifestyle changes and exercise. Drug therapy should be considered if these measures do not work or in the presence of CV risk factors, HMOD, or preexisting cardiovascular disease.

Antihypertensive drug treatment in white-coat hypertension: data from the Plaque HYpertension Lipid-Lowering Italian Study

AIM

Little evidence is available on whether antihypertensive treatment lowers cardiovascular risk in white-coat hypertension (WCH). Protection might be indirectly inferred, however, from the blood pressure (BP) effects of treatment as in trials BP reduction is linearly related to outcome reduction. We analyzed the effect of antihypertensive treatment on office and ambulatory BP in WCH using data from the Plaque HYpertension Lipid-Lowering Italian Study (PHYLLIS).

METHODS

: Office and ambulatory blood pressure were measured in 470 hypertensive patients randomized to fosinopril or hydrochlorothiazide alone or combined with a statin before treatment and at 6 month or yearly intervals during 2.6 years of follow-up. Patients were divided into two groups according to whether before randomization to treatment office and 24-h mean BP were elevated (sustained hypertension) or office BP was elevated but 24-h BP values were normal (WCH).

RESULTS

: In both sustained hypertension and WCH antihypertensive treatment was associated with an early marked office BP reduction, which persisted virtually unchanged throughout the treatment period. In contrast, 24-h (and day and night) BP showed a marked and persistent treatment-related fall in sustained hypertension but no change in WCH. The results were similar when data were separately analyzed in patients under fosinopril or diuretic, with or without statin treatment.

CONCLUSION

: In WCH, antihypertensive treatment can effectively and durably reduce office BP. This reduction is accompanied by the inability to lower ambulatory BP from the normal values characterizing this condition at baseline. This appears to be unrelated to the type of treatment employed.

Controversies in Hypertension I: The Optimal Assessment of Blood Pressure Load and Implications for Treatment

The most important factor in treating hypertension is assessing an individual patient's true blood pressure load, the cornerstone being research-grade office determination. Office blood pressure should be supplemented with out-of-office measurement, including home and ambulatory monitoring (if available), which we consider complementary and not interchangeable. Controversy remains for initiation of treatment of white coat hypertension, where cardiovascular risk lies between normotension and sustained hypertension; antihypertensive therapy should be considered unless low cardiovascular risk, wherein pressures should be followed for progression to sustained hypertension. Available data do not support intensification of therapy for the white coat effect due to the similar cardiovascular risk to controlled hypertension. Given the higher cardiovascular risk of the masked effect, initiation of therapy for masked hypertension and intensification for masked uncontrolled hypertension are indicated, acknowledging the dearth of supporting data. Optimally, randomized controlled trials are needed to determine the benefit of treating the 4 incongruous phenotypes between office and out-of-office measurements, that is, those with white coat or masked effects. We make no recommendations regarding chronotherapy pending results of ongoing trials.

Role of ambulatory blood pressure monitoring in elderly hypertensive patients

Background

Arterial hypertension is facing some changes in the last years. Its prevalence is increasing in elderly subjects. This growing prevalence is due to longer survival of the population worldwide, among other factors. On the other hand, recent guidelines have insisted in the relevance of out of office blood pressure measurements, to improve diagnostic and management of hypertension. Therefore, elderly subjects with hypertension could benefit from out of office blood pressure measurements, like ambulatory blood pressure measurements; nevertheless, there are very few or no specific recommendations regarding this.

Aim

In this review, we will gather the most important information about this subject.

Results

As hypertension in the elderly has some specific characteristics related to aging of the cardiovascular system, the most important aspect could be that these characteristics make ambulatory blood pressure measurement suitable for its use in elderly. Among those a higher prevalence of white coat hypertension, white coat phenomenon, and a higher nocturnal blood pressure and higher prevalence of nondipper and riser pattern, represent aspects that should be considered for better diagnostic and an improved management.

Conclusion

As the prevalence of hypertension will grow in the next years, more studies specifically directed to this subject are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-022-00205-6.

A clinical algorithm to determine target blood pressure in the elderly: evidence and limitations from a clinical perspective

As the elderly population is growing rapidly, management of hypertension in South Korea faces major challenges because the proportion of elderly hypertension patients is also increasing. The characteristics of this population are also much more complex than younger patients. Elderly hypertension is characterized by wide variations in (1) fitness or biological age, (2) white-coat effect, (3) poor functional status or frailty, (4) dependency in activities of daily living or institutionalization, (5) orthostatic hypotension, and (6) multiple comorbidities. All of these should be considered when choosing optimal target blood pressure in individual patients. Recent randomized clinical trials have shown that the benefits of intensive blood pressure control for elderly patients is greater than previously thought. For generalization of these results and implementation of the guidelines based on these studies, defining the clinician's role for individualization is critically important. For individualized decisions for target blood pressure (BP) in the elderly with hypertension, four components should first be checked. These consist of (1) the minimum requirement of functional status and capability of activities of daily living, (2) lack of harmful evidence by the target BP, (3) absence of white-coat hypertension, and (4) standing systolic BP ≥ 110 mmHg without orthostatic symptoms. Risk of decreased organ perfusion by arterial stenosis should be screened before starting intensive BP control. When the target BP differs among comorbidities, the lowest target BP should be given preference. After starting intensive BP lowering therapy, tolerability should be monitored, and the titration should be based on the mean level of blood pressure by office supplemented by out-of-office BPs. Applications of the clinical algorithms will be useful to achieve more standardized and simplified applications of target BP in the elderly.

