Does the treatment of hypertension in persons older than 80 years improve clinical outcomes?

Treatment of hypertension in the very elderly reduces the risk of fatal stroke and death from any cause. Previous studies using high-dose diuretics and beta-blockers had not found a similar benefit, perhaps because of the adverse effects of high-dose diuretics and the lack of benefit of beta-blockers. (LOE = 1b)

Beckett NS, Peters R, Fletcher AE, et al, for the HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008;358:1887-1898.  [PMID:18378519]

Randomized controlled trial (double-blinded)

Government

Concealed

Outpatient (any)

Data regarding the benefit of treating hypertension in the very elderly are sparse and mixed. Although some studies have shown a reduced risk of stroke, there is also data suggesting an increase in all-cause mortality, especially with target systolic blood pressures below 140 mm Hg. In this study, 3845 patients older than 80 years with a systolic blood pressure between 160 and 199 mm Hg without medication were identified. The patients were a mix of those with systolic hypertension and systolic/diastolic hypertension. They were randomly assigned to receive sustained-release indapamide 1.5 mg daily or placebo. Patients with recent stroke, secondary or accelerated hypertension, heart failure, or renal impairment were excluded. If the target blood pressure of 150/80 mm Hg was not achieved, perindopril (2 mg or 4 mg) or matching placebo could be added. Appoximately 25% of active treatment patients were receiving indapamide alone at the end of the study; the rest were receiving indapamide and perindopril. The mean duration of follow-up was 2.1 years, with a range of 0 to 6.5 years. Patients in the active treatment group had lower rates of fatal stroke (absolute risk reduction [ARR] 0.42%/year, p= 0.046, NNT = 240/year), all-cause mortality (ARR 1.2%, p = 0.02, NNT = 80/year), heart failure (ARR 0.95%, p<0.001, NNT = 105), and any cardiovascular event (ARR 1.7%, p<0.001, NNT = 59). There were fewer serious adverse events in the active treatment group as well.