Editorials

What Can We Learn From the American Heart Association and American College of Cardiology Expert Consensus Document on Geriatric Hypertension?
Stanley S. Franklin, MD
Heart Disease Prevention Program, UCI School of Medicine, University of California, Irvine, Irvine, California

Address for correspondence: Stanley S. Franklin, MD Associate Medical Director Heart Disease Prevention Program University of California, Irvine Sprague Hall 112 Irvine, CA 92697 ssfranklinmd@earthlink.net

The expert consensus document in the elderly1 is designed to cover topics that have incomplete evidence-based information regarding clinical practice, and therefore often must be altered signicantly on the basis of future randomized controlled trials (RCTs). Hence, it is not uncommon for consensus documents to have both strengths and potential weaknesses. For example, the guidelines stress the importance of using 24-hour ambulatory blood pressure (BP) measurement as the ideal method of diagnosing both masked and white-coat hypertension1 ; indeed, errors of detection are magnied in the elderly population with isolated systolic hypertension (ISH) because of increased BP variability contributing to white-coat hypertension and white-coat effect. The consensus statement1 emphasizes these points but neglects to mention that recruitment of elderly subjects for RCTs exclusively by clinic BP will perpetuate the inclusion of those with white-coat hypertension and excessive white-coat effect and exclude those with masked hypertension. These errors of recruitment may lead to mistakes in dening optimal target BP treatment goals for the elderly hypertensive subjects in general and for specic subgroups in particular, such as those with diabetes, chronic kidney disease, and cerebrovascular and cardiovascular disease. Guidelines for initiating and dening the target goal of antihypertensive therapy in the elderly have been updated.1 Indeed, to date, there have been no intervention trials involving the elderly that used systolic BP (SBP) target goals of <140 or <150 mm Hg, but instead used SBP target goals of <160 mm Hg; surprisingly, national and international guidelines used target goals of <140 mm Hg for all ages, largely on the basis of expert opinion rather than on outcome of RCTs. The new consensus statement1 conrms that antihypertensive therapy should be started in uncomplicated hypertension in persons age 6579 years with a SBP of 140 mm Hg or a diastolic BP (DBP) of 90 mm Hg, with a target goal of <140/90 mm Hg (again, based on expert opinion only); however, in persons age 80 years, the threshold for starting therapy and target goal was raised to a SBP of 150 mm Hg. Importantly, BP should also be measured with the patient in the standing position for 13 minutes to evaluate for postural hypotension

The author has no funding, nancial relationships, or conicts of interest to disclose.

Received: September 21, 2011 Accepted: September 23, 2011

(not an infrequent nding in the elderly), and these standing values can be used to determine target goals.1 Furthermore, this consensus statement implies (again, based on expert opinion) that physiological rather than chronological age of 80 years can be considered in lowering SBP to <140145 mm Hg with 2 or 3 antihypertensive agents that are well tolerated.1 There has been doubt as to the age limit beyond which there was no benet or even increased risk for treating geriatric hypertension. In 1991, the landmark double-blinded, placebo-controlled Systolic Hypertension in the Elderly Program (SHEP) study rst established that older patients with ISH and a mean age of 72 years beneted from antihypertensive lowering of stage 2 ISH (160 mm Hg). The Hypertension in the Very Elderly Trial (HYVET) study,2 voted the outstanding BP trial of 2008, involved the very old (age 80105 years, mean age 83 years) and utilized a randomized, double-blind, placebo-controlled protocol in 3845 subjects with sustained SBP of 160 mm. This study of stage 2 ISH and systolic-diastolic hypertension showed that there was a signicant reduction in both fatal (45%) and all strokes (34%) and heart failure (72%), and reduction in both cardiovascular (27%) and all-cause mortality (28%).2 Therefore, there is overwhelming evidence that effective pharmacological lowering of BP by a mean decrease of 12/4 mm Hg reduced cardiovascular events in this elderly population.2 On the other hand, there are questions that remain unanswered in the HYVET study.1 The majority of recruited subjects for HYVET were healthy and robust; would an increasing number of frail elderly give different results? Second, what is the optimal BP target goal for maximizing therapeutic benet in the HYVET study? Furthermore, RCTs in subjects recruited with ambulatory BP monitoring or home BP monitoring are needed to answer these important questions. The question of which class of drugs is best suited to start rst in patients with ISH remains controversial.1 Diuretics and calcium channel blockers have been shown to be effective in the elderly in lowering BP and in reducing cardiovascular events in major intervention studies.1 Of the diuretics, chlorthalidone, with a substantially longer half-life than hydrochlorothiazide, is twice as potent at the same dosage and is especially effective in controlling nighttime hypertension.1 Beta-blockers have been used for the treatment of hypertension, but evidence for the reduction in cardiovascular disease events in older patients with uncomplicated hypertension has been unconvincing.3
Clin. Cardiol. 35, 1, 12 (2012) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI:10.1002/clc.21004 2012 Wiley Periodicals, Inc.

