Hypertension in elderly patients

Investigation of the effect of education based on the health belief model on the adoption of hypertension-controlling behaviors in the elderly

Purpose

Hypertension is one of the risk factors for cardiovascular diseases and stroke, and has a direct relationship with aging. The aim of this study was to investigate the effect of education based on the health belief model (HBM) on the adoption of hypertension-controlling behaviors in the elderly.

Methods

The present quasiexperimental study was conducted on 100 hypertensive elderly persons from Qom, Iran. The questionnaire was completed by the participants before, immediately after, and 3 months after the intervention.

Results

The results of repeated measure analysis of variance showed a significant difference in the scores of the constructs in the intervention and nonintervention groups before, immediately after, and 3 months after the intervention (P<0.001).

Conclusion

Education based on the HBM increases the performance and enhances the health beliefs regarding hypertension in the elderly population with hypertension. Therefore, it is recommended to consider the HBM to enhance self-care behaviors in the elderly.

Is Peri-Operative Isolated Systolic Hypertension (ISH) a Cardiac Risk Factor?

We are presenting a review of Isolated Systolic Hypertension (ISH) as a cardiovascular risk factor with emphasis on the perioperative period.

Isolated systolic hypertension is associated with aging and is the most frequent subtype (65%) among patients with uncontrolled hypertension. ISH is strongly associated with increased risks of cardiac and cerebrovascular events exceeding those in comparably aged individuals with diastolic hypertension. Patients with ISH show an increase in left ventricular (LV) mass and an increase in the prevalence of left ventricular hypertrophy (LVH). These LV changes increase cardiovascular events and frequently lead to diastolic dysfunction (DD). Treatment to reduce elevated systolic blood pressure has been shown to reduce the risk of cardiovascular events.

In the perioperative setting, essential hypertension has not been found to be a significant risk factor for cardiac complications. Most of the studies were based on the definition of essential hypertension and underpowered in sample size. The significance of perioperative ISH, however, is not well studied, partly due to its recognition only fairly recently as a cardiovascular risk factor in the non-surgical setting, and partly due to the evolving definition of ISH.

Perioperative cardiac complications remain a significant problem to the healthcare system and to the patient. Although the incidence of perioperative cardiac complications is prominent in high-risk patients as defined by the Revised Cardiac Risk Index (RCRI), the bulk of the cardiac complications actually occur in low-risk group. Currently, little understanding exists on the occurrence of perioperative cardiac complications in low- risk patients. A factor such as ISH, with its known pathophysiological changes, is a potential perioperative risk factor.

We believe ISH is an under-recognized perioperative risk factor and deserves further studying. Our research group has recently been funded by the Heart Stroke Foundation (HSF) to examine ISH as a perioperative risk factor (PROMISE Study).

Prevention of cardiovascular events by treating hypertension in older adults: an evidence-based approach

Hypertension in older adults is not well controlled in clinical practice. Isolated systolic hypertension is often more difficult to manage. A systematic PubMed search was conducted to look for evidence showing benefits of lowering blood pressure (BP) in older hypertensive adults. Lowering BP in these individuals significantly reduces the risk of coronary artery disease, stroke, and cardiovascular and all-cause mortality. Based on trial evidence, a low-dose diuretic should be considered the most appropriate first-step treatment for preventing cardiovascular morbidity and mortality. Therapy with >1 medication is often necessary to reduce BP in these patients. There is unequivocal evidence that cardiovascular events can be prevented in older adults, even those older than 80 years, by treating hypertension.

Heart disease and aging

CAD is the most common cause of death in older persons and was present in 43% of 1,160 men and in 41% of 2,464 women, mean age 81 years. Hypertension was present in 60% of these older women and in 57% of these older men. The prevalence of valvular aortic stenosis, aortic regurgitation, mitral regurgitation, and MAC increases with age in older men and in older women. The prevalence and incidence of CHF increase with age. CHF is the most common cause of hospitalization in persons aged 65 years and older. The prevalence of normal LV ejection fraction associated with CHF increases with age and is higher in older women than in older men. The prevalence of chronic atrial fibrillation increases with age and was present in 16% of 1,160 older men and in 13% of 2,464 older women. Atrial fibrillation is an independent predictor of new coronary events and thromboembolic stroke in older persons. Older persons who have unexplained syncope should have 24-hour ambulatory electrocardiograms to determine whether pauses of longer than 3 seconds are present that require permanent pacemaker implantation.

Trait anger, anger expression, and ambulatory blood pressure: a meta-analytic review

A meta-analysis of 15 studies was conducted to investigate the relationship between trait anger and ambulatory blood pressure. Overall, the experience of anger was significantly and positively associated with systolic blood pressure (r+ = 0.049), but not reliably associated with diastolic blood pressure (r+ = 0.028). After removing an outlier, the expression of anger was found to have a reliable inverse relationship with diastolic blood pressure (r+ = -0.072). No reliable relationship between expression of anger and systolic blood pressure (r+ = -0.041) was found. These results continue to support the modest role of self-reported trait anger and anger expression in blood pressure levels. Several suggestions for future research are discussed, including increasing the focus on the complexity and synergism of these effects.

Congestive heart failure induced by the combination of atrial fibrillation and tricuspid regurgitation

Atrial fibrillation (AF) and tricuspid regurgitation (TR) may induce congestive heart failure (CHD). Using electrocardiography and echocardiography, we examined the clinical characteristics and haemodynamic findings in 100 patients with AF + TR + CHF, AF + TR, AF or TR. The fractional shortening in all groups with AF was significantly decreased compared with the TR group. The ejection fraction in patients with AF + TR + CHF was significantly lower than in the TR group. Twenty-four of the 72 patients with AF and TR (with or without CHF) were treated, and 13 were monitored for heart rate and severity of TR. Eight months after start of treatment the heart rate and typical symptoms and signs of heart failure had improved significantly in nine patients, but the severity of TR did not change. TR worsened in the remaining four patients but they did not develop CHF. Our results suggest that increased heart rate due to the combination of AF and TR could be responsible for CHF.

Treatment of hypertension with an angiotensin II-receptor antagonist compared with an angiotensin-converting enzyme inhibitor: a review of clinical studies of telmisartan and enalapril

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II (ATII)-receptor antagonists suppress the effects of ATII and are effective antihypertensive agents. However, the use of ACE inhibitors is sometimes associated with intolerable side effects (eg, cough, angioedema), and patients may develop a compensatory rise in ATII levels. ATII-receptor antagonists have tolerability profiles similar to that of placebo and inhibit the effects of ATII more completely by blocking the AT1 receptor.