White-coat hypertension/effect is associated with higher arterial stiffness and stroke events

OBJECTIVES

The risk profile of white-coat hypertension/effect (WCH/E) remains unclear. This study aimed to investigate the relationship between WCH/E, markers of cardiovascular risk and cerebrovascular events.

METHODS

This is a sub-group analysis of The Arterial Stiffness In lacunar Stroke and Transient ischemic attack (ASIST) study, which recruited 96 patients aged at least 40 years old with a diagnosis of transient ischemic attack or lacunar stroke in the preceding 14 days. Thirty-two patients with target blood pressure (clinic blood pressure <140/90 mmHg and daytime ambulatory blood pressure <135/85 mmHg) and 30 patients with WCH/E (clinic blood pressure ≥140/90 mmHg and daytime ambulatory blood pressure <135/85 mmHg) were included in the analysis.

RESULTS

Patients with WCH/E were older and had a higher BMI. Central SBP (145 ± 13 vs. 118 ± 8 mmHg, P < 0.001) and DBP (82 ± 8 vs. 76 ± 7 mmHg, P = 0.004) were higher in those with WCH/E. They also had higher arterial stiffness measured by carotid-femoral pulse wave velocity (11.9 ± 3.0 vs. 9.6 ± 2.3 m/s, P = 0.002) and cardio-ankle vascular index (10.3 ± 1.3 vs. 9.4 ± 1.7, P = 0.027). Regression analysis showed an independent relationship between WCH/E and both measures of arterial stiffness. Lacunar strokes were more prevalent in those with WCH/E (47 vs. 22%, P = 0.039) and individuals in this group were more likely to have had a lacunar stroke than a transient ischemic attack (odds ratio 9.6, 95% CI 1.5-62.6, P = 0.02).

CONCLUSION

In this cohort of patients with lacunar stroke and transient ischemic attack, WCH/E was associated with elevated markers of cardiovascular risk and a higher prevalence of lacunar stroke. These results suggest that WCH/E is associated with adverse cardiovascular risk.

Update in Hypertension

The treatment of elevated blood pressure (BP) can improve cardiovascular (CV) event rates. Current BP targets depend on expected CV event rates in individuals as assessed by concurrent medical conditions and other risk factors. Importantly, the means by which BP is measured has evolved. This evolution is driven by recognition that techniques different than routine office BP measurements can provide a better assessment of future CV risk.

White-Coat Hypertension: Pathophysiological and Clinical Aspects: Excellence Award for Hypertension Research 2020

Few issues of modern cardiovascular medicine have been as controversial as the relationship between white-coat hypertension (WCH), that is, a common condition in which office blood pressure is elevated while out-of-office blood pressure (ambulatory blood pressure or home blood pressure) is normal. While earlier studies showed no increased risk of cardiovascular events in WCH compared with the normotensive state, more recent studies have changed this conclusion by showing that an increased cardiovascular risk represents a trait of this hypertensive phenotype. The present article will review a number of issues related to WCH, that is, its definition, pathophysiological background, clinical alterations, and prognostic significance. This will be done by considering the available evidence published during the last decades, with special focus on the data collected in PAMELA (Pressioni Arteriose Monitorate e Loro Associazioni)-a research project performed with a cross-sectional and longitudinal design, which has provided a series of novel clinical information on WCH throughout the years. The final part of the article will discuss the therapeutic implications of the abovementioned evidence, as well as some controversial or still undefined issues related to WCH, whose investigation will be an important goal to pursue by future research.

Screening for Hypertension in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Hypertension is a major risk factor for cardiovascular disease and can be modified through lifestyle and pharmacological interventions to reduce cardiovascular events and mortality.

OBJECTIVE

To systematically review the benefits and harms of screening and confirmatory blood pressure measurements in adults, to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, Cochrane Collaboration Central Registry of Controlled Trials, and CINAHL; surveillance through March 26, 2021.

STUDY SELECTION

Randomized clinical trials (RCTs) and nonrandomized controlled intervention studies for effectiveness of screening; accuracy studies for screening and confirmatory measurements (ambulatory blood pressure monitoring as the reference standard); RCTs and nonrandomized controlled intervention studies and observational studies for harms of screening and confirmation.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction; meta-analyses and qualitative syntheses.

MAIN OUTCOMES AND MEASURES

Mortality; cardiovascular events; quality of life; sensitivity, specificity, positive and negative predictive values; harms of screening.

RESULTS

A total of 52 studies (N = 215 534) were identified in this systematic review. One cluster RCT (n = 140 642) of a multicomponent intervention including hypertension screening reported fewer annual cardiovascular-related hospital admissions for cardiovascular disease in the intervention group compared with the control group (difference, 3.02 per 1000 people; rate ratio, 0.91 [95% CI, 0.86-0.97]). Meta-analysis of 15 studies (n = 11 309) of initial office-based blood pressure screening showed a pooled sensitivity of 0.54 (95% CI, 0.37-0.70) and specificity of 0.90 (95% CI, 0.84-0.95), with considerable clinical and statistical heterogeneity. Eighteen studies (n = 57 128) of various confirmatory blood pressure measurement modalities were heterogeneous. Meta-analysis of 8 office-based confirmation studies (n = 53 183) showed a pooled sensitivity of 0.80 (95% CI, 0.68-0.88) and specificity of 0.55 (95% CI, 0.42-0.66). Meta-analysis of 4 home-based confirmation studies (n = 1001) showed a pooled sensitivity of 0.84 (95% CI, 0.76-0.90) and a specificity of 0.60 (95% CI, 0.48-0.71). Thirteen studies (n = 5150) suggested that screening was associated with no decrement in quality of life or psychological distress; evidence on absenteeism was mixed. Ambulatory blood pressure measurement was associated with temporary sleep disturbance and bruising.