Combination therapy is favored over monotherapy for many reasons: increased efcacy, avoidance of side effects because of lower dosage and reciprocal drug effects, convenience when given in a single pill, and further reduction in morbidity and mortality when compared with single antihypertensive agents, as proven in RCTs.1 Indeed, most elderly hypertensives need combination therapy to reach therapeutic goal; when goal therapy is 20/10 mm Hg above SBP/DBP target goal, it may be preferable to start with combination therapy.1 Importantly, using blockade of the renin-angiotensin-aldosterone-system (RAAS) is a logical foundation for therapy; combining the RAAS inhibitor with either a diuretic or calcium channel blocker is scientically logical, and tends to restore dose responsiveness regardless of the activity of the RAAS and/or the extent of salt sensitivity. Elderly individuals with complicated hypertension (ie, with associated coronary heart disease, left ventricular hypertrophy, diastolic or systolic cardiac dysfunction, heart failure, atrial brillation, stroke, diabetes, or chronic renal failure) will require specic therapy for their primary complication, in addition to antihypertensive medication. Whether lowering BP to <130/80 mm Hg in these high-risk cardiovascular disease patients further reduces morbidity and mortality remains controversial. There is probable heterogeneity of responses1 ; patients who are prone to develop stroke, macroproteinuric chronic kidney disease, heart failure, or aortic aneurysms will prot by having their hypertension lowered to <30/80 mm Hg, whereas those with coronary heart disease may not benet from BP <130/70, and may indeed be at greater risk with these lower levels of BP because of reduction in coronary blood ow, resulting in ischemia.4 Resistant hypertension is dened as failure of a rational 3-drug regimen, including an adequate dose of a diuretic to reduce BP <140/90 mm Hg.1 The many causes of resistant hypertension include stage 2 ISH, older age with increased arterial stiffness, black race, obesity, diabetes, sleep apnea, excessive alcohol intake, stage 3 chronic kidney disease (especially with macroalbuminuria), secondary causes of hypertension, and living in the southeastern United States.

It should also be noted that not every patient with resistant hypertension, as dened above, is at the same risk; in a Spanish population study,5 as many as one-third of patients with resistant hypertension were found to have whitecoat resistance, and therefore many of them may have been overtreated. Therefore, there is a special need to use 24-hour ambulatory BP monitoring on patients with resistant hypertension.5 The use of aldosterone inhibitors has been especially effective in successfully reversing resistant hypertension. Not only is hyperaldosteronism present in 20% of patients with resistant hypertension, but also, in the absence of elevated blood aldosterone levels, the response rate to these inhibitors (spironolactone or eplerenone) when added as a fourth agent results in a mean reduction of 20/10 mm Hg of SBP/DBP; this represents approximately twice as large a response as obtained with the addition of other classes of antihypertensive agents.6 Indeed, as with most consensus documents, the present encyclopedic treatise on hypertension in the elderly, reviewing 740 recent and past publications, has major strengths and some weaknesses.

References
1. Aronow WS, Feig JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2011; 57:20372114. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358: 18871898. Lavie CJ, Messerli FH, Milani RV. Beta-blockers as rst-line antihypertensive therapy: the crumbling continues. J Am Coll Cardiol. 2009;54:11621164. Bangalore S, Kumar S, Lobach I, et al. Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and Bayesian random-effects metaanalyses of randomized trials. Circulation. 2011;123:27992810. De la Sierra A, Segura J, Banegas JR, et al. Clinical features of 8295 patients with resistant hypertension classied on the basis of ambulatory pressure monitoring. Hypertension. 2011;57:898902. Epstein M, Calhoun DA. The role of aldosterone in resistant hypertension: implications for pathogenesis and therapy. Curr Hypertens Rep. 2007;9:98105.

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Clin. Cardiol. 35, 1, 12 (2012) S.S. Franklin: AHA and ACC consensus document on geriatric hypertension Published online in Wiley Online Library (wileyonlinelibrary.com) DOI:10.1002/clc.21004 2012 Wiley Periodicals, Inc.