Hyper- or hypotension in an older population: where do clinicians stand?

摘要

Recently, large multi-centre studies have shown that treatingnhypertension in an older population is beneficial innreducing stroke, heart failure and all-cause mortality [1].nThe immediate question that poses itself is whether therenis a price to pay in terms of associated morbidity or evennmortality arising from controlling high blood pressure (BP)nto an extreme degree. Can lowering older people’s bloodnpressure too much result in postural (orthostatic)nhypotension (OH) that can be potentially detrimental?nAnd if the answer to that question is in the affirmative,nwhat is the optimal or ideal level of BP that is beneficialnbut at the same time free from the associated adversenevents of OH? We need large epidemiological studies tondetermine the prevalence of OH in older people in thencommunity as well as in care home settings. The studynby S. Ibrahim [2] is an attempt to establish the basicnmuch-needed information in addressing this complicatednarea by quantifying the magnitude of the problem [2]. Thisnstudy addressed the prevalence of OH in a large cohort ofn3,775 females, mostly older women (mean age 68 years)nover a 2-year period, and showed a high prevalence ofnOH of 28%. However, this study excluded almost halfnof the older population, namely older males. A similar recentnstudy in Finland highlighted a higher prevalence ofnOH in 34% of community elderly people [3]. Both studiesnfound an association of OH with the total number of regularnmedications taken [2, 3]. Although Shah’s studynincluded women only, it was still in line with other epidemiologicalnstudies; the Finnish study found nonsignificantngender differences in the population studiednwith OH [3]. The prevalence of OH depends on the populationnstudied and the definition used in quantifying thendegree of OH. It may seem obvious that OH increasesnwith age and co-morbidities, but such information fromnwell-designed epidemiological studies is crucial in safelynsetting up health policies and guidelines for the managementnof high BP in the elderly while avoiding OH.nHistorically, the deleterious impact of systolic and diastolicnhypotension and their prognostic indication of cardiovascularndeath have been extensively reported [4], and morenrecently in the Rotterdam study [5].