Medical Research: What is the background for this study? What are the main findings?
Response: Hypertension is a very common condition and as adults age they are more likely to have hypertension. Knowing how best to treat hypertension in older adults is important for healthcare practitioners; however, dilemmas arise when treating older adults. Which medication to choose, which dose, and which blood pressure to target are all factors to consider. Additionally, old age is accompanied by many physiologic changes to the body and these changes may affect the safety and effectiveness of medicines that treat hypertension. The evidence base (number of studies) for safe and effective treatments shrinks substantially in older populations and guidelines offer conflicting recommendations for older adults.
This systematic review had the goal to collect and compare recent hypertension guidelines and major hypertension studies with respect to age. Information that will help clinicians evaluate the benefits and harms of using antihypertensive medications in people 65 years and older.
The main findings are that older adults ([65 years) have been excluded from clinical trials in the past and this continues to impact the ability to develop evidence-based clinical practice guidelines for management of hypertension in older adults. Adverse effects of antihypertensive medications are not consistently reported in trials with older adults, so accurately weighing risks and benefits in this population is challenging. While benefits are clear for a systolic blood pressure less than 150 mmHg, stricter control in adults over 65 years is not shown to be consistently better.
Medical Research: What should clinicians and patients take away from your report?
Response: The goal of a systolic pressure at or below 140 mmHg has been around a long time, and there’s still skepticism among some practitioners about accepting a higher blood pressure in older adults. When we looked at the body of evidence, it was not convincing that 140 mmHg should be the goal for older adults. Practitioners need to understand that keeping systolic blood pressure in older adults below 150 mmHg is important, it’s what we consider a mild level of control. For older adults that level is also good enough. After an extensive review, there was no significant evidence that more intensive management is necessary. The risks of these medications should be weighed against the benefits, it is difficult to do this when risks are not reported as meticulously as the benefits are reported. In a lot of ways, practitioners are left to make educated guesses at the best course of treatment for the patient. It’s important to respect the unknown, in terms of decision making and make sure the older patient understands what we do know about treating high blood pressure and what we don’t know, as part of shared decision making.
Medical Research: What recommendations do you have for future research as a result of this study?
Response: We definitely need more research in older population. For example, there are only a few studies that pertain to adults over the age of 80 years. We also need more standardization in treatment regimens that are used in clinical trials. There is too much heterogeneity in medications that are used in clinical trials and this poses problems for combining and comparing the results of different studies. We need adverse events to be carefully recorded and reported in hypertension trials.