Lown Cardiovascular Research Foundation

Harvard Heart Letter | July 2008

Age no barrier to blood pressure control

New work shows it’s never too late to treat high blood pressure.

Much is known about the benefits of treating high blood pressure. It helps prevent strokes, heart attacks, heart failure, and premature death from cardiovascular disease. One of the persistent questions is this: do elderly folks with high blood pressure reap these benefits, too?

Doctors have worried that treating high blood pressure in people over age 75 or 80 might cause more trouble than it prevents. The possibility exists that taking medicine to lower blood pressure could harm the heart, kidneys, or brain, cause faints or falls, or lead to harmful interactions with medications for other conditions. The completed Hypertension in the Very Elderly Trial (HYVET) allays some of those worries.

Treatment benefits outstrip risks

HYVET included nearly 4,000 men and women between the ages of 80 and 105, all with high blood pressure. Half took indapamide, a diuretic (water pill), either alone or with perindopril, an ACE inhibitor. The other half took a placebo.

After two years, the average systolic pressure (the top number of a blood pressure reading) had dropped a whopping 30 points; the diastolic pressure (the lower number) had fallen 13 points.

The lower blood pressures paid off. Among people taking the blood pressure medicine, there were 30% fewer strokes, 64% fewer cases of heart failure, and 21% fewer deaths from any cause than there were in the placebo group. What’s more, not only did the expected increase in side effects among people taking the medications never materialize, but low potassium levels, fainting, and other unwanted side effects were less common in the drug treatment group than in the placebo group (The New England Journal of Medicine, May 1, 2008).

Don’t delay

Since the late 1950s, researchers have progressively widened the pool of people who might benefit from medications to lower blood pressure. Beginning with those whose blood pressure was so high it posed an immediate threat to life, it now includes people with heart disease, diabetes, or kidney disease, as well as millions of otherwise healthy individuals. The elderly represented a kind of final frontier in this work. With the HYVET results, it’s apparent that they, too, benefit from keeping blood pressure in check.

One trial, of course, can’t answer all the outstanding questions. What’s the best treatment target for older people? HYVET used 150/80, while current U.S. guidelines suggest 140/90, or 130/80 for people with diabetes or kidney disease. What are the best drugs for lowering blood pressure in the elderly? HYVET used a diuretic not commonly prescribed in the United States (indapamide) with or without an ACE inhibitor. Chlorthalidone, hydrochlorothiazide, or another more commonly used diuretic should have the same impact, but that needs to be tested.

Even without these answers, it’s time to add blood pressure control to bypass surgery, angioplasty, cholesterol lowering, and other interventions that benefit older folks as much as younger ones.