OBJECTIVE

This review summarizes clinical studies comparing the efficacy and tolerability of the ATII-receptor antagonist telmisartan with the ACE inhibitor enalapril in patients with hypertension.

METHODS

Randomized, controlled clinical trials comparing telmisartan with enalapril in patients with primary hypertension were identified through a PubMed search of the English-language literature from 1998 through 2001 and from bibliographic data provided by the manufacturer of telmisartan.

RESULTS

In 2 randomized, double-blind, placebo-controlled trials (total number of patients, 647), telmisartan 40 or 80 mg/d was at least as effective as enalapril 20 mg/d for lowering blood pressure (BP) in patients with mild to moderate hypertension. An open-label, titration-to-response study involving 86 patients with severe hypertension found that telmisartan 80 to 160 mg/d was as efficacious as enalapril 20 to 40 mg/d. The antihypertensive effects of telmisartan 20 to 80 mg/d and enalapril 5 to 20 mg/d were comparable in 278 elderly patients (age > or = 65 years) with mild to moderate hypertension enrolled in a 26-week, double-blind, dose-titration study. A double-blind, titration-to-response study in 71 patients with moderate renal impairment and mild to moderate hypertension found equivalent reductions in BP with telmisartan 40 to 80 mg/d and enalapril 10 to 20 mg/d without any clinically relevant decline in renal function. Telmisartan tended to be better tolerated than enalapril in this study, with fewer patients experiencing treatment-related adverse events (8.9% vs 26.9%, respectively).

CONCLUSIONS

Based on the literature included in this review, telmisartan and enalapril produced comparable reductions in BP in a broad range of patients with hypertension. Telmisartan appeared to have a better tolerability profile.

The cardioprotective role of beta-blockers in patients with diabetes mellitus

This paper reviews the role of beta-blockers in the prevention of cardiovascular morbidity and mortality in patients with diabetes mellitus. There is good evidence from randomized controlled trials that beta-blockers, in particular the lipophilic agents, substantially reduce cardiovascular mortality and morbidity. However, hitherto beta-blockers have been underused in diabetic patients, perhaps because of perceived risks of beta-blocker therapy. Reappraisal of the evidence suggests that the traditional reluctance to use beta-blockers in this group is based on fears of adverse effects that are largely unfounded.

Periodontal management of patients with cardiovascular diseases

Periodontists are often called upon to provide periodontal therapy for patients with a variety of cardiovascular diseases. Safe and effective periodontal treatment requires a general understanding of the underlying cardiovascular diseases, their medical management, and necessary modifications to dental/periodontal therapy that may be required. In this informational paper more common cardiovascular disorders will be discussed and dental management considerations briefly described. This paper is intended for the use of periodontists and members of the dental profession.

Coronary heart disease risk factors in the elderly

Hypertension, dyslipidemia, impaired glucose tolerance, and obesity remain the major modifiable risk factors for most of the coronary disease afflicting the elderly. The relative risk associated with these established risk factors diminishes with advancing age, but this is offset by a greater absolute and attributable risk. Diabetes is increasing alarmingly in prevalence and operates more powerfully in women, eliminating their coronary disease resistance (relative to men). Interest in this entity now focuses on the insulin resistance syndrome promoted by abdominal obesity that has become so common in the elderly. The isolated systolic hypertension and large pulse pressure that predominate in the elderly is now recognized as a coronary disease hazard. Dyslipidemia, characterized by a high total to high-density lipoprotein cholesterol ratio, is the most predictive lipid profile for coronary disease in the elderly. High triglycerides, accompanied by low high-density lipoprotein cholesterol usually signifies insulin resistance and more atherogenic, small, dense low-density lipoprotein. Left ventricular hypertrophy is an ominous harbinger of coronary disease. Fibrinogen and the leukocyte count are correlated coronary disease risk factors that may indicate unstable lesions. Novel risk factors, such as hemostatic factors, homocysteine, lipoprotein(a), C-reactive protein, and hyperinsulinemia, are worthy of attention, but the efficacy of correcting them in the elderly has not yet been demonstrated. Nor has the efficacy of hormone replacement therapy in women. All the coronary risk factors tend to cluster, and the hazard posed by each is greatly influenced by the burden of coexisting risk factors. High-risk elderly candidates for coronary disease can be efficiently targeted for treatment by global risk assessment, using only the major established risk factors. The distinction between primary and secondary prevention in the elderly is less clear than in the middle-aged because they often have advanced presymptomatic vascular pathology that imposes a coronary event rate comparable to that of the middle-aged who have already sustained a clinical event. Declines in coronary mortality rates in the United States have included the elderly, justifying optimism about the efficacy of preventive measures. Most of the elderly have sufficient remaining life expectancy to warrant vigorous preventive management. Trials of risk factor modification in the elderly indicate that decades of exposure to modifiable risk factors can be countered by measures implemented late in life.

The Relationship Between Blood Pressure and Mortality in the Oldest Old

OBJECTIVES

To explore the relationship between systolic and diastolic blood pressure and risk of 6-year, all-cause mortality in men and women age 65 to 84 versus those 85 and older.

DESIGN

A population-based longitudinal study.

SETTING

This study was conducted at four different sites: East Boston, Massachusetts; New Haven, Connecticut; two rural counties in Iowa; and Piedmont, North Carolina.

PARTICIPANTS

12,802 community-dwelling persons age 65 and older.

MEASUREMENTS

Baseline measurements collected include demographics, self-reported chronic medical conditions, blood pressure measurements, medications, health habits, and hospitalizations.

RESULTS

Unadjusted actuarial survival analyses show that men age 65 to 84 years with systolic blood pressure < 130 mmHg have significantly lower mortality compared with those with systolic blood pressure > or = 180 mmHg (P < .0001). In contrast, men 85 and older with systolic blood pressure > or = 180 mmHg have significantly lower mortality compared with those with systolic blood pressure < 130 mmHg (P < .0001). In Cox proportional hazards analyses controlling for other predictors of survival, the hazard of death associated with each 10-mmHg increase in systolic blood pressure is positively associated among men age 65 to 84 years and negatively associated among men age 85 and older (Hazard ratio and 95% confidence interval (CI): 1.04 (1.01, 1.07) for younger men vs 0.92 (0.86, 0.99) for older men). Among women age 65 to 84, the hazard of death significantly increased with increase in systolic blood pressure (P < .0001), while there was no relationship between level of systolic blood pressure and survival in women 85 and older. Both men 65 to 84 years old and those 85 and older showed a negative relationship between diastolic blood pressure and all-cause mortality (Hazard ratio 0.93, 95% CI (0.88-0.97) for men age 65-84 years, and Hazard ratio 0.90, 95% CI 0.80-1.02 for men 85 and older).

