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Treating the older hypertensive patient—an overview
Introduction Treating the Older Hypertensive Patient-An SUZANNE OPARIL,
M.D.
tWn/ngham,
Overview
Alabama
ypertension in older people is a particularly H timely topic. It is estimated that by the year 2000 there will be more than 30 million Americans over the age of 65. Of these persons, 64 percent will have hypertension (systolic blood pressure at least 140 mm Hg and/or diastolic blood pressure at least 90 mm Hg) [l]. Among the older population, the prevalence of hypertension is highest in black women (82.9 percent) and lowest in white men (59.2 percent). Approximately 7 to 10 percent of these older hypertensive persons will have isolated systolic hypertension (blood pressure at least 160iless than 90 mm Hg) [l]. Isolated systolic hypertension is significantly more prevalent (60 to 100 percent) in women than in men [l]. In older patients both diastolic hypertension and isolated systolic hypertension are associated with a two- to threefold increase in the risk of cardiovascular mortality [l]. Multiple clinical trials have demonstrated reduced incidence of cardiovascular morbidity and mortality with treatment of diastolic hypertension in older patients [2,3]. Further, the Systolic Hypertension in the Elderly Program found that it is possible to control blood pressure effectively with pharmacologic treatment in approximately 90 percent of older patients with isolated systolic hypertension [4]. The ongoing Systolic Hypertension in the Elderly Program is currently evaluating whether this druginduced reduction in systolic blood pressure in older patients reduces the incidence of cardiovascular morbidity and mortality. The pharmacologic treatment of diastolic hypertension or isolated systolic hypertension in older patients differs somewhat from the treatment of hypertension in younger patients. Older persons tend to have con-
tracted intravascular volumes, impaired renal function, and a diminished ability to metabolize andlor excrete drugs. All of the major classes of antihypertensive drugs have been shown to be effective in older patients. However, beta-adrenergic blockers may be poorly tolerated in this group, since they may precipitate congestive heart failure and a low-output state. Centrally acting drugs have been associated with sedation. Recent studies have shown that angiotensinconverting enzyme inhibitors are highly effective and usually well-tolerated in the older population [5,6]. In this symposium, we will consider in depth the epidemiology of hypertension in older patients and its importance as a cardiovascular risk factor. We will highlight special considerations in the clinical pharmacology, efficacy, and toxicity of antihypertensive drugs in these patients. Finally, we will review the use of angiotensin-converting enzyme inhibitors, lisinopril (Prinivil) in particular, in the treatment of hypertension.
REFERENCES 1. Glfford RW Jr: Geriatric hypettenslon: chalrman’s comments on the NIH Working Group report Geriatrics 1987; 42: 45-50. 2. Hypertension Detection and Followup Program Cooperative Group: Five-year findings of the Hypertension Detection and Followup Program: II-mortality by race, sex, and age. JAMA 1979: 242: 2572-2577 3. European Working Pariy on High Blood Pressure in the Elderly: Mortality and morbidity results from the European Working Party. Lancet 1985; I: 1349-1354. 4. Huiley SB, Furberg CD, Gurland B, etal: Systolic Hypertension in the Elderly Program (SHEP): Antihypertensive efficacy of chlorthalldone. Am J Cardiol 1985; 56: 913-920. 5. Woo J, Woo KS, Valiance-Owen .I: The use of the angiotensin-converhng enzyme (ACE] Inhibitor enalaprll in the treatment of mild to moderate hypertension in the elderly. Br J Clan Pratt 1987; 41: 845-847. 6. Tuck ML, Katz LA, Kirkendall WM, et al: Low-dose captopril in mild to moderate geriatric hypertension. J Am Geriatr Sot 1986; 34: 693-696.
From the Hypertension Program, Division of Cardiovascular Disease, The University of Alabama at Birmingham, Birmingham, Alabama. Requests for reprints should be addressed to Dr. Suzanne Oparil, Director, Hypertension Program, Dlvlsion of Cardiovascular Disease, The University of Alabama at Birmingham, Room 1034, Zelgler Research BulldIng, Birmingham, Alabama 35294.
