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Should Hypertension Treatment Intensify with Age?

Summary and Comment |
June 12, 2013

Should Hypertension Treatment Intensify with Age?

  1. Joel M. Gore, MDAU045

In a feasibility study, targeting antihypertensive treatment to 130/80 mm Hg rather than 140/85 mm Hg significantly increased cerebral blood flow in elderly patients.

  1. Joel M. Gore, MDAU045

Hypertension leads to reduced cerebral blood flow (CBF), which is associated with cognitive decline. However, aggressive blood pressure (BP) reduction in the elderly may produce cerebral hypoperfusion, resulting in falls and, possibly, stroke. In a proof-of-concept study, investigators recruited 37 primary-care patients aged ≥70 with uncontrolled clinical hypertension (defined as a systolic BP of >150 mm Hg as averaged from the second and third of 3 sitting measurements) while taking ≤1 antihypertensive medication. Patients were randomized to receive protocol-defined antihypertensive treatment to a target BP lower than either 130/80 mm Hg (intensive) or 140/85 mm Hg (usual). Magnetic resonance imaging to measure CBF and 24-hour ambulatory BP monitoring were performed at baseline and after 12 weeks of treatment.

At baseline, mean BP and mean CBF did not differ significantly between the two groups, and CBF did not correlate with any BP measure (clinical, ambulatory, aortic, systolic, or diastolic). At 12 weeks, mean clinical BP fell significantly from baseline in both groups; however, the reduction was significantly greater in the intensive group than in the usual group (26/17 vs. 15/5 mm Hg). Mean CBF did not change significantly from baseline in the usual group but increased significantly in the intensive-treatment group, regardless of baseline CBF. In both groups, the change in CBF correlated significantly with change in systolic BP.

Comment

In this small study, intensive blood-pressure treatment (targeted to <130/80 mm Hg) increased cerebral blood flow in elderly patients with hypertension. Whether increasing CBF by aggressive BP reduction slows cognitive decline or decreases cognitive impairment and — possibly — dementia compared with current, more conservative BP targets remains unclear. The latest revision of the National Heart, Lung, and Blood Institute's Joint National Committee guidelines is eagerly awaited and should shed light on BP goals in the elderly.

  • Disclosures for Joel M. Gore, MD at time of publication Grant / research support NIH; NIH-NHLBI; NSF

Citation(s):

Reader Comments (4)

Gordon Rafool, MD Physician, Geriatrics, Gessler Clinic Florida

In this very small population of patients; I find it very difficult to agree with the authors. Especially in light of the latest article by European Society of Hypertension and the European Society of Cardiology states that bp is controlled when a person's BP is 140/90.

Jan Newman

While positive changes in CBF occurred under the unique test conditions of the study , there is no evidence that that translates into better clinical outcomes. In fact CBF in supine condition in an MRI has zero to do with how orthostatic the patient becomes when standing or dehydrated. Studies like this are so poorly conceived that they are detrimental to patient care as invariably clinicians will generalize these results to clinical care.

Competing interests: None declared

MIQUEL DEMUR

reducing hypertension with magnesium, oligoelements, vitamins, proteins is better because stress is caused by falls in this element.

DAYAN ARIEL GARCIA Physician, Cardiology, Centro Medico de alta tecnologia Tucupita delta

I find it very consistent with the current trend of the elderly population identify as a special sector antihertensiva labile to medications and the high percentage of stroke in this population group

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