CONCLUSION

In men age 85 and older, higher systolic blood pressure is associated with better survival.

Similar effects of isolated systolic and combined hypertension on left ventricular geometry and function: the LIFE Study

Echocardiograms of 143 patients with isolated systolic hypertension were compared to 808 patients with combined (systolic and diastolic) hypertension. All patients met electrocardiographic criteria for left ventricular hypertrophy and were evaluated off medication. Patients with isolated systolic hypertension were older, shorter, weighed less, and were mostly women, but body mass index (BMI) was similar in both groups. Systolic blood pressure (SBP) was 172 mm Hg in isolated systolic hypertension, 174 mm Hg in combined (P = not significant). Diastolic blood pressure was 83 and 101 mm Hg, respectively (P < .001). Despite having mean arterial pressure 12 mm Hg lower than patients with combined hypertension, the group with isolated systolic hypertension had equally severe abnormalities of left ventricular mass, left ventricular geometric patterns, and measures of systolic and diastolic function. Peripheral resistance was lower and pulse pressure/stroke volume ratio (arterial stiffness index) was higher and the isovolumic relaxation time shorter in isolated systolic hypertension. Multiple regression analyses identified age, height, BMI, stress-corrected mid wall shortening, stroke volume, male gender, and systolic or mean blood pressure (but not isolated systolic hypertension) as independent correlates of left ventricular mass. Relative wall thickness was independently associated with isolated systolic hypertension (P = .001) in addition to mean pressure and other covariates. The present results add support to the concept that systolic blood pressure (SBP) is a stronger determinant than diastolic pressure of cardiac target organ damage in hypertension.

Midlife vascular risk factors and Alzheimer's disease in later life: longitudinal, population based study

OBJECTIVE

To examine the relation of midlife raised blood pressure and serum cholesterol concentrations to Alzheimer's disease in later life.

DESIGN

Prospective, population based study.

SETTING

Populations of Kuopio and Joensuu, eastern Finland.

PARTICIPANTS

Participants were derived from random, population based samples previously studied in a survey carried out in 1972, 1977, 1982, or 1987. After an average of 21 years' follow up, a total of 1449 (73%) participants aged 65-79 took part in the re-examination in 1998.

MAIN OUTCOME MEASURES

Midlife blood pressure and cholesterol concentrations and development of Alzheimer's disease in later life.

RESULTS

People with raised systolic blood pressure (>/=160 mm Hg) or high serum cholesterol concentration (>/=6.5 mmol/l) in midlife had a significantly higher risk of Alzheimer's disease in later life, even after adjustment for age, body mass index, education, vascular events, smoking status, and alcohol consumption, than those with normal systolic blood pressure (odds ratio 2.3, 95% confidence interval 1.0 to 5.5) or serum cholesterol (odds ratio 2.1, 1.0 to 4.4). Participants with both of these risk factors in midlife had a significantly higher risk of developing Alzheimer's disease than those with either of the risk factors alone (odds ratio 3.5, 1.6 to 7.9). Diastolic blood pressure in midlife had no significant effect on the risk of Alzheimer's disease.

CONCLUSION

Raised systolic blood pressure and high serum cholesterol concentration, and in particular the combination of these risks, in midlife increase the risk of Alzheimer's disease in later life.

Reversal of pathophysiologic changes with long-term lisinopril treatment in isolated systolic hypertension

The purpose of this study was to evaluate in a prospective, double-blind, placebo-controlled study the effect of long-term (2-year) lisinopril treatment on cardiovascular end-organ damage in patients with previously untreated isolated systolic hypertension (ISH). All patients with ISH were derived from a population screening program. End-organ damage measurements, done initially and after 6 and 24 months of treatment, included measurements of aortic distensibility and echocardiographic left ventricular mass index (LVMI) and diastolic function. Blood pressure was measured by office and ambulatory measurements. Of the 97 subjects with ISH selected from the screening, 62 (30 lisinopril) completed the study according to protocol. Office blood pressure decreased in both groups, but ambulatory results significantly decreased with lisinopril-treatment only. Aortic distensibility increased significantly with lisinopril, as opposed to a decrease in placebo-treated subjects. The main effect of increased distensibility occurred between 6 and 24 months, whereas ambulatory blood pressure changed mainly in the first 6 months of treatment. LVMI decreased in both treatment groups, with a significantly higher reduction in lisinopril-treated subjects. Left ventricular diastolic function showed no significant changes in either group. The vascular pathophysiologic alterations of ISH-a decreased aortic distensibility-can be improved with long-term lisinopril treatment, whereas values deteriorate further in placebo-treated subjects. These results, in one of the first studies including subjects with previously untreated ISH only, indicate that lisinopril treatment might favorably influence the cardiovascular risk of ISH.

[Clinical trials in the elderly: ethical and methodologic considerations]

INTRODUCTION

Based on a literature review, main ethical and methodological issues raised by the implementation of randomized clinical trials involving elderly patients are discussed.

CURRENT KNOWLEDGE AND KEY POINTS

Despite their rapidly growing number and the subsequent significant increase in consumption of health care services and its cost, elderly patients have seldom been involved in clinical trials.

FUTURE PROSPECTS AND PROJECTS

However, the need for accurate scientific information on which relevant therapeutic decisions regarding this vulnerable population may be based has introduced marked changes in attitudes towards either clinical trials conducted in the elderly or requirements of various licensing authorities in regard to assessment of new drugs in elderly patients. Although difficulties pertaining to controlled clinical trials involving elderly patients may hamper both planning and carrying out of studies, completion of such trials may be achieved.

Effect of enalapril and nifedipine on orthostatic hypotension in older hypertensive patients

OBJECTIVE

To compare the effect of enalapril with long-acting nifedipine on orthostatic hypotension in older patients.

DESIGN

A prospective, double blinded, cross-over study.

SETTING

The outpatient clinic of a university hospital.

PARTICIPANTS

Thirty-nine patients aged 65 years or older with systolic blood pressure (SBP) of 140-190 mm Hg and diastolic blood pressure (DBP) of 90-110 mm Hg.