CONCLUSIONS AND RELEVANCE

Screening using office-based blood pressure measurement had major accuracy limitations, including misdiagnosis; however, direct harms of measurement were minimal. Research is needed to determine optimal screening and confirmatory algorithms for clinical practice.

Relationship between office isolated systolic or diastolic hypertension and white-coat hypertension across the age spectrum: a home blood pressure study

OBJECTIVE

The current study investigated the prevalence of white-coat hypertension (WCH) and white-coat uncontrolled hypertension (WUCH) throughout the age spectrum among individuals with office isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH) and systolic-diastolic hypertension (SDH) who were untreated or treated with antihypertensive medications, respectively.

METHODS

We cross-sectionally evaluated 8809 untreated (42% males, 52.1 ± 16.2 years) and 9136 treated (39% males, 59.7 ± 14.5 years) individuals from two independent Brazilian populations who underwent home blood pressure monitoring. Participants were also categorized as younger (<40 years), intermediate (≥40 and <60 years) and older (≥60 years) age.

RESULTS

Unadjusted and adjusted analyses showed that the frequency of WCH and WUCH was significantly greater (P < 0.05) in ISH and IDH than SDH at all age groups. Logistic regression analysis adjusted for sex, BMI and studied population showed that, compared with SDH, ISH had in average 4.1, 3.1 and 1.6-fold greater risk of WCH and 3.3, 3.6 and 2.0-fold greater risk of WUCH at younger, intermediate and older ages, whereas IDH had in average 2.3, 2.6 and 2.0-fold greater risk of WCH and 3.8, 3.2 and 3.8-fold greater risk of WUCH at younger, intermediate and older ages, respectively.

CONCLUSION

ISH and IDH were associated with higher prevalence of WCH and WUCH than SDH across all age spectrum. In addition, treated and untreated ISH individuals with age less than 60 years and treated IDH individuals of all ages had the highest risk of having WCH phenotypes.

Cardiovascular Alterations and Management of Patients With White Coat Hypertension: A Meta-Analysis

A large and growing body of literature has focused on the association between "white coat hypertension" (WCH) and the underlying target organ damage. The evidence suggests that WCH is may not an entirely benign phenomenon. However, whether patients with WCH should receive antihypertensive drugs is unresolved. Therefore, we performed a meta-analysis to fully determine the ability of WCH to alter cardiovascular structure and to determine whether patients with WCH could benefit from drug intervention. Medline, EMBASE, and the Cochrane Library were searched from inception through 21 Oct 2019. A total of 25 studies (8,100 individuals) were included. In participants with WCH, values of aortic pulse wave velocity, augmentation index, intima-media thickness, interventricular septum thickness, left ventricular posterior wall thickness, and left ventricular mass index were lower than those with sustained hypertension, but greater than those in the normotensive group. Of note, antihypertensive drug therapy did not reduce the risk of cardiovascular events in patients with WCH. WCH is accompanied by alterations of cardiovascular structure; however, the benefits from antihypertensive therapy are limited.

Hypertension, heart failure, and frailty in older people: A common but unclear situation

Hypertension and heart failure are common conditions in older people. Comorbidity, together with aging, is commonly associated with frailty, which is a cause of a worse prognosis, more hospitalizations, increased dependency, and mortality. Despite being increasingly common conditions, data on the prevalence and influence of frailty in hypertensive older patients with HF are lacking. This may be due to the multidimensional aspects of frailty and the differing tools used to evaluate it. Nevertheless, in clinical practice, it is common to see frail hypertensive patients with HF but the specific characteristics of this group of patients, including multimorbidity and frailty, and the lack of data from registries or randomized clinical trials make the diagnosis and management of these patients more difficult than in those of other ages. This review focuses on what is known and on where future investigations should focus in this common but unclear situation.

Management of hypertension in the very old: aggressive reduction of blood pressure is harmful in most patients

Arterial hypertension is particularly prevalent in the elderly and treatment is required according to the literature. Treatment in subjects between 65 and 80 years of age resembles by characteristics and results that obtained in younger population. The treatment of arterial hypertension in the very elderly differs in a relevant percentage of them. It is quite similar in those with a good physical fitness with or without cardiovascular disease. A series of factors as the presence of real sustained hypertension, orthostatic hypotension, frailty and disability, and the boundary of safety recommended by international recent guidelines analysed here are relevant to characterize a clearly elevated risk of complications in the remaining very elderly patients.

Blood Pressure Measurement and Treatment Decisions

White-coat and masked hypertension are important hypertension phenotypes. Out-of-office blood pressure measurement is essential for the accurate diagnosis and monitoring of these conditions. This review summarizes literature related to the detection and diagnosis, prevalence, epidemiology, prognosis, and treatment of white-coat and masked hypertension. Cardiovascular risk in white-coat hypertension appears to be dependent on the presence of coexisting risk factors, whereas patients with masked hypertension are at increased risk of target organ damage and cardiovascular events. There is an unmet need for robust data to support recommendations around the use of antihypertensive treatment for the management of white-coat and masked hypertension.

Current status of white coat hypertension: where are we?

