Lowering BP can benefit even the elderly

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Hypertensive patients older than 80 years of age who took BP medication cut their overall mortality rate by more than a fifth and their chances of a cardiovascular event by more than a third in a recent clinical trial. Previous studies had suggested that treating these patients might actually increase mortality.

Led by researchers at Imperial College of London, the study was a randomized, double-blind trial conducted in 13 countries, mainly in Europe. With 3,845 participants, it is the largest trial to focus solely on lowering BP in the very elderly.

The patients ranged in age from 80 to 105, and all had a systolic BP >140 mm Hg. They were randomized to receive placebos or the diuretic indapamide (Lozol) supplemented with 2 or 4 mg of the ACE inhibitor perindopril (Aceon) as needed. After an average two years of follow-up, 48% of the treated patients reached the BP target of 150/80, compared with 19.9% of the placebo arm (N Engl J Med. 2008;358:1887-1898).

When compared with the control group, the treated patients had 30% fewer strokes, 39% fewer fatal strokes, 21% fewer deaths from any cause, and 32% fewer CV deaths. Heart failure was reduced by more than two thirds (64%). The results were so dramatic that the trial was cut short so the placebo participants could start treatment without delay.

The improved overall mortality rate was “a new and unexpected result,” said trial coordinator Nigel Beckett, MB, ChB. “People who deal with the very elderly have always been a little concerned about a balance between benefit and adverse effects,” he explains. “Hopefully, we have squashed the idea that it is a balance between risk and benefit because this trial was all benefit.” The reductions in heart failure and stroke were especially important because “anyone who deals with the elderly knows these events are what they fear most,” he added.

In an accompanying editorial John B. Kostis, MD, chairman of the department of medicine at Robert Wood Johnson Medical School in New Brunswick, N.J., welcomes the study. “The results prove it is not too late to start hypertensive therapy in older people,” he writes, “and it expands the upper limit of the age spectrum for which there is evidence…of a treatment benefit” (N Engl J Med. 2008;358:1958-1960).

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