INTERVENTION

Enalapril 5-20 mg od or nifedipine 30-90 mg od for 8 weeks, followed by 4 weeks washout and cross-over for a second 8-week period.

MEASUREMENTS

Supine and standing 0-, 1-, and 5-minutes blood pressure was recorded before and at the end of each treatment period.

RESULTS

At baseline, SBP was 158.8 +/- 8.7 mm Hg, and DBP was 97.1 +/- 5.9 mm Hg. There was a decline in SBP of 6.1 +/- 2.7 mm Hg and 8.4 +/- 4.1 mm Hg after 1 and 5 minutes of standing, respectively. Both agents caused a significant decline in supine blood pressure. Enalapril: supine SBP 158.8 +/- 8.7 to 143 +/- 7.3 mm Hg; supine DBP 97.1 +/- 5.9 to 85.1 +/- 5.1 mm Hg (P = .0001). The drop in SBP after standing for 5 minutes was only 2.4 +/- 1.6 mm Hg with no change in diastolic values. A > or = 10 mm Hg drop in SBP was observed in only three patients, and no patient experienced a decline of 20 mm Hg or more. Nifedipine: supine SBP: 160.3 +/- 9 to 145.3 +/- 8.1 mm Hg; supine DBP: 96.3 +/- 5.7 to 86.3 +/- 5.8 (P = .0001). Nifedipine induced an orthostatic decline in SBP values; there was an 8.7 +/- 4.8 mm Hg difference between supine and 5 minutes standing values (P = .0005) without change in diastolic values. An orthostatic decline in SBP of > or = 10 mm Hg occurred in 13 patients, and there was a drop of > or = 20 mm Hg in six patients. The cross-over of enalapril and nifedipine reproduced the hypotensive effect and reversed the postural effect. (P = .0002 nifedipine vs enalapril)

CONCLUSIONS

Enalapril and nifedipine were equipotent in reducing supine blood pressure levels. Enalapril also reduced the number of orthostatic episodes significantly, whereas nifedipine aggravated this phenomenon.

Prevalence, treatment, and control of hypertension by sociodemographic factors among the Dutch elderly

The study objective was to assess the prevalence, level of treatment, and control of hypertension in a general elderly population according to age and sociodemographic factors. We conducted a cross-sectional analysis of 7983 participants of the Rotterdam Study who were >/=55 years old and living in a district of Rotterdam. The prevalence of hypertension was based on blood pressure levels (>/=160/95 mm Hg) and the use of blood pressure-lowering medication for the indication of hypertension, type of treatment, and control of hypertension. Systolic blood pressure rises with age, whereas diastolic blood pressure declines. The prevalence of hypertension increases with age and was higher among women (39%) than among men (31%). About 80% of the hypertensives were aware of having hypertension, and 82% of the 80% were treated. For 70% of them, treatment was adequate with reference to conservative criteria. Hypertension was more prevalent among persons not living in a home for the elderly, for more-educated men, and for less-educated women. Persons without a partner and men living in a home for the elderly had a higher risk of being unaware of or of not being treated for existing hypertension. Treatment was more often successful among those living in a home for the elderly. The prevalence of hypertension was higher among older women and increased with age in both genders. A large proportion of hypertensive elderly persons were aware and were successfully treated for hypertension. The degree of awareness and control appeared to be affected by sociodemographic factors. More importantly, the majority of hypertensives did not have their hypertension well controlled. This group requires more attention by medical practitioners to reduce the burden of cardiovascular diseases in elderly persons.

Midlife blood pressure and dementia: the Honolulu-Asia aging study

We studied the association of mid-life blood pressure to late age dementia, specifically Alzheimer's disease and vascular dementia. Data are from the cohort of 3703 Japanese-American men who were followed in the Honolulu Heart Program (HHP;1965-1971), and subsequently re-examined in 1991 for dementia. We assessed the risk (odds ratio (95% CI)) for dementia associated with categories of systolic (SBP) and diastolic blood pressure (DBP), stratified by never/ever treatment with anti-hypertensive medications, and adjusting for age, education, apolipoprotein epsilon allele, smoking and alcohol intake. Among those never treated (57% sample), the risk for dementia was OR 95% CI 3.8 (1.6-8.7) for DBP of 90-94 mm Hg, and 4. 3 (1.7-10.8) for DBP of 95 mmHg and over compared to those with DBP of 80 to 89 mm Hg. Compared to those with SBP of 110 to 139 mm Hg, the risk for dementia was 4.8 (2.0-11.0) in those with SBP 160 mm Hg and higher. Blood pressure was not associated with the risk for dementia in treated men. These results were consistent for Alzheimer's disease and vascular dementia. This study suggests elevated levels of blood pressure in middle age can increase the risk for late age dementia in men never treated with anti-hypertensive medication.

The older man's heart and heart disease

CAD is the most common cause of death in older men and was present in 44% of 664 men, mean age 80 years. Independent risk factors for new coronary events in older men include increasing age, prior CAD, cigarette smoking, hypertension, diabetes mellitus, high serum total cholesterol, and low serum HDL cholesterol. In older men with hypertension, echocardiographic LVH is a powerful independent predictor of new coronary events, atherothrombotic brain infarction, and CHF. In 554 older men with a mean age of 80 years, two-dimensional and Doppler echocardiography demonstrated that the prevalence of aortic stenosis was 14%, 1 + aortic regurgitation or greater was 31%, rheumatic mitral stenosis was 0.4, 1 mitral regurgitation or greater was 32%, mitral annular calcium was 35%, hypertrophic cardiomyopathy was 3%, idiopathic dilated cardiomyopathy was 1%, left atrial enlargement was 29%, LVH was 41%, and abnormal LVEF was 29%. The prevalence and incidence of CHF increase with age in older persons. The prevalence of a normal LVEF associated with CHF as a result of prior myocardial infarction or hypertension was 22% in men aged 60 to 69 years, 33% in men aged 70 to 79 years, 41% in men aged 80 to 89 years, and 47% in men aged 90 years or older.

Cardiovascular consequences of the aging process

There are many challenges in the study of the normal age-associated changes that occur in the cardiovascular system, the most important of which is the fact that cardiovascular disease is so common in the elderly. In animal models and healthy humans, three age-associated changes with increasing age include (1) impaired left ventricular diastolic filling, (2) reduction in the adrenergic responsiveness to catecholamines, and (3) an increase in arterial stiffness. These changes likely are influenced by the increasingly sedentary lifestyle in the elderly. These age-associated changes also influence the manifestations of cardiovascular disease in the elderly and the response to therapy.