September
23, 1988
The American Journal of Medicine
Volume 85 (suppl 3B)
1
M.D.
tWn/ngham,
Overview
Alabama
ypertension in older people is a particularly H timely topic. It is estimated that by the year 2000 there will be more than 30 million Americans over the age of 65. Of these persons, 64 percent will have hypertension (systolic blood pressure at least 140 mm Hg and/or diastolic blood pressure at least 90 mm Hg) [l]. Among the older population, the prevalence of hypertension is highest in black women (82.9 percent) and lowest in white men (59.2 percent). Approximately 7 to 10 percent of these older hypertensive persons will have isolated systolic hypertension (blood pressure at least 160iless than 90 mm Hg) [l]. Isolated systolic hypertension is significantly more prevalent (60 to 100 percent) in women than in men [l]. In older patients both diastolic hypertension and isolated systolic hypertension are associated with a two- to threefold increase in the risk of cardiovascular mortality [l]. Multiple clinical trials have demonstrated reduced incidence of cardiovascular morbidity and mortality with treatment of diastolic hypertension in older patients [2,3]. Further, the Systolic Hypertension in the Elderly Program found that it is possible to control blood pressure effectively with pharmacologic treatment in approximately 90 percent of older patients with isolated systolic hypertension [4]. The ongoing Systolic Hypertension in the Elderly Program is currently evaluating whether this druginduced reduction in systolic blood pressure in older patients reduces the incidence of cardiovascular morbidity and mortality. The pharmacologic treatment of diastolic hypertension or isolated systolic hypertension in older patients differs somewhat from the treatment of hypertension in younger patients. Older persons tend to have con-
tracted intravascular volumes, impaired renal function, and a diminished ability to metabolize andlor excrete drugs. All of the major classes of antihypertensive drugs have been shown to be effective in older patients. However, beta-adrenergic blockers may be poorly tolerated in this group, since they may precipitate congestive heart failure and a low-output state. Centrally acting drugs have been associated with sedation. Recent studies have shown that angiotensinconverting enzyme inhibitors are highly effective and usually well-tolerated in the older population [5,6]. In this symposium, we will consider in depth the epidemiology of hypertension in older patients and its importance as a cardiovascular risk factor. We will highlight special considerations in the clinical pharmacology, efficacy, and toxicity of antihypertensive drugs in these patients. Finally, we will review the use of angiotensin-converting enzyme inhibitors, lisinopril (Prinivil) in particular, in the treatment of hypertension.
REFERENCES 1. Glfford RW Jr: Geriatric hypettenslon: chalrman’s comments on the NIH Working Group report Geriatrics 1987; 42: 45-50. 2. Hypertension Detection and Followup Program Cooperative Group: Five-year findings of the Hypertension Detection and Followup Program: II-mortality by race, sex, and age. JAMA 1979: 242: 2572-2577 3. European Working Pariy on High Blood Pressure in the Elderly: Mortality and morbidity results from the European Working Party. Lancet 1985; I: 1349-1354. 4. Huiley SB, Furberg CD, Gurland B, etal: Systolic Hypertension in the Elderly Program (SHEP): Antihypertensive efficacy of chlorthalldone. Am J Cardiol 1985; 56: 913-920. 5. Woo J, Woo KS, Valiance-Owen .I: The use of the angiotensin-converhng enzyme (ACE] Inhibitor enalaprll in the treatment of mild to moderate hypertension in the elderly. Br J Clan Pratt 1987; 41: 845-847. 6. Tuck ML, Katz LA, Kirkendall WM, et al: Low-dose captopril in mild to moderate geriatric hypertension. J Am Geriatr Sot 1986; 34: 693-696.
From the Hypertension Program, Division of Cardiovascular Disease, The University of Alabama at Birmingham, Birmingham, Alabama. Requests for reprints should be addressed to Dr. Suzanne Oparil, Director, Hypertension Program, Dlvlsion of Cardiovascular Disease, The University of Alabama at Birmingham, Room 1034, Zelgler Research BulldIng, Birmingham, Alabama 35294.
September
23, 1988
The American Journal of Medicine
Volume 85 (suppl 3B)
1