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COMMENTARY |
Geriatric Subacute Unit, Geriatric Rehabilitation and Extended Care, Bay Pines VA Medical Center, Bay Pines, and University of South Florida, Tampa.
There is no doubt that cardiovascular disease is the leading cause of mortality and morbidity in elderly people, and that treating hypertension decreases the incidence of cardiovascular illness in this population. It is much less clear, however, that managing hypertension in the asymptomatic very old (>80 years) imparts any benefit on mortality and morbidity. In fact, a critical review of the literature suggests just the opposite. In his elegant review of hypertension in the very old, Dr. Goodwin makes a compelling case for treating hypertension in the very old with caution, if at all (27). I applaud Dr. Goodwin for promoting awareness of what continues to be an obstinately unpopular position—mainly that elevated blood pressure in the very old does not necessarily need to be lowered.
The beneficial effect of controlling hypertension was documented as early as 1967 in the Veterans Administration Cooperative Study, which was published in 3 parts between 1967 and 1972. These studies convincingly demonstrated a reduction in cardiovascular morbidity in all subjects, including those older than 60 years of age. Similar results were noted in the Hypertension Detection and Follow-up Program (HDFP) and the Australian National Blood Pressure (ANBP) study, published in 1979 and 1980, respectively. These early studies were the springboard for many other large controlled studies, all of which tout the protective effect of lowering blood pressure on cardiovascular disease. Such studies include the Hypertension in the Elderly Project (HEP), the European Working Party on High Blood Pressure in the Elderly (EWPHE), the Swedish Trial in Older Patients with Hypertension (STOP-Hypertension), the Systolic Hypertension in the Elderly Program (SHEP), and the Medical Research Council (MRC) trial, among many others. They conclude that the greater the systolic or diastolic blood pressure in elderly persons (>60–65), the greater the risk of mortality and morbidity of cardiovascular causes. On the other hand, there is perhaps an equally large, and often neglected, body of work that clearly demonstrates increased survival in the very old with elevated blood pressure. This second group is represented by at least 5 large studies of equally good design, if less marketable names. They demonstrated improved survival in the very old (>80–85) with higher blood pressure, and increased mortality with treatment. These references will not be included, as they can be found in the root review, or the articles that actuated it (2,3).
Both of the above seemingly contradictory results are valid. The apparent discrepancy can be explained by a closer analysis of the studies, which, in fact, measure different end points in slightly different populations. Two points of contention must be made when comparing these 2 groups of studies. First, conclusions applied to elderly people as a group cannot necessarily be extrapolated to all age cohorts within the group, and second, one must differentiate cardiovascular mortality from total mortality.
The first distinction exemplifies the diversity of elderly people, and how standards of care in younger individuals do not always apply to elderly persons. For example, the European Working Party on Hypertension in the Elderly (EWPHE) demonstrated the benefit of treating blood pressure on mortality in the older than 60 years of age group. The older than 80 years subgroup, however, did not show any statistically significant benefit. Similar results can be seen in the STOP-Hypertension, the European Trial on Isolated Systolic Hypertension in the Elderly (Sys-Eur), and the HEP studies. The benefit of blood pressure control in elderly people appears to be derived mainly from the 60–80-year-old subgroup. If the older population is viewed as a single group, one fails to appreciate the abating benefit of blood pressure control with age. This finding need not be entirely surprising, as it is seen with weight, body mass index, and cholesterol, all of which afford grave prognosis as they decline in the very old.
The second distinction, differentiating cardiovascular mortality from all-cause mortality, becomes of increasing interest in the very old. Most of the studies described in the first group above were designed to assess cardiovascular risk prevention. Some reported all-cause deaths, but none described other causes of death. While all studies reported a decline in cardiovascular mortality and morbidity, both the SHEP study and the MRC trial showed no statistically significant decline in all-cause deaths in the treatment group. It is possible, then, that treating hypertensive elderly people changes the cause of death (e.g., infections, malignancies), with only a modest improvement in survivability. An even more disturbing question that must be addressed is: How much additional mortality and morbidity is due to treatment, particularly in the very old who are not expected to have much cardiovascular benefit from lowering blood pressure? Such pathology may include falls, hip and other fractures, skin breakdown, confusion, vascular dementia, and fatigue. Perhaps the only thing worse than a debilitating disease is an iatrogenic debilitating disease.
The concerted effort of the American Heart Association and many other groups has dramatically reduced the impact of cardiovascular disease in elderly people. The optimal management of hypertension in the very old, however, remains controversial. Since it is difficult to define a "normal" blood pressure for this diverse group, treatment judgment must be based on the available outcome studies. On this basis, I do not advocate antihypertensive therapy in the asymptomatic very old, nor do I wish to withhold treatment from those who will benefit. Each case must be individualized with attention towards other risk factors (e.g., diabetes), history of cardiovascular disease, life expectancy, quality of life, and patient preference. The life expectancy of a 65 year old in the United States is just under 20 years—at 85, it is still approximately 5 years. If there is an inordinately large proportion of elderly people with markedly elevated blood pressures, perhaps it is because of, rather than despite, their blood pressures.
Acknowledgments
Address correspondence to Ramzi R. Hajjar, MD, CMD, Geriatric Rehabilitation and Extended Care, Bay Pines VA Medical Center, 10000 Bay Pines Boulevard, Bay Pines, FL 33744. E-mail: hajjarrr{at}aol.com
REFERENCES
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