Prevalence of heart disease in older women in a nursing home

The prevalence of coronary artery disease (CAD) and the incidence of new coronary events are similar in older men and women. Independent risk factors for new coronary events in older women include age, prior CAD, cigarette smoking, hypertension, diabetes mellitus, high serum total cholesterol and triglycerides, and low serum high-density lipoprotein cholesterol. Older women have a higher prevalence of hypertension than older men. In older women with hypertension, echocardiographic left ventricular hypertrophy is a powerful independent predictor of new coronary events, atherothrombotic brain infarction, and congestive heart failure (CHF). Older women have a higher prevalence of rheumatic mitral stenosis and of mitral annular calcium than older men. Older women and men have a similar prevalence of valvular aortic stenosis, aortic regurgitation, mitral regurgitation, hypertrophic cardiomyopathy, and idiopathic dilated cardiomyopathy. The prevalence and incidence of CHF increase with age. The prevalence of normal left ventricular ejection fraction associated with CHF increases with age and is higher in older women than in older men. The prevalence of chronic atrial fibrillation increases with age and is similar in older men and women. Atrial fibrillation is an independent predictor of new coronary events and thromboembolic stroke in older women. Older women with unexplained syncope should have 24-hour ambulatory electrocardiograms to determine whether pauses > 3 seconds are present, requiring permanent pacemaker implantation.

Risk factors for new coronary events in older African-American men and women

Independent risk factors for new coronary events in older African-American men were (1) age (risk ratio = 1.037), (2) cigarette smoking (risk ratio = 2.231), (3) hypertension (risk ratio = 2.531), (4) serum total cholesterol (risk ratio = 1.012), (5) serum high-density lipoprotein (HDL) cholesterol (inverse association) (risk ratio = 0.948), and (6) prior coronary artery disease (CAD) (risk ratio = 2.288). Independent risk factors for new coronary events in older African-American women were (1) cigarette smoking (risk ratio = 2.202), (2) hypertension (risk ratio = 2.344), (3) diabetes mellitus (risk ratio = 1.632), (4) serum total cholesterol (risk ratio = 1.008), (5) serum HDL cholesterol (inverse association) (risk ratio = 0.936), (6) age (risk ratio = 1.026), and (7) prior CAD (risk ratio = 2.368).

Undertreatment of hypertension in older Mexican Americans

OBJECTIVE

To identify the prevalence of hypertension and factors associated with nontreatment and poor control of hypertension in Mexican Americans aged 65 years and older.

DESIGN

A population-based survey of older Mexican Americans conducted in 1993-1994.

SETTING

Subjects residing in five Southwestern states: Texas, New Mexico, Colorado, Arizona, and California.

PARTICIPANTS

An area probability sample of 3050 noninstitutionalized Mexican American men and women aged 65 and older took part in a 90-minute in-home interview, which included review of all medications taken and two sitting blood pressure measurements.

OUTCOME MEASURES

Measured were previous diagnoses of hypertension, current medication for hypertension, and current blood pressure

RESULTS

Sixty-one percent of older Mexican-Americans were hypertensive, and 51% of those with hypertension were taking antihypertensive medications. Only 25% of hypertensive subjects (18% of males and 30% of females) were in good blood pressure control (i.e., systolic blood pressure < 140 mm Hg and diastolic blood pressure < 90 mm Hg). In multivariate analyses, factors associated with increased likelihood of treatment included female gender (OR = 1.9), history of heart disease (OR = 2.4), possessing a regular source of health care (OR = 2.7), and having seen a physician two or more times in the previous year (OR = 3.8). These were also independent predictors of good blood pressure control.

CONCLUSION

Nontreatment of hypertension is still a major public health concern in older Mexican Americans. We estimate that adequate blood pressure control in this population would prevent approximately 30,000 adverse cardiovascular events over 10 years, affecting approximately 6% of the entire Mexican American older population.

Effect of quinapril and triamterene/hydrochlorothiazide on cardiac and vascular end-organ damage in isolated systolic hypertension

We compared, in a prospective double-blind randomized study, the effect of the angiotensin-converting enzyme inhibitor quinapril (QUI) with that of triamterene/hydrochlorothiazide (THCT) treatment on cardiovascular end-organ damage in subjects with untreated isolated systolic hypertension (ISH). End-organ damage measurements, performed initially and after 6 and 26 weeks of treatment, included echocardiographic determination of left ventricular mass index (LVMI) and of diastolic function and measurement of aortic distensibility and peripheral vascular resistance. Blood pressure was significantly reduced in the 44 subjects (21 QUI, 23 THCT) completing the study. Both LVMI and aortic distensibility had changed at 6 weeks, with comparable improvements in both groups. LV diastolic function showed overall no significant changes, although patterns of early filling did differ between the two drug groups. Peripheral vascular resistance appeared to increase between 6 and 26 weeks in THCT subjects only, along with a decreased aortic distensibility. Blood pressure and LV mass were rapidly and markedly reduced in both treatment groups of ISH subjects, paralleled by an improvement of aortic distensibility. In interpreting these results, the pathophysiologic alterations in ISH need to be taken into account, because these differ strongly from those in diastolic hypertension. Results of LV diastolic function and peripheral vascular resistance were less clear but appear to show less favorable changes in the THCT subjects treatment group.

Trends in hypertension prevalence, treatment, and control: in a well-defined older population

To assess medical attention focused on hypertension (HBP) in the elderly, this study examines trends in HBP prevalence, treatment, and control status in a defined population of persons > or = 65 years of age enrolled in a large HMO. Random samples of approximately 400 persons were drawn for the years 1967, 1974, 1981, and 1988. First recorded ambulatory pressures, available on over 90% of subjects in each period, were obtained from medical records. Prevalence of HBP (SBP > or = 160 and/or DBP > or = 95, and/or taking anti-HBP drugs) ranged between 44% to 53%. Proportion with HBP on treatment increased from 25% in 1967 to 60% in 1988 (P<.001); proportion on treatment and controlled (SBP < 160, DBP < 95) increased from 8% to 34% (P<.001). Mean population SBP declined from 155.2 in 1967 to 144.0 in 1988 (P<.001); mean DBP declined from 85.2 to 81.2 (P<.001). Proportion with isolated systolic hypertension (ISH) (SBP > or = 160, DBP < 90) remained unchanged at 12% to 14%. Use of diuretics and adrenergic antagonist agents declined while use of beta blockers and newer classes of anti-HBP drugs increased significantly among treated hypertensives in the 1980s. These findings parallel HBP trends in younger adults from National Health Survey data though we find evidence of a substantial gap in addressing the problem in the elderly, who constitute the population at greatest risk of cardiovascular complications of HBP.

