Should We Treat Hypertension in Very Old People?
In the HYVET, relatively healthy octogenarians benefited from antihypertensive therapy.
In most of the "hypertension in the elderly" trials conducted in the 1980s and 1990s, the age threshold for enrollment was 60. Thus, the benefit of treating hypertension in very old patients has remained unclear.
The 3845 generally healthy people in the randomized HYVET (Hypertension in the Very Elderly Trial) were 80 or older (mean age, 84) with systolic blood pressure >160 mm Hg and diastolic BP <110 mm Hg (mean, 173/91 mm Hg); most resided in eastern Europe or China. They received either the nonthiazide diuretic indapamide (Lozol and generics) or placebo, plus the angiotensin-converting–enzyme inhibitor perindopril if necessary. Target blood pressure was 150/80 mm Hg. The study was supported partly by a manufacturer of both drugs.
At 2 years, mean systolic and diastolic BPs were lowered by 15 and 6 mm Hg, respectively, in the active treatment group compared with the placebo group. The incidence of the primary endpoint, fatal or nonfatal stroke, was lower with active treatment than with placebo (12.4 vs. 17.7 strokes per 1000 patient-years), but the difference just missed significance (P=0.06). The number needed to treat to prevent one stroke was about 100 during 2 years of treatment. Two-year all-cause mortality was significantly lower with active treatment (about 10% vs. 12%; P=0.02), resulting in early termination of the trial. The incidence of heart failure, but not myocardial infarction, was lowered significantly with antihypertensive therapy. Only two serious adverse events were attributed to active-drug therapy.
Comment: These results suggest that treatment is worthwhile for relatively healthy people in their 80s with substantially elevated blood pressure. However, several considerations remain for U.S. physicians. First, can outcomes with indapamide (which is not used widely in the U.S.) be extrapolated to outcomes with hydrochlorothiazide? Second, are these findings applicable to typical U.S. patients, particularly those who already take multiple medications? And third, the near-absence of serious adverse events attributed to drug therapy seems almost too good to be true.
— Allan S. Brett, MD
Published in Journal Watch General Medicine April 17, 2008
Beckett NS et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008 Mar 31