An Expert Opinion From the European Society of Hypertension–European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects

Bénétos, Athanase; Bulpitt, Christopher J.; Petrovic, Mirko; Ungar, Andrea; Rosei, Enrico Agabiti; Cherubini, Antonio; Redón, Josep; Grodzicki, Tomasz; Dominiczak, Anna F.; Strandberg, Timo; Mancia, Giuseppe

doi:10.1161/hypertensionaha.115.07020

Cited by 162 publications

(97 citation statements)

References 43 publications

(67 reference statements)

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“…3 In exploratory analyses from SPRINT, 23 the cardiovascular benefit of lowering SBP to a target goal of <120 mm Hg, as compared with <140 mm Hg, was consistent regardless of the degree of individual frailty status or gait speed. Conversely, observational studies in older adults illustrate that the relationship between on-treatment BP and outcomes differs by frailty.…”

Section: February 2017mentioning

confidence: 96%

“…The optimal BP goal for older adults continues to be debated and its determination is a pressing need. 2,3 SBP tends to rise with age, and the prevalence of hypertension is 60% to 90% in older adults. 4,5 More than 60% of older people with hypertension have isolated systolic hypertension (ISH) 5,6 : elevated SBP but normal or even low DBP, as a consequence of reduced elasticity and compliance of large arteries and atherosclerosis.…”

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confidence: 99%

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On-Treatment Blood Pressure and Cardiovascular Outcomes in Older Adults With Isolated Systolic Hypertension

et al. 2017

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By 2050, older adults (aged ≥65 years) will number >1 billion worldwide, representing 15% of the global population.1 Despite the ubiquity of this aging phenomenon, there is often uncertainty in the clinical management of older adults, particularly with regard to intensity of therapy.2 Hypertension, defined as systolic BP (SBP) of ≥140 mm Hg or diastolic BP (DBP) of ≥90 mm Hg, is one such example. The optimal BP goal for older adults continues to be debated and its determination is a pressing need. 2,3 SBP tends to rise with age, and the prevalence of hypertension is 60% to 90% in older adults. 4,5 More than 60% of older people with hypertension have isolated systolic hypertension (ISH) 5,6 : elevated SBP but normal or even low DBP, as a consequence of reduced elasticity and compliance of large arteries and atherosclerosis. 6,7 Because ISH is associated with high risk for serious health problems, including coronary heart disease (CHD), stroke, heart failure, and kidney disease, [8][9][10] the urgency is greater than ever to determine on-treatment BP levels at which cardiovascular risks are minimized in older adults with ISH.Using data from the VALISH study (Valsartan in Elderly Isolated Systolic Hypertension), a randomized controlled trial designed to compare the effect of intensive (SBP target <140 mm Hg) versus moderate (≥140 and <150 mm Hg) SBP-lowering treatment on cardiovascular outcomes in older Japanese patients with ISH, 11,12 we sought to assess the Abstract-Our aim was to assess optimal on-treatment blood pressure (BP) at which cardiovascular disease (CVD) and all-cause mortality risks are minimized in Japanese older adults with isolated systolic hypertension. We used data from the VALISH study (Valsartan in Elderly Isolated Systolic Hypertension) that recruited older adults (n=3035; mean age, 76 years) with systolic BP (SBP) of ≥160 mm Hg and diastolic BP of <90 mm Hg. Patients were treated by valsartan.Patients were also categorized into 3 groups based on achieved on-treatment SBP of <130 mm Hg (n=317), 130 to <145 mm Hg (n=2025), or ≥145 mm Hg (n=693). The primary outcome was composite CVD (coronary heart disease, stroke, heart failure, cardiovascular deaths, other vascular diseases, and kidney diseases) with secondary outcome being all-cause mortality. Cox proportional hazards models were used to assess the CVD risk for each group. Over a median 3-year follow-up (8022 person-years), 93 CVD events and 52 deaths occurred. Using the on-treatment SBP of 130 to <145 mm Hg as reference stratum, the multivariable-adjusted hazard ratios and 95% confidence intervals of CVD and all-cause mortality risks for those with SBP<130 mm Hg were 2.08 (1.12-3.83) and 2.09 (0.93-4.71) and for those with SBP≥145 mm Hg were 2.29 (1.44-3.62) and 2.51 (1.35-4.66), respectively. On-treatment diastolic BP yielded no relationships with CVD or all-cause mortality risk. In conclusion, among Japanese older adults with isolated systolic hypertension, SBP in the range between 130 and 144 mm Hg was associated with minimal adverse ou...