Blood pressure and cardiovascular morbidity and mortality rates in the elderly

The influence of blood pressure on the development of cardiovascular disease and mortality rate beyond 75 years of age has been uncertain. A reported inverse relation to mortality rate noted in the very old could reflect poor cardiovascular health. This report examines the impact of blood pressure on cardiovascular morbidity and mortality rates and all-cause mortality rate in those aged 75 to 94 years. For this analysis the data were the Framingham study subjects found free of cardiovascular disease and a second sample of those with cardiovascular disease present on the biennial examinations. Investigation of the relation of systolic and diastolic blood pressures to all causes and cardiovascular morbidity and mortality rates within each 2-year interval for those aged 75 to 94 years was carried out. Over the period of 38 years of follow-up there were increasing cardiovascular morbidity and mortality rates with increasing blood pressure levels for both men and women in the sample free of cardiovascular disease. In those with cardiovascular disease at the biennial examination there was a distinct U-shaped curve of cardiovascular mortality rate in relation to systolic blood pressure in men with a substantial increase in mortality rate below systolic pressures of 120 mm Hg for both men and women. Excess mortality rate reported in elderly persons with low blood pressure appears to be a result of poor cardiovascular health and not from the low pressure itself. The excess mortality rate reported for low blood pressure levels in persons older than 75 years derives from the inclusion of the substantial proportion of this age group who have cardiovascular disease.

Factors influencing unawareness of hypertension among older Mexican Americans

BACKGROUND

The objective of the study was to identify factors associated with unawareness of hypertension among Mexican Americans age 65 years and older.

METHODS

This was a population-based survey of 3,050 older Mexican Americans conducted in five Southwestern states in 1993-1994. An in-home interview included sociodemographics, review of medications, and blood pressure measurements.

RESULTS

Sixty percent of all subjects were hypertensive, and 37% of these were unaware of their diagnosis. Unaware hypertensive had significantly higher mean blood pressures than did aware hypertensives (145.7/ 86.2 mm Hg vs 142.4/83.1 mm Hg). While 77% of aware hypertensives were treated, only 10% of unaware hypertensives were treated. In multivariate analyses, factors associated with unawareness included male gender (OR = 1.8), being married (OR = 1.6), having Medicaid (OR = 1.6), having made fewer than two visits to a doctor in the past year (OR = 2.8), having a history of heart disease (OR = 0.57) or stroke (OR = 0.37), and having poor self-reported health (OR = 0.43).

CONCLUSION

Despite 3 decades of hypertension detection and education programs, unawareness of hypertension remains high among older Mexican Americans. There is a continued need for community-based education programs for hypertensives who are unaware of their diagnosis, and also there is need for programs to increase access to primary care physicians.

Baseline correlates with quality of life among men and women with medication-controlled hypertension. The trial of nonpharmacologic interventions in the elderly (TONE)

OBJECTIVES

To examine Quality of Life (QOL) and its correlates among older adults with medication-controlled hypertension.

DESIGN

Baseline data from the TONE clinical trial.

MEASUREMENTS

Demographic variables (age, race, income), hypertension treatment (medication class, years treated), health status (obesity, physical symptoms), and QOL status (MOS-Short-Form 36, Jenkins Sleep Disturbance, and CES-D Depression).

PARTICIPANTS

A total of 975 men and women, aged 60 to 81 years and free of major diseases and disability, with a screening blood pressure (BP) of < or = 145/85 mm Hg, treated medically for hypertension with antihypertensive medication.

RESULTS

On average, TONE participants reported a QOL level on the SF-36 that was similar to or better than that reported by older adults in the general population. However, there was a strikingly high prevalence of physical complaints or symptoms: 90.3% of men and 93.3% of women experienced one or more physical symptoms or complaints, and nearly 50% reported that such symptoms had disrupted their daily functioning. Among variables-considered, only the physical symptoms index score, number of severe symptoms, and obesity status were correlated consistently with QOL among TONE men and women. Lower QOL scores were associated with higher symptom scores and with obesity. Neither medication class nor age were appreciably associated with QOL status.

CONCLUSIONS

Physical symptoms, rather than medication class and age, were the strongest correlates of QOL in TONE. This underscores the importance of identifying the etiology of symptoms as a means to improve the QOL of order hypertensive persons rather than substituting medication. The association of poorer physical well-being with obesity suggests that weight reduction to manage BP may also improve QOL for some individuals.

Inappropriate prescribing and health outcomes in elderly veteran outpatients

OBJECTIVE

To determine the relationship of inappropriate prescribing in the elderly to health outcomes.

SETTING

General Medical Clinic of the Durham Veterans Affairs Medical Center.

PATIENTS

A total of 208 veterans more than 65 years old who were each taking five or more drugs and participated in a pharmacist intervention trial.

MEASUREMENTS

Prescribing appropriateness was assessed by a clinical pharmacist using the medication appropriateness index (MAI). A summed MAI score was calculated, with higher scores indicating less appropriate prescribing. The health outcomes were hospitalization, unscheduled ambulatory or emergency care visits, and blood pressure control.

RESULTS

Bivariate analyses revealed that mean MAI scores at baseline were higher for those with hospital admissions (18.9 vs. 16.9, p = 0.07) and unscheduled ambulatory or emergency care visits (18.8 vs. 16.3, p = 0.05) over the subsequent 12 months than for those without admissions and emergency care visits. MAI scores for antihypertensive medications were higher for patients with inadequate blood pressure control (> 160/90 mm Hg) than for those whose blood pressure was controlled (4.7 vs. 3.1, p = 0.02).

CONCLUSIONS

Inappropriate prescribing appeared to be associated with adverse health outcomes. This findings needs to be confirmed in future studies that have larger samples and control for potential confounders.

Preventive medicine and screening in older adults

PURPOSE

To review important current issues, studies, recommendations and controversies relating to preventive medicine and screening in older people. STUDY SELECTION/DATA ABSTRACTION: MEDLINE searches for literature on prevention and screening with regard to older adults as well as each individual condition reviewed; bibliographical reviews of textbooks, journal articles, government and advocacy organization task force reports, and recommendations. Important information synthesized and discussed qualitatively.

