"Hypertension Treatment in the Very Elderly".The New England Journal of Medicine. 2008. 358(18):1887-1898.PubMed•Full text•PDF

Contents

1Clinical Question
2Bottom Line
3Major Points
4Guidelines
5Design
6Population
6.1Inclusion Criteria
6.2Exclusion Criteria
6.3Baseline Characteristics
7Interventions
8Outcomes
8.1Primary Outcome
8.2Secondary Outcomes
9Criticisms
10Funding
11Further Reading

Clinical Question

Does antihypertensive treatment in patients 80 years of age or older lead to a reduction in the rate of fatal or nonfatal stroke without significantly increasing the risk of death?

Bottom Line

Antihypertensive treatment with indapamide (sustained release), with or without perindopril, significantly reduces the risks of death from stroke and death from any cause in very elderly patients with hypertension.

Major Points

Guidelines

Current guidelines do not directly reflect the results from this study, as they typically address a general adult population with hypertension, with less focus specifically on those 80 years and older.

Design

Multicenter, double-blind, parallel-group, randomized, placebo-controlled trial.

Population

N=3,845 patients aged 80 years or older.

Inclusion Criteria
- 80 years of age or older
- Persistent hypertension with a sustained systolic blood pressure of 160 mm Hg or more

Exclusion Criteria
- Contraindications to trial medications
- Secondary hypertension
- Recent hemorrhagic stroke, heart failure requiring antihypertensive medication, or significant renal impairment

Baseline Characteristics
- Patients were well matched with a mean age of 83.6 years and mean seated blood pressure of 173.0/90.8 mm Hg
- 11.8% with a history of cardiovascular disease
- 6.9% with diabetes

Interventions

- Patients received either indapamide (sustained release, 1.5 mg) or matching placebo
- Perindopril (2 or 4 mg) or matching placebo could be added to achieve the target blood pressure of 150/80 mm Hg

Outcomes

Primary Outcome
- 30% reduction in the rate of fatal or nonfatal stroke (P=0.06)

Secondary Outcomes
- 39% reduction in the rate of death from stroke (P=0.05)
- 21% reduction in the rate of death from any cause (P=0.02)
- 23% reduction in the rate of death from cardiovascular causes (P=0.06)
- 64% reduction in the rate of heart failure (P<0.001)
- Fewer serious adverse events in the active treatment group (P=0.001)

Criticisms

- It is unclear if the results are generalizable to more frail elderly populations
- The true cause of death can be difficult to establish in the very elderly, especially when they are not monitored in their last hours of life and autopsies are not commonly performed

Funding

Supported by grants from the British Heart Foundation and the Institut de Recherches Internationales Servier.

Further Reading

The full text and supplementary information can be reviewed for more detailed findings and data interpretation.