White coat hypertension (WCH) is characterised by an elevated clinic blood pressure (BP) with normal ambulatory or home BP. It is well recognised in clinical practice and occurs in approximately one-third of untreated patients with elevated clinic BP. Current evidence suggests that WCH is associated with cardiovascular risk factors, including the development of sustained hypertension and the presence of target organ damage. However, its effects on cardiovascular outcomes remain a matter of debate. There is also insufficient evidence from randomised controlled trials to determine whether WCH warrants treatment. This narrative review aims to provide an update on the current understanding of WCH. It focuses on the clinical characteristics and potential implications of WCH, its relationship to cardiovascular risk and the evidence regarding treatment. Gaps in existing research are also highlighted.

Going Beyond the Guidelines in Individualising the Use of Antihypertensive Drugs in Older Patients

Hypertension is commonly diagnosed in older patients, with increasing cardiovascular (CV) risk as systolic blood pressure (BP) increases. Maximising CV risk reduction must be reconciled with minimising the risk of treatment-related harms and burden, especially among frail, multi-morbid and older old patients who have been excluded from most randomised trials. Contemporary clinical guidelines, based on such trials, differ in their recommendations as to threshold levels warranting treatment with antihypertensive drugs (AHDs) and target levels that should be achieved. In optimising AHD prescribing in older patients, we propose the following decision framework: decide therapeutic goals in accordance with patient characteristics and preferences; estimate absolute CV risk; measure and profile BP accurately in ways that account for lability in BP levels and minimise error in BP measurement; determine threshold and target BP levels likely to confer net benefit, taking into account age, co-morbidities, frailty and cognitive function; and consider situations that warrant AHD deprescribing on the basis of potential current or future harm. In applying this framework to older persons, and based on a review of relevant randomised trials and observational studies, individuals most likely to benefit from treating systolic BP to no less than 130 mmHg are those of any age who are fit and have high baseline systolic BP (≥ 160 mmHg); high CV risk, i.e. established CV disease or risk of CV events exceeding 20% at 10 years; previous stroke or transient ischaemic attack; heart failure; and stage 3-4 chronic kidney disease with proteinuria. Individuals most likely to be harmed from treating BP to target systolic < 140 mmHg are those who have no CV disease and aged over 80 years; moderate to severe frailty, cognitive impairment or functional limitations; labile BP and/or history of orthostatic hypotension, syncope and falls; or life expectancy < 12 months. Treatment should never be so intense as to reduce diastolic BP to < 60 mmHg in any older person. At a time when guidelines are calling for less conservative management of hypertension in all age groups, we contend that a more temperate approach, such as that offered here and based on the totality of available evidence, may assist in maximising net benefit in older patients.

From Clinical Trials to Bedside: the Use of Antihypertensives in Aged Individuals. Part 1: Evaluation and Evidence of Treatment Benefit

PURPOSE OF REVIEW

Use of antihypertensives in older adults can be complicated by the potential for undesired effects on comorbidities, adverse effects of the drugs, and overall medication burden. The purpose of this two-part review is to discuss contemporary issues encountered in the management of hypertension in aged individuals, with a particular focus on the individualization of treatment. In part 1, we discuss the evaluation of the aged hypertensive patient and review the clinical trial evidence for treatment benefit of hypertension in the elderly.

RECENT FINDINGS

Elderly patients with suspected hypertension need careful evaluation of their blood pressure, as errors in measurement technique, inaccurate devices, or overreliance on office blood pressure readings may lead to under- or over-treatment, thereby increasing risks of adverse medication effects and/or cardiovascular events. Epidemiologic evidence in older adults suggests a link between low blood pressure and increased mortality. However, key prospective hypertension trials such as HYVET and SPRINT, which were focused in mostly healthy, community-dwelling elderly cohorts, have unequivocally demonstrated benefits of lowering blood pressure in reducing cardiovascular events in the very elderly. Recent evidence also suggests benefit in reducing the risks of cognitive impairment. Hypertension is a major modifiable risk factor and the benefits of treatment in lowering cardiovascular events are realized for most individuals, even at advanced ages.

The role of wrist monitors to measure blood pressure in older adults

BACKGROUND

Arterial hypertension is a common condition in older adults with increasing data about blood pressure (BP) targets and antihypertensive treatment in this population. Recent studies have opened new discussions about the different usual and unusual methods of blood pressure monitoring. However, there are no evidence-based recommendations whether BP should be measured at upper arms or at wrist, which seems to be more comfortable in older and frail people.

AIMS

The purpose of this study was to test the quality of wrist BP monitors as diagnostic method in older adults.

METHODS

BP measurements at both upper arms and at both wrists were compared under standardized conditions in 605 patients ≥ 75 years. Differences in wrist and upper arm BP were, furthermore, correlated with various diagnoses and parameters including ankle-brachial-index (ABI).

RESULTS

In patients of 75-80 years, there were no differences in BP measurements at upper arms compared to wrists whereas in patients > 80 years, BP measurements at wrists were significantly lower than at upper arms. In both age groups BP measured at wrist was significantly lower in patients with ABI < 0.9.

CONCLUSIONS

BP wrist monitors could be considered as a serious alternative in adults of 75-80 years or in older persons with normal ABI values.

Blood Pressure Measurements with Different Currently Available Methods in Elderly Hypertensive Hospitalized Patients: A Real World Cross-Sectional Study

BACKGROUND

The reliability of blood pressure (BP) measurement in hospitalized patients is a topic of debate and the therapeutic implication of the routinely collected BP profiles is probably overestimated. When measurements are performed in elderly patients, further potential sources of misinterpretation occur.