DATA SYNTHESIS

Data and recommendations are presented for most common preventive services, including primary prevention and screening for cardiovascular diseases and risk factors, common malignancies, endocrine and infectious diseases, osteoporosis, sensory deficits, and dementia.

CONCLUSIONS

The goal of preventive medicine in older people should be not only reduction of premature morbidity and mortality but preservation of function and quality of life. Attempts to prevent diseases of old age should start in youth; the older the patient, the less likely the possibility or value of primary and secondary prevention, and the greater the stress must be on tertiary prevention. Age 85 is proposed as a general cutoff range beyond which conventional screening tests are unlikely to be of continued benefit; however, care must always be individualized. Emphasis should be on offering the best proven and most effective interventions to the individuals at highest risk of important problems such as cardiovascular diseases, malignancies, infectious and endocrine diseases, and other important threats to function in older people. Breast cancer screening, smoking cessation, hypertension treatment, and vaccination for infectious diseases are thus far among the most firmly proven and well accepted specific preventive measures, with physical exercise also being particularly promising. Although more research is needed, a current working approach is necessary and possible. A summary table of recommendations and information tools such as reminders or flowsheets may be valuable in helping the physician carry out prevention and screening programs.

High prevalence of concentric remodeling in elderly individuals with isolated systolic hypertension from a population survey

Echocardiographic determination of left ventricular mass index (LVMI) is shown to be valuable in the assessment of cardiovascular risk. Determination of left ventricular geometry, including concentric remodeling, provides additional prognostic information. In isolated systolic hypertension (ISH), the few echocardiographic studies available show an increased LVMI, but criteria and patient populations differ. No comparison with diastolic hypertension (DH) has been made, nor has left ventricular geometry (with concentric remodeling) been evaluated. We compared both LVMI and left ventricular geometry of newly diagnosed ISH subjects with normotensive and DH subjects, all previously untreated and from the same population. The echocardiographic LVMI of 97 previously untreated ISH subjects (4 x systolic pressure > or = 160 mm Hg, diastolic pressure < 95 mm Hg) was clearly elevated compared with values in age- and sex-matched normotensive subjects (98 and 71 g/m2, respectively; P < .001). The geometric pattern was abnormal in most ISH subjects, with a high prevalence (43%) of concentric remodeling. Both LVMI and left ventricular geometry of ISH subjects did not differ significantly from values in DH subjects (LVMI, 92 g/m2; concentric remodeling, 56%). Sex differences in LV geometry in ISH were present only with the Framingham criteria, not with the Koren criteria. This study shows a high prevalence of concentric remodeling in elderly individuals with previously untreated ISH. The increase of LVMI and abnormality in left ventricular geometry are comparable with those in DH subjects, further defining the place of ISH as a cardiovascular risk factor in the elderly. Whether there are sex differences in cardiac adaptation in ISH and whether the geometric classification can be used to adjust treatment remain to be investigated.

Hypertension in Elderly Persons

OBJECTIVE

To provide an overview of the prevalence of hypertension in the elderly population and discuss the advantages and disadvantages of various classes of antihypertensive drugs.

METHODS

We review the published clinical trials on treatment of elderly patients with hypertension and describe adverse reactions that are frequently associated with antihypertensive therapy.

RESULTS

On the basis of the standard for control of hypertension established by the National Health and Nutrition Examination Survey for 1988-1991 (140/90 mm Hg), almost 75% of all African-Americans and 50% of all whites 60 to 74 years of age have hypertension. If modifications in lifestyle (such as weight reduction and increase in exercise) do not normalize blood pressure levels, drug therapy is warranted. Meta-analyses of major trials of treatment of hypertension have revealed significant reductions in cardiovascular-related mortality and stroke, and available data indicate that prudent use of antihypertensive agents is associated with an acceptable degree of toxicity. Low-dose thiazide diuretics and b-blockers remain the agents of choice.

CONCLUSION

Several trials have substantiated the effectiveness of treatment of hypertension in elderly subjects. Drug therapy should be initiated at low doses, and careful follow-up should monitor for adverse effects.

Risk factors for new coronary events in a large cohort of very elderly patients with and without coronary artery disease

Independent risk factors for new coronary events in older men include age, prior coronary artery disease, cigarette smoking, systemic hypertension, diabetes mellitus, serum total cholesterol, and serum high-density lipoprotein cholesterol (inverse association). Independent risk factors for new coronary events in older women include age, prior coronary artery disease, cigarette smoking, systemic hypertension, diabetes mellitus, serum total cholesterol, serum high-density lipoprotein cholesterol (inverse association), and serum triglycerides (weak association).

A randomised controlled trial of stress reduction for hypertension in older African Americans

We tested the short-term efficacy and feasibility of two stress education approaches toe the treatment of mild hypertension in older African Americans. This was a randomized, controlled, single-blind trial with 3 months of follow-up in primary care, inner-city health center. Of 213 African American men and women screened, 127 individuals (aged 55 to 85 years with initial diastolic pressure of 90 to 109 mm Hg, systolic pressure of < or = 189 mm Hg, and final baseline blood pressure of < or = 179/104 mm Hg) were selected. Of these, 16 did not complete follow-up blood pressure measurements. Mental and physical stress reduction approaches (Transcendental Meditation and progressive muscle relaxation) were compared with a lifestyle modification education control program and with each other. The primary outcome measures were changes in clinic diastolic and systolic pressures from baseline to final follow-up, measured by blinded observers. The secondary measures were linear blood pressure trends, changes in home blood pressure, and intervention compliance. Adjusted for significant baseline differences and compared with control, Transcendental Meditation reduced systolic pressure by 10.7 mm Hg (P < .0003) and diastolic pressure by 6.4 mm Hg (P <.00005). Progressive muscle relaxation lowered systolic pressure by 4.7 mm Hg (P = 0054) and diastolic pressure by 3.3 mm Hg (P <.02). The reductions in the Transcendental Meditation group were significantly greater than in the progressive muscle relaxation group for both systolic blood pressure (P = .02) and diastolic blood pressure (P = .03). Linear trend analysis confirmed these patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

The epidemiology of hypertension control in populations

Despite an aging population, prevalence rates for hypertension in the U.S. remain stable due to a decrease in rates in women but a corresponding increase in rates for men. Epidemiological factors which may contribute to these rates are discussed. The lack of a threshold for the association between blood pressure and disease events means that the majority of events occur in the larger number of people with mild disease. Because the efficacy and cost-effectiveness of medical therapy to lower mildly elevated blood pressure remains controversial, population-based strategies to effect behavior change are the most prudent course for this, the largest group at risk. Targeted, resource-intensive medical intervention for those at high risk combined with hygienic measures for the population with mildly elevated blood pressure from the basis for an effective public health strategy.

