It’s never been clear how much is achieved by treating hypertension in patients who are 80 or older. The Hypertension in the Very Elderly Trial (HYVET) sought to address that question, studying 3,845 individuals aged 80 or older with very high blood pressure (BP). The inclusion criteria was systolic BP between 160 and 190 mm Hg and diastolic BP over 110 mm Hg. Patients were randomized to either a diuretic (indapamide) with an ACE inhibitor (perindopril) or placebo; target BP was 150/80 mm Hg, with the average BP of subjects starting at 173/91 mm Hg. The active-treatment and placebo groups were well matched. Mean age was 83.6 years, and 11.8% had a history of cardiovascular disease. Median follow-up was only 1.8 years. At 2 years, the mean blood pressure while sitting was 15.0/6.1 mm Hg lower in the active-treatment group than in the placebo group. In an intention-to-treat analysis, active treatment was associated with a 30% reduction in the rate of fatal or nonfatal stroke, a 21% reduction in the rate of total mortality and a 64% reduction in the rate of heart failure. Fewer serious adverse events were reported in the active-treatment group (358 vs 448 in the placebo group).

Future research needs to investigate efficacy in older people with less severe hypertension, and to weigh benefits from targets lower than 150/80 mm Hg. But meanwhile, there should be no doubt that management of hypertension can’t be ignored in the “healthy” elderly — those that will have a good quality of life within the next five years. Blood pressure management reduced mortality by 20%, stroke by a third and congestive heart failure (CHF) admissions by close to two-thirds. These results are very pertinent to clinical practice, as both patients and physicians fear stroke. In addition, most of my elderly patients complain of shortness of breath. Reducing the burden of CHF is extremely important.

Sales reps from the pharmaceutical industry are regularly trying to tell me that their drug is best. In mild hypertension all agents are equally effective at lowering BP and decreasing cardiovascular risk. The only exception would be to avoid using beta blockers in patients above the age of 60 for uncomplicated hypertension. Beta-blockers can increase elastic recall of the aorta and may lead to less protection for stroke in an elderly population.

Final thoughts

Remember beta blockers are the first-line therapy for the management of angina, systolic CHF, vascular protection in post myocardial infarction and heart rate control in atrial fibrillation. For patients with end organ damage and established vascular disease, blocking the renin-angiotensin system becomes more important.