Immediate and late benefits of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial

Abstract

Objective To assess if very elderly people with hypertension obtain early benefit from antihypertensive treatment.Design One year open label active treatment extension of randomised controlled trial (Hypertension in the Very Elderly Trial (HYVET)).Setting Hospital and general practice based centres mainly in eastern and western Europe, China, and Tunisia.Participants People on double blind treatment at the end of HYVET were eligible to enter the extension.Interventions Participants on active blood pressure lowering treatment continued taking active drug; those on placebo were given active blood pressure lowering treatment. The treatment regimen was as used in the main trial-indapamide SR 1.5 mg (plus perindopril 2-4 mg if required)-with the same target blood pressure of less than 150/80 mm Hg. Main outcome measuresThe primary outcome was all stroke; other outcomes included total mortality, cardiovascular mortality, and cardiovascular events. ResultsOf 1882 people eligible for entry to the extension, 1712 (91%) agreed to participate. During the extension period, 1682 patient years were accrued. By six months, the difference in blood pressure between the two groups was 1.2/0.7 mm Hg. Comparing people previously treated with active drug and those previously on placebo, no significant differences were seen for stroke (n=13; hazard ratio 1.92, 95% confidence interval 0.59 to 6.22) or cardiovascular events (n=25; 0.78, 0.36 to 1.72). Differences were seen for total mortality (47 deaths; hazard ratio 0.48, 0.26 to 0.87; P=0.02) and cardiovascular mortality (11 deaths; 0.19, 0.04 to 0.87; P=0.03). ConclusionVery elderly patients with hypertension may gain immediate benefit from treatment. Sustained differences in reductions of total mortality and cardiovascular mortality reinforce the benefits and support the need for early and long term treatment.Trial registration Clinical trials NCT00122811.

Follow-up of Blood-Pressure Lowering and Glucose Control in Type 2 Diabetes

“…Although our blood-pressure findings appear to be different from those of the UKPDS, the point estimates for the major mortality end points are similar and are consistent with other post-trial follow-up studies of blood-pressure-lowering therapy in patients at high risk for cardiovascular events. [9][10][11][12][13] Indeed, a comparison of in-trial and post-trial numbers of events suggests that the cumulative reductions in mortality in the perindopril-indapamide group can be ascribed largely to a carrying forward of the effects observed during randomized treatment. It is possible that with even longer post-trial follow-up these effects might have further dissipated, as occurred in the UKPDS.…”

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

“…Third, because the trial was prematurely interrupted by the Safety Monitoring Board (because of the evidence of protective effect of BP reduction in the treated group), the follow-up was rather short (median, 1.8 years). Despite the observation that in the HYVET patients the rate of events remained lower in the originally treated group 1 year after the trial termination, 9 this requires the duration of benefit to be determined. Finally, the 2013 ESH/ESC guidelines state that the HYVET deliberately recruited patients in good physical and mental conditions and excluded ill and frail individuals, who are common among octogenarians, and also excluded patients with clinically relevant orthostatic hypotension, 1 thereby emphasizing probably the most important limitation of the available information, ie, leaving out of consideration the influence of patients' general health, concomitant medication, and frailty on the decision about antihypertensive treatment implementation.…”

GPs’ perspectives on secondary cardiovascular prevention in older age: a focus group study in the Netherlands

“…4 This undertreatment could needlessly increase the CVD burden in older age, as secondary cardiovascular preventive treatment has been shown to be effective even in older age. [6][7][8][9] Understanding these low prescription rates, 4 requires insight into the ideas that healthcare professionals have regarding secondary cardiovascular prevention. Various doctor-related mechanisms may contribute to the observed undertreatment; for example, lack of knowledge 10,11 or difficulties interpreting current guidelines, 12 resistance to application of current guidelines in older age, 13 lack of skills, lack of time, 14 reduced sense of self-efficacy, 15 uncertainty about their role, 16 or lack of financial resources.…”