FOR the first time, clinicians have guidelines on the prevention and treatment of hypertension specifically in individuals aged 65 years or older. The guidance, released in April, comes from an expert panel convened by the American College of Cardiology and the American Heart Association (Aronow WS et al. J Am Coll Cardiol. 2011;57[20]:2037-2114).

Although hypertension is prevalent in this older population, found in 64% of men and 78% of women, control is far less common, said Wilbert S. Aronow, MD, clinical professor of medicine at New York Medical College/Westchester Medical Center and a cochair of the expert panel. “If you take a population age 70 or older, one-third of men and onefourth of women are adequately treated,” Aronow said. “And many clinicians are still unwilling to treat patients with hypertension; they believe it will increase mortality.”

That belief has been reinforced over the years by studies suggesting that lowering blood pressure, while reducing risks of stroke and vascular complications, might increase risks for other adverse conditions. Moreover, rigorous study of hypertension control in the
very old (those aged 80 years and older) has been nonexistent. But a 2008 study changed the landscape.

The study, Hypertension in the Very Elderly Trial (HYVET), looked at treatment of 3845 patients aged 80 years or older randomized to antihypertensive therapy (indapamide [sustained release] with or without perindopril) or placebo. Compared with those receiving
placebo, those enrolled in the active treatment group reduced their sitting mean systolic and diastolic blood pressures by 15.0 and 6.1mmHg and saw a 64% reduction in the rate of heart failure, a 23% reduction in the rate of death from cardiovascular causes, and a 21% reduction in the rate of death from any cause (Beckett NS et al. N Engl J Med. 2008;358[18]:1887-1898). And while the HYVET investigators were unable to show treatment benefit regarding the study’s primary end point of fatal or nonfatal stroke (the trial was stopped after about 2 years of follow-up for ethical reasons), the findings were compelling enough for Aronow to suggest developing
and issuing guidelines for this patient population.

GUIDANCE
While HYVET provided the impetus for compiling a guidance document, the lack of rigorous research on other elements regarding the prevention and management of hypertension in individuals aged 65 years or older means that many of the panel’s recommendations
are based on expert opinion.

The evaluation of an elderly patient with known or suspected hypertension should begin with an accurate
blood pressure measurement. Blood pressure for this population should be measured with the patient standing for 1 to 3 minutes to evaluate for postural hypotension or hypertension, the guidance said.
Once a blood pressure reading is taken, the physician needs to determine whether it represents hypertension.In the younger population, a systolic and diastolic blood pressure reading of less than 120 and 80mmHg, respectively, is considerednormotensive and serves as a treatment goal for those with prehypertension or hypertension. Blood pressures increase naturally in elderly patients due to age-associated stiffening of the large arteries, so the expert panel suggests a systolic and diastolicblood pressure goal inuncomplicated hypertension of below 140 and 90mmHg, respectively, for those aged 65 years or older. They also state that it is unclear whether target。