METHODS

We conducted a subanalysis of a previous study including 79 over 80-year-old hypertensive patients, hospitalized in an internal medicine ward. Five modalities of BP evaluations (measurement by physicians and nurses, self-measurement by patients, Finometer® beat-to-beat finger monitoring, and 24h monitoring) were analyzed, considering agreement and accuracy.

RESULTS

The mean (SD) age of the patients was 86.9±4.9 years (50% women). Patients' self-measurements of both systolic and diastolic BP (SBP and DBP) did not differ significantly from daytime 24-hour monitoring (D24hBPM) (mean difference -1.52, SE 1.71; p: ns and -0.58, SE 1.19 mmHg; p: ns). Conversely, SBP and DBP registered by nurses did significantly differ (mean difference -7.34, SE 1.42; p=0.007 and -4.7, SE 1.05 mmHg; p=0.003). SBP and DBP measured by patients also showed the better concordance, with lowest biases, and narrowest limits of agreements (LoA) and for SBP higher Kappa statistic values (bias 1.5, LoA -28.9 to 31.9; κ 0.563 and bias 0.6, LoA -20.4 to 21.5 mmHg; κ 0.412). The patients' sensitivity and specificity in predicting hypertensive systolic D24hBPM were 84.8% and 69.7%, respectively.

CONCLUSIONS

In elderly hospitalized patients an alternative to 24hBPM, self-measurements by patients offer the better agreement and reliability in detecting hypertensive values.

Home blood pressure and cardiovascular outcomes in very elderly patients receiving antihypertensive drug therapy: a subgroup analysis of Home blood pressure measurement with Olmesartan Naive patients to Establish Standard Target blood pressure (HONEST) study

The appropriate target blood pressure (BP) in elderly patients with hypertension remains uncertain. We investigated the relationship between morning home systolic blood pressure (MHSBP) during follow-up and cardiovascular (CV) risk in outpatients receiving olmesartan-based treatment aged <75 years (n = 16799) and ≥75 years (n = 4792) in the HONEST study. In the follow-up period (mean 2.02 years), the risk for major CV events was significantly higher in patients with MHSBP ≥155 mmHg compared with <125 mmHg in both age groups in Cox proportional hazards model adjusted for other risk factors and there was no significant difference in trend between the two groups (interaction P = 0.9917 for MHSBP). Hazard ratios for CV events for 1-mmHg increase in MHSBP were similar in patients aged <75 years and in patients aged ≥75 years. The incidence of adverse drug reactions related to excessive BP lowering was lower in patients <75 years than in patients ≥75 years (0.73 vs 1.02%, P = 0.0461). In conclusion, the study suggests even in patients ≥75 years antihypertensive treatment targeting the same MHSBP levels in patients <75 years may be beneficial in reducing CV risk when treatment is tolerated.

White Coat Hypertension: to Treat or Not to Treat?

Definition of white coat hypertension (WCH) traditionally relies on elevated office blood pressure (BP) during repeated visits concomitant with normal out-of-office BP values, as assessed by home and/or 24-h ambulatory BP monitoring measurements. Accumulating evidence focusing on the association of WCH with target organ damage and, more importantly, with cardiovascular events indicates that the risk conveyed by this condition is intermediate between normotension and sustained hypertension. This article will review a number of issues concerning WCH with particular emphasis on the following: (1) prevalence and clinical correlates, (2) association with target organ damage and cardiovascular events, (3) therapeutic interventions. Data will refer to the original WCH definition, based on out-of-office BP determined by 24-h ambulatory BP monitoring; at variance from home BP measurement, this approach rules out the potentially confounding effect of a clinically relevant abnormal BP phenotype such as isolated nocturnal hypertension.

Considerations for Optimal Blood Pressure Goals in the Elderly Population: A Review of Emergent Evidence

Recent hypertension clinical trials and national guideline updates have created a debate on the most appropriate treatment goals in elderly patients with hypertension. In 2014, recommendations by the Eighth Joint National Committee allowed a more lenient goal for patients 60 years and older compared with previous guidelines. Since then, several large clinical trials and meta-analyses have added more information regarding strict versus lenient treatment goals. Most recently, the American College of Cardiology and American Heart Association Task Force published their highly anticipated hypertension guideline developed in conjunction with nine additional interdisciplinary organizations. This review discusses the culmination of emerging data to provide more insight into the treatment of hypertension in the elderly. A literature search was conducted using PubMed, the Cumulative Index of Nursing and Allied Health, the Cochrane database, and by hand-searching references from relevant articles. The following key terms were used: hypertension, blood pressure, systolic, and elderly. Available literature suggests that it is reasonable to target an office systolic blood pressure of less than 130 mm Hg in elderly patients with hypertension. An individualized approach is reasonable for those who are institutionalized, with high comorbidity burden, or have a short life expectancy. A diastolic blood pressure of less than 60 mm Hg should be avoided due to the potential for an increase in cardiovascular risk. The method of blood pressure measurement is extremely important to consider when determining the blood pressure goal, and proper procedures for accurate blood pressure measurement must be followed. Other factors important to consider may include the patient's comorbidities, frailty, as well as the patient's potential for adverse drug reactions.

