“The Lower the BP the Better” Paradigm in the Elderly

摘要

If a man will begin with certainties, he shall end in doubts; but if he will be content to begin with doubts, he shall end in certainties. — —Francis Bacon, The Advancement of Learning, year 1605 Hypertension is a growing public health problem in elderly people, with a prevalence up to 80% in individuals aged ≥70 years. Isolated systolic hypertension accounts for 60% to 75% of cases, systolic blood pressure (BP) being the dominant prognostic marker.1 Unfortunately, the rate of hypertension control only minimally improved over last year’s in elderly subjects when compared with the younger people.2Several randomized clinical trials tested the benefit of treatment in elderly patients with isolated systolic hypertension or systolic-diastolic hypertension. Staessen et al3 reviewed 8 randomized clinical trials carried out in patients with isolated systolic hypertension and aged ≥60 years. Active treatment reduced total mortality by 13%, cardiovascular (CV) mortality by 18%, all CV complications by 26%, stroke by 30%, and coronary events by 23%. The benefits of treatment in octogenarians remained unproved for years up to the results of the Hypertension in the Very Elderly Trial, in which 3845 patients aged ≥80 years with systolic BP ≥160 mm Hg were randomized to indapamide or placebo. Perindopril or matching placebo was added if necessary to achieve the target BP of 150/80 mm Hg. The trial was stopped after less than 2 years of follow-up because of a beneficial effect of treatment on several outcomes including all-cause mortality, although the primary study outcome, fatal or nonfatal stroke, was only marginally reduced (by …