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Section: February 2017mentioning

confidence: 96%

mentioning

confidence: 99%

On-Treatment Blood Pressure and Cardiovascular Outcomes in Older Adults With Isolated Systolic Hypertension

et al. 2017

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“…In fitter patients, a therapeutic strategy similar to that used in younger individuals may be used. In the subgroup with loss of autonomy and major functional limitations (e.g., those needing daily assistance for their basic activities), higher systolic blood pressure goals should be considered (e.g., 145-160 mmHg) and treatment should be reduced in the presence of low supine systolic blood pressure (,130 mmHg) or presence of orthostatic hypotension (125,126).…”

Section: Older Adults (Aged ‡65 Years)mentioning

confidence: 99%

Diabetes and Hypertension: A Position Statement by the American Diabetes Association

et al. 2017

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Background The aims of this study were to investigate the effects of age, gender, body mass index (BMI), glycaemic control, socioeconomic status, dyslipidaemia, hypertension, ischaemic heart disease (IHD) and smoking status in type 2 diabetes in a population-based analysis. Methods Data were collected from 46 General Practice databases in 2009 and 2014. Cox regressions were run in the non-diabetes population plus type 2 diabetes patients. Results People with type 2 diabetes (n=16,643) had higher mortality rates than non-diabetes subjects. Ranked in order of Hazard Ratio (HR), increasing age (HR 2.31), smoking (HR 1.79), IHD (HR 1.65), deprivation (HR 1.36), hypertension (HR 1.23) and male gender (HR 1.20) all increased mortality risk (p<0.01). Statin therapy was associated with better outcome (HR 0.65, p<0.01). Abnormal lipid levels whilst not on a statin signi cantly increased mortality risk for raised total-cholesterol (HR 1.74) and low HDL-cholesterol (HR 1.48) but not for triglycerides (HR 0.67) (all p<0.01). Conclusions This large study con rmed that the all-cause mortality risk in people with type 2 diabetes remains elevated. In the study we demonstrated that a man with type 2 diabetes of 5-10 years duration who smoked, had hypertension and IHD plus lived in the most deprived area had a HR of 6.2 compared with a non-smoking, normotensive, non-diabetes subject without IHD living in the least deprived area.. Further research is required to understand the gender risk difference in all-cause mortality in type 1 compared with type 2 diabetes and why obesity plus raised triglycerides appear to be protective. Highlights Ranked in order of Hazard Ratio (HR), increasing age (HR 2.31), smoking (HR 1.79), Ischaemic Heart Disease (IHD) (HR 1.65), deprivation (HR 1.36), hypertension (HR 1.23) and male gender (HR 1.20) all increased mortality risk (p<0.01). This study demonstrated that a man with type 2 diabetes of 5-10 years duration who smoked, had hypertension and IHD plus lived in the most deprived area had a HR of 6.2 compared with a nonsmoking, normotensive, non-diabetes subject without IHD living in the least deprived area. Smoking prevalence decreased with duration falling from 26.8% for diabetes <5 yrs to 17.7% for diabetes >10 yrs. Body Mass Index > 30kg/m 2 appeared to reduce mortality risk (HR 0.77, p<0.01).

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“…These new ACC/AHA guidelines received critiques from experts, questioning SPRINT’s methodology [63] and its generalizability [64]. Some experts consider that these guidelines downplay the adverse effects of antihypertensive treatment, such as falls due to hypotension [65] and the risk for overtreatment and polypharmacy [10, 66], especially in frail oldest-old patients [65]. In reaction, some experts have developed their own guidelines with more conservative treatment recommendations accounting for detrimental effects of low BP reported in cohort studies [67].…”

Section: International Guidelines For Hypertension Management In Oldementioning

confidence: 99%

Screening and treatment of hypertension in older adults: less is more?

et al. 2018

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Screening and treatment of hypertension is a cornerstone of cardiovascular disease (CVD) prevention. Hypertension causes a large proportion of cases of stroke, coronary heart disease, heart failure, and associated disability and is highly prevalent especially among older adults. On the one hand, there is robust evidence that screening and treatment of hypertension prevents CVD and decreases mortality in the middle-aged population. On the other hand, among older adults, observational studies have shown either positive, negative, or no correlation between blood pressure (BP) and cardiovascular outcomes. Furthermore, there is a lack of high quality evidence for a favorable harm-benefit balance of antihypertensive treatment among older adults, especially among the oldest-old (i.e., above the age of 80 years), because very few trials have been conducted in this population. The optimal target BP may be higher among older treated hypertensive patients than among middle-aged. In addition, among frail or multimorbid older individuals, a relatively low BP may be associated with worse outcomes, and antihypertensive treatment may cause more harm than benefit. To guide hypertension screening and treatment recommendations among older patients, additional studies are needed to determine the most efficient screening strategies, to evaluate the effect of lowering BP on CVD risk and on mortality, to determine the optimal target BP, and to better understand the relationship between BP, frailty, multimorbidity, and health outcomes.

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An Expert Opinion From the European Society of Hypertension–European Union Geriatric Medicine Society Working Group on the Management of Hypertension in Very Old, Frail Subjects

Cited by 162 publications

References 43 publications

On-Treatment Blood Pressure and Cardiovascular Outcomes in Older Adults With Isolated Systolic Hypertension

On-Treatment Blood Pressure and Cardiovascular Outcomes in Older Adults With Isolated Systolic Hypertension

Diabetes and Hypertension: A Position Statement by the American Diabetes Association

Screening and treatment of hypertension in older adults: less is more?

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