Hypertension in the Very Elderly - A Call to Improve Blood Pressure Management of Our PAD Patients

Wahlberg, E.

doi:10.1016/j.ejvs.2008.06.005

« Previous Next »European Journal of Vascular & Endovascular Surgery
Volume 36, Issue 4 , Pages 407-408, October 2008

Hypertension in the Very Elderly - A Call to Improve Blood Pressure Management of Our PAD Patients

The Heart Center, Linköping University Hospital, SE-585 51 Linköping, Sweden

published online 04 August 2008.

Blood pressure treatment is overlooked in elderly PAD patients, and especially in vascular surgical wards and clinics. During the preoperative work-up of a Critial Limb Ischemia (CLI) patient in his or her eight decade of life pronounced ulcer pain or concomitant diseases takes precedence. Furthermore, multiple medications make us reluctant to tamper with the drug list and adjust prescriptions with the realistic view that we are indeed surgeons and not specialists in vascular medicine. In light of all the health problems the CLI patients suffer from, control of hypertension is not a priority.

There are also other issues that contribute to our unwillingness to control hypertension. Many of us remember occasional CLI patients with a quickly deteriorating foot status and increased pain following addition of a second or third anti-hypertensive drug. This presumed “reduction in perfusion-pressure” to the foot has never been reproduced in clinical studies and are not scientifically proven.¹, ² While it may be relevant from time to time this potential issue with anti-hypertensive treatment is probably exaggerated and is not a strong argument against proper blood pressure control.

Unfortunately the scientific support for aggressive blood pressure control in the elderly has also been weak. Few studies are designed to