White-Coat Hypertension: the Neglected Subgroup in Hypertension

The clinical prognostic importance of white coat hypertension (WCH), that is, the clinical condition characterized by an increase of office but a normal ambulatory or home blood pressure (BP) is since a long time matter of considerable debate. WCH accounts for a consistent portion of hypertensive patients (up to 30–40%), particularly when hypertension is mild or age is more advanced. Although scanty and inconsistent information is available on the response of office and out-office BP to antihypertensive treatment and the cardiovascular (CV) protection provided by treatment, an increasing body of evidence focusing on the association of WCH with CV risk factors, subclinical cardiac and extra-cardiac organ damage and, more importantly, with CV events indicates that the risk entailed by this condition is intermediate between true normotension and sustained hypertension. This review will address a number of issues concerning WCH with particular attention to prevalence and clinical correlates, relation with subclinical target organ damage and CV morbidity/mortality, therapeutic perspectives. Several topics covered in this review are based on data acquired over the past 20 years by the Pressioni Arteriose Monitorate E Loro Associazioni (PAMELA) study, a longitudinal survey performed by our group on the general population living in the surroundings of Milan area in the north part of Italy.

The ageing heart: the systemic and coronary circulation

Most cardiovascular disease (CVD) occurs in patients over the age of 60. However, most evidence-based current cardiovascular guidelines lack evidence in an older population, due to the under-representation of older patients in randomised trials. Blood pressure rises with age due to increasing arterial stiffness, and stricter control results in improved outcomes. Myocardial ischaemia is also more common with increasing age, due to a combination of coronary artery disease and myocardial changes. However, despite higher rates of adverse outcomes, older patients are offered guideline-based therapy less frequently. Frailty is an independent predictor of mortality in adults over the age of 60, yet remains poorly assessed; slow gait speed is a key marker for the development of frailty and for adverse outcomes following intervention. Few trials have assessed frailty independent of age; however, there is evidence that non-frail older patients derive significant benefit from therapy, highlighting the urgent need to include frailty as a measure in clinical trials of treatment in CVD.In this review, the authors appraise the literature in regard to the cardiovascular changes with ageing, specifically in relation to the systemic and coronary circulation and with a particular emphasis on frailty and its implication in the evaluation and treatment of CVD.

White-coat hypertension is a risk factor for cardiovascular diseases and total mortality

BACKGROUND

Whether white-coat hypertension (WCH) is an innocent phenomenon is controversial.

METHOD

In this study, we evaluated the association of WCH and the risk of cardiovascular diseases (CVDs) and mortality, stratified by baseline antihypertensive treatment status. Databases (PubMed, EMBASE, CINAHL Plus, Scopus, and Google Scholar) were searched for prospective studies with data on CVD and total mortality associated with WCH. The primary outcomes were the risk of CVD and total mortality associated with WCH stratified by antihypertensive treatment status. The relative risks of events compared with normotension were calculated.

RESULTS

A total of 23 cohorts (20 445 individuals), 11 cohorts (8656 individuals), and 12 cohorts (21 336 individuals) were included for analysis of cardiovascular risk associated with WCH in patients without baseline antihypertensive treatment (untreated), or under antihypertensive treatment (treated) or mixed population (including both untreated and treated patients), respectively. In untreated cohorts, WCH was associated with a 38 and 20% increased risk of CVD and total mortality compared with normotension, respectively. In the mixed population, WCH was associated with a 19 and 50% increased risk of CVD and total mortality. However, in the treated patients, neither the risk of CVD, nor total mortality was increased in WCH. Meta-regression analyses indicated that neither differences of clinic blood pressure, nor out-of-office blood pressure variables were correlated with risk of CVD in WCH.

CONCLUSION

We concluded that WCH is associated with long-term risk of CVD and total mortality in patients without antihypertensive treatment. Close follow-up should be performed in WCH patients.

White coat effect in hypertensive patients: the role of hospital environment or physician presence

This study was to evaluate the role of hospital environment or physician presence for white coat effect (WCE) in hypertensive patients. At first, 54 hypertensive outpatients diagnosed on office blood pressure (OBP) were included for 2-week placebo run in. During the second week of the run in period, home BP was measured using electronic BP monitors for 5-7 days. Finally, 26 sustained hypertensive patients with home systolic BP/diastolic BP over 135/85 (but <180/110) mm Hg were enrolled for 8-week treatment of nifedipine controlled-release tablet. In the visit day, BP was measured by patient-self (OBP-p) or by doctor (OBP-d) according to order determined with randomization method. The self-BP measurement was performed in a reception room of hospital. The differences between home BP and OBP-d or OBP-p were calculated as WCE calculated on doctor-measurement (WCE-d) or WCE calculated on patient-measurement (WCE-p), respectively. The home and OBP were measured with the same BP device for each patient during the study period. In the total 54 outpatients received placebo, the WCE-d was similar to the WCE-p (for systolic BP 6.6 ± 14.4 vs. 6.8 ± 15.8 mm Hg, NS; for diastolic BP 3.3 ± 8.8 vs. 2.9 ± 9.2 mm Hg, NS). Meanwhile, the 26 sustained hypertensive patients had similar systolic WCE-d and WCE-p (4.8 ± 10.3 vs. 5.0 ± 12.2 mm Hg, NS) at placebo stage. Similarly, these values were comparable (3.0 ± 14.0 vs. 2.2 ± 14.4 mm Hg, NS) in treatment stage. Hospital environment plays a main role for the WCE in hypertensive patients.