Trends in medication choices for hypertension in the elderly. The decline of the thiazides

We studied the evolution in choice of antihypertensive therapy in the elderly over a seven-year period and defined factors associated with such prescribing. To accomplish this, we performed a retrospective analysis of 8428 enrollees older than 65 years of age in the New Jersey Medicaid and Medicare programs newly begun on antihypertensive therapy between 1982 and 1988. Diuretics were the most common agents prescribed (51%), followed by calcium channel blockers (14%), beta-blockers (13%), central adrenergic antagonists (11%), and angiotensin-converting enzyme inhibitors (5%). However, the use of diuretics declined sharply during the latter part of the time interval studied. Using logistic regression modeling, we determined that the odds of a subject being started on a diuretic compared with any other antihypertensive drug decreased from 1.0 during the referent years 1982 to 1984 to 0.75 in 1985 to 1986 and to 0.41 in 1987 to 1988, after controlling for demographics, comorbidity, and hospital and physician visits (P < .001). The relative odds of diuretic use were significantly increased (P < .05) for the oldest subjects (odds ratio, 1.28 for age 85 and older versus ages 65 to 74 odds), women (odds ratio, 1.15), and blacks (odds ratio, 1.14). Despite the growing evidence during the study interval of the efficacy of diuretics in treating hypertension in the elderly, diuretic use diminished throughout this period in relation to other antihypertensive drugs. Subject characteristics (oldest subjects, women, and blacks) were important determinants of physicians' choice of antihypertensive therapy.

First-line therapy option with low-dose bisoprolol fumarate and low-dose hydrochlorothiazide in patients with stage I and stage II systemic hypertension

This 30-center, randomized, double-blind, placebo-controlled, parallel-group study was designed to (1) establish that 6.25 mg of hydrochlorothiazide (HCTZ) given once daily with 5 mg of bisoprolol fumarate can contribute to antihypertensive effectiveness in patients with stage I and stage II (mild to moderate) systemic hypertension; and (2) assess whether this formulation was more effective or possessed a safety advantage over standard monotherapy with bisoprolol or 25 mg of HCTZ. Results showed that HCTZ 6.25 mg contributed significantly to the antihypertensive effectiveness of bisoprolol 5 mg. Bisoprolol 5 mg/HCTZ 6.25 mg (B5/H6.25) produced significantly greater mean reductions from baseline in sitting systolic and diastolic blood pressure (-15.8 mm Hg/-12.6 mm Hg) than bisoprolol 5 mg alone (-10.0 mm Hg/-10.5 mm Hg) and HCTZ 25 mg alone (-10.2 mm Hg/-8.5 mm Hg). A 73% response rate was achieved with the low-dose formulation compared with 61% for the bisoprolol 5 mg (B5) group and 47% for the HCTZ 25 mg (H25) group. B5/H6.25 was found to be significantly more effective than B5 or H25 in all subgroups of patients, regardless of gender, race, age, or smoking history. Antihypertensive effects were maintained during the 24-hour dosing interval. The incremental effectiveness of B5/H6.25 was not accompanied by an increase in the frequency or severity of adverse experiences; the incidence of adverse experiences in the B5/H6.25 group was comparable to that in the placebo group. B5/H6.25 was shown to provide safety advantages over H25, as shown by less hypokalemia (< 1% with B5/H6.25 versus 6.5% with H25).(ABSTRACT TRUNCATED AT 250 WORDS)

Hypertension in the elderly population: prevalence data from an urban area in Sweden

Data from the total urban elderly population (75 years and older) in Kungsholmen, Stockholm, were used to calculate age- and sex-specific prevalence of hypertension. Blood pressure was measured as part of the examination in the population survey (the Kungsholmen Project). The blood pressure of 1751 elderly people and any antihypertensive treatment were recorded. The prevalence of hypertension was 54 and 59 per 100 population for men and women, respectively. No great variation was observed with age or sex. Isolated systolic hypertension was most frequent with increasing prevalence in advanced ages, while isolated diastolic hypertension and systolic and diastolic hypertension showed a tendency of decreased prevalence with age. In the subjects studied, 18% were being treated for hypertension. Hypertension was detected in 47% of those not undergoing treatment. Among those, 76% had high blood pressure measurements. Our data demonstrate that hypertension is a prevalent disease in the very old, in both sexes, and support the need for hypertension screening programs as well as programs to evaluate the efficacy and benefits of treatment in this age group.

Comparison of bisoprolol with atenolol for systemic hypertension in four population groups (young, old, black and nonblack) using ambulatory blood pressure monitoring. Bisoprolol Investigators Group

The antihypertensive effects of drugs are partly determined by characteristics of the patients treated. A randomized, double-blind study used 24-hour ambulatory blood pressure (BP) monitoring to compare the effects of 2 beta blockers, bisoprolol (10 to 20 mg; n = 107) and atenolol (50 to 100 mg; n = 96), administered once daily in 4 population groups. After a 4-week placebo period, patients with an office diastolic BP between 95 and 114 mm Hg were stratified according to race and age, and were randomly assigned to treatment with bisoprolol or atenolol for 8 weeks. BP averages measured by automated monitoring for the 24-hour periods were compared between groups. In elderly patients, the reductions in both average 24-hour systolic and diastolic BP were greater with bisoprolol than with atenolol (13 +/- 3/13 +/- 1 mm Hg [n = 23] vs 4 +/- 2/6 +/- 1 mm Hg [n = 30]; p < 0.01). Similarly, bisoprolol produced greater reductions in average 24-hour diastolic BP than did atenolol in nonblack patients (16 +/- 2/12 +/- 1 mm Hg [n = 85] vs 12 +/- 2/9 +/- 1 mm Hg [n = 83]; p = 0.02). Bisoprolol and atenolol were similar in the black (10 +/- 5/9 +/- 3 mm Hg [n = 22] and 10 +/- 6/6 +/- 3 mm Hg [n = 13], respectively) and young (15 +/- 1/11 +/- 1 mm Hg [n = 84] and 16 +/- 2/10 +/- 1 mm Hg [n = 66], respectively) groups.(ABSTRACT TRUNCATED AT 250 WORDS)