ArticlesAntihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials*
Introduction
Randomised controlled trials have clearly shown the clinical benefit of treating even mildly hypertensive people with drugs to lower blood pressure, either through strategy comparison1 or in placebo-controlled trials,2, 3 mainly based on diuretics or β-blockers. The effect of treatment is beneficial in elderly hypertensive patients with systolic and diastolic hypertension4 or with isolated systolic hypertension.5, 6 The effect of treatment is greater in hypertensive people over 60 or 65 years old if expressed as an absolute risk reduction,7 because elderly people have a greater risk of cardiovascular disease without treatment than younger people.
However, Amery and colleagues8 used a trend analysis in their trial to suggest that the treatment might be less effective or even harmful above the age of 80 years. Given lack of certainty about the efficacy of such treatment in very elderly people, a specific trial was started in 1994.9, 10 The results of that trial are not yet available, so we have collected data from subgroups of randomised controlled trials to assess the evidence for and against antihypertensive treatment in people over age 80.
Section snippets
Trials
In our analysis, we included all available subgroup data from randomised controlled clinical trials to give a non-biased estimate of the effect of treatment in hypertensive people of 80 years or older compared with that of placebo, no treatment, or lower dosage. We identified trials by use of a literature review, contacts with the principal investigators of published trials or the authors of meta-analyses, and the results of a systematic review by Mulrow and colleagues11 for the Cochrane
Results
Six of the trials that are included in most meta-analyses on drugs to lower blood pressure in older people did not recruit patients over 80 years old.1, 15, 16, 17, 18, 19 The data from the Kuramoto trial20 were not available by subgroup. To our knowledge, that trial is the only eligible one that we were not able to include in our analysis. The data from five trials5, 22, 23, 24, 25 that included people over 80 were available from the INDANA database of individual patients.21 These five trials
Discussion
Our review is based on several data sources, but we made no further attempt to identify any unpublished trial data that would cause potential publication bias. If any reader knows of completed trials for which data are not yet published, we would like them to contact us.
We analysed data from subgroups of trials that had not been specifically designed to test our hypothesis—that antihypertensive treatment is beneficial in hypertensive patients aged 80 years or older. Overall, our results suggest
References (32)
- et al.
Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension
Lancet
(1997) - et al.
Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly Trial
Lancet
(1985) - et al.
Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension)
Lancet
(1991) - et al.
Considerations for the meta-analysis of randomized clinical trials: summary of a panel discussion
Control Clin Trials
(1989) Five-year findings of the Hypertension Detection and Follow-up Program—I: reduction in mortality of persons with high blood pressure, including mild hypertension
JAMA
(1979)The Australian therapeutic trial in mild hypertension
Lancet
(1980)MRC trial of treatment of mild hypertension: principal results
BMJ
(1985)- et al.
Hypertension in the elderly: implications and generalizability of randomized trials
JAMA
(1994) Prevention of stroke by antihypertensive drug treatment in older persons with isolated hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP)
JAMA
(1991)- et al.
New meta-analysis of treatment of hypertension: improving the estimate of therapeutic benefit
J Hum Hypertens
(1996)
Influence of antihypertensive drug treatment on morbidity and mortality in patients over the age of 60 years: EWPHW results: sub-group analysis based on entry stratification
J Hypertens
The Hypertension in the Very Elderly Trial (HYVET)
J Hum Hypertens
The Hypertension in the Very Elderly Trial (HYVET): rationale, methodology and comparison with previous trials
Drugs Aging
Antihypertensive drug therapy in the elderly
A general parametric approach to the meta-analysis of randomized clinical trials
Stat Med
Effect of two different therapeutic approaches on total and cardiovascular mortality in a cardiovascular study in the elderly (CASTEL)
Jpn Heart J
Cited by (616)
Management of high blood pressure in primary cardiovascular prevention for old and very old adults
2022, NPG Neurologie - Psychiatrie - GeriatrieHypertension in the Elderly
2019, Encyclopedia of Biomedical Gerontology: Volume 1-3Hypertension in the elderly
2019, Encyclopedia of Biomedical GerontologyAntihypertensive treatment in people of very old age with frailty: Time for a paradigm shift?
2023, Journal of HypertensionPulse Wave Velocity and Blood Pressure Variability as Prognostic Indicators in Very Elderly Patients
2023, Journal of Clinical Medicine
- *
Members listed at end of paper