Unfounded concerns about the use of automated office blood pressure measurement in SPRINT

SPRINT reported significantly fewer cardiovascular events when patients with a higher cardiovascular risk were treated to a target systolic blood pressure (BP) of <120 versus <140 mm Hg. In SPRINT, BP was recorded using the automated office BP (AOBP) method, with multiple readings being taken automatically with the patient resting alone. This technique for BP measurement eliminates the white-coat effect and gives lower BP readings than conventional manual office BP. Critics have questioned if the readings were actually taken with the subject alone and have expressed concerns about the time taken to obtain the readings and the cost of automated sphygmomanometers. Others have suggested that the findings in SPRINT can be applied to current clinical practice if a correction factor is used to convert conventional BP readings to AOBP. This article responds to these criticisms and explains why current methods for recording BP in clinical practice should be changed to AOBP, the technique for BP measurement used in SPRINT.

Antihypertensive treatment decreases arterial stiffness at night but not during the day. Results from the Hypertension in the Very Elderly Trial

The main Hypertension in the Very Elderly Trial (HYVET) demonstrated a very marked reduction in cardiovascular events by treating hypertensive participants 80 years or older with a low dose, sustained release prescription of indapamide (indapamide SR, 1.5 mg) to which was added a low dose of an angiotensin converting enzyme inhibitor in two-thirds of cases (perindopril 2-4 mg). This report from the ambulatory blood pressure sub-study investigates whether changes in arterial stiffness and ambulatory blood pressure (BP) could both explain the benefits observed in the main trial. A total of 139 participants were randomized to placebo [67] and to active treatment [72] and had both day and night observations of BP and arterial stiffness as determined from the Q wave Korotkoff diastolic (QKD) interval. The QKD interval was 5.6 ms longer (p = 0.017) in the actively treated group at night than in the placebo group. This was not true for the more numerous daytime readings so that 24-h results were similar in the two groups. The QKD interval remained longer at night in the actively treated group even when adjusted for systolic pressure, heart rate and height. The reduced arterial stiffness at night may partly explain the marked benefits observed in the main trial.

Hypertension in the frail elderly

Extant data indicate that treating to lower systolic pressure confers significant advantage to younger people in general good health and to relatively healthy octogenarians. Few data exist to guide practitioners on the treatment of frail elderly hypertensives. Chronological age alone does not suffice to make useful judgments regarding therapy. The definition of frailty remains controversial. One method, use of a simple questionnaire or a test of walking speed is practical but not universally accepted. Frail subjects, while at higher risk for cardiovascular complications, seem to benefit less or not at all from antihypertensive drug treatment. Clinicians should treat robust older patients as they would younger patients because the benefits far outweigh the low risk of adverse effects. Successful antihypertensive therapy in those younger than 80 years should not be discontinued simply because that age milestone has been crossed. Treatment of frail older patients must be individualized. Some frail survivors age 80 years or older may actually fare better with elevated systolic pressures. Pending the cognitive function substudy of Systolic Blood Pressure Intervention Trial, there is little evidence that antihypertensive treatment benefits established cognitive dysfunction. Because hypertension in middle age is a good predictor of later cognitive dysfunction, the clinical approach should be one of early prevention.

The Utility of Ambulatory Blood Pressure Monitoring for Diagnosing White Coat Hypertension in Older Adults

The beneficial effect of antihypertensive medication on reducing the risk of cardiovascular disease (CVD) events is supported by data from randomized controlled trials of older adults with hypertension. However, in clinical practice, overtreatment of hypertension in older adults may lead to side effects and an increased risk of falls. The diagnosis and treatment of hypertension is primarily based on blood pressure measurements obtained in the clinic setting. Ambulatory blood pressure monitoring (ABPM) complements clinic blood pressure by measuring blood pressure in the out-of-clinic setting. ABPM can be used to identify white coat hypertension, defined as elevated clinic blood pressure and non-elevated ambulatory blood pressure. White coat hypertension is common in older adults but does not appear to be associated with an increased risk of CVD events among this population. Herein, we review the current literature on ABPM in the diagnoses of white coat hypertension in older adults, including its potential role in preventing overtreatment.

Effectiveness of olmesartan-based treatment on home and clinic blood pressure in elderly patients with masked and white coat hypertension

Few large-scale studies have evaluated the effectiveness of angiotensin receptor blockers in patients with masked hypertension (MH) and white coat hypertension (WCH) based on age using real-world blood pressure (BP) data. We used data from the Home BP measurement with Olmesartan Naive patients to Establish Standard Target BP (HONEST) study to investigate the effectiveness of olmesartan-based treatment by patient age (<65 years of age, n=9817; 65–74 years of age, n=6792; ⩾75 years of age, n=4732), focusing on morning home BP (strongly associated with cardiovascular disease and useful for MH and WCH diagnosis). Sixteen weeks of treatment changed morning home BP (mean systolic/diastolic) by −18.1/−9.7, −15.9/−7.4 and −14.2/−6.4 mm Hg and clinic BP by −20.1/−11.3, −17.3/−8.7 and −15.4/−7.2 mm Hg, in these age groups, respectively (P<0.0001). Pulse pressure decreased (−7.8 to −8.8 mm Hg, P<0.0001). Patients aged ⩾80 years experienced similar BP and pulse pressure changes. In patients aged ⩾75 years, mean morning and clinic BP after 16 weeks was 137.5/74.8 and 129.7/70.4 mm Hg, respectively, in MH patients and 132.3/72.2 and 139.7/72.7 mm Hg, respectively, in WCH patients. Regardless of age, only elevated clinic or home BP values decreased to target ranges. The incidence of adverse effects associated with excessive BP lowering was low in all of the age groups. In conclusion, our study suggests that olmesartan-based treatment was safe and useful for managing MH, WCH and sustained hypertension in elderly patients. The lack of a placebo group was a limitation of the study.

Effect of long-term antihypertensive treatment on white-coat hypertension

Limited evidence is available on the extent and frequency by which antihypertensive treatment lowers office blood pressure (BP) in white-coat hypertension (WCH). Data are even more scanty and discrepant on the corresponding effect on ambulatory BP (ABP). In the hypertensive patients of the European Lacidipine Study on Atherosclerosis (ELSA), office and ABP were measured before treatment and at 6-month (office BP) or 12-month (ABP) intervals during the 4-year administration of calcium channel blocker-based or β-blocker-based treatment. The two groups were pooled and data were analyzed separately in patients with both office and ABP elevation (n=1670; sustained hypertension) or WCH (n=251; office BP elevation only). In sustained hypertension, office and 24-hour mean systolic BP were both markedly reduced through the treatment period, the mean change being -20.0±12.5 and -10.1±11.0 mm Hg, respectively (P<0.0001 for both). In striking contrast, in WCH the office BP reduction was almost as marked as in sustained hypertension (-19.1±11.2 mm Hg; P<0.0001), whereas 24-hour systolic BP values showed no fall or a slight progressive significant increase, its mean change during treatment being 1.6±8.6 mm Hg (P=0.007). Lowering of office BP occurred at a lower treatment intensity in WCH than in sustained hypertension. Similar findings were obtained for diastolic BP. In WCH, antihypertensive treatment should not be expected to have a lowering effect on ABP, even when office BP undergoes a concomitant marked and persistent reduction. The consequence of this contrasting effect on the incidence of hypertension-related outcomes remains to be established.

Olmesartan in the treatment of hypertension in elderly patients: a review of the primary evidence

Hypertension, particularly systolic hypertension, is prevalent in the elderly and increases with advancing age, in part because of age-related endothelial dysfunction and increased arterial stiffness. There is strong evidence from randomized clinical trials that supports the use of antihypertensive treatment for effective and sustained blood pressure (BP) control in older patients to reduce the risk of vascular-related morbidity and mortality, particularly cerebrovascular accidents, including stroke. Furthermore, current evidence and guidelines suggest that all major classes of antihypertensive agents are equally effective in controlling BP and preventing cardiovascular events in older patients. Diuretics are commonly used in elderly patients, but recent outcomes data have raised doubt about their long-term benefits. Renin-angiotensin system inhibitors have a better tolerability profile than diuretics. Extensive clinical evidence has demonstrated the excellent efficacy and tolerability profile of olmesartan medoxomil (OM)--an angiotensin II receptor blocker AT1 receptor antagonist--including in elderly patients. Randomized and observational studies have shown that OM provides effective BP control across the 24 h dosing interval in the elderly. It also has a good tolerability profile, a pharmacokinetic profile unaffected by age and a low propensity for drug interactions. An additional factor is that OM once-daily regimens are simple and straightforward, which can be an important factor in maintaining adherence to therapy in elderly patients. This article provides an overview of the main recent clinical evidence supporting the use of OM-based therapy in elderly patients with hypertension.

Inter-arm blood pressure difference in hospitalized elderly patients--is it consistent?

Inter-arm blood pressure difference (IAD) is recognized as a risk factor for cardiovascular mortality. Its reproducibility in the elderly is unknown. The authors determined the prevalence and reproducibility of IAD in hospitalized elderly patients. Blood pressure was measured simultaneously in both arms on two different days in elderly individuals hospitalized in a geriatric ward. The study included 364 elderly patients (mean age, 85±5 years). Eighty-four patients (23%) had systolic IAD >10 and 62 patients (17%) had diastolic IAD >10 mm Hg. A total of 319 patients had two blood pressure measurements. Systolic and diastolic IAD remained in the same category in 203 (64%) and 231 (72%) patients, respectively. Correlations of systolic and diastolic IAD between the two measurements were poor. Consistency was not affected by age, body mass index, comorbidities, or treatment. IAD is extremely common in hospitalized elderly patients, but, because of poor consistency, its clinical significance in this population is uncertain.

European Society of Hypertension position paper on ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring (ABPM) is being used increasingly in both clinical practice and hypertension research. Although there are many guidelines that emphasize the indications for ABPM, there is no comprehensive guideline dealing with all aspects of the technique. It was agreed at a consensus meeting on ABPM in Milan in 2011 that the 34 attendees should prepare a comprehensive position paper on the scientific evidence for ABPM.This position paper considers the historical background, the advantages and limitations of ABPM, the threshold levels for practice, and the cost-effectiveness of the technique. It examines the need for selecting an appropriate device, the accuracy of devices, the additional information and indices that ABPM devices may provide, and the software requirements.At a practical level, the paper details the requirements for using ABPM in clinical practice, editing considerations, the number of measurements required, and the circumstances, such as obesity and arrhythmias, when particular care needs to be taken when using ABPM.The clinical indications for ABPM, among which white-coat phenomena, masked hypertension, and nocturnal hypertension appear to be prominent, are outlined in detail along with special considerations that apply in certain clinical circumstances, such as childhood, the elderly and pregnancy, and in cardiovascular illness, examples being stroke and chronic renal disease, and the place of home measurement of blood pressure in relation to ABPM is appraised.The role of ABPM in research circumstances, such as pharmacological trials and in the prediction of outcome in epidemiological studies is examined and finally the implementation of ABPM in practice is considered in relation to the issue of reimbursement in different countries, the provision of the technique by primary care practices, hospital clinics and pharmacies, and the growing role of registries of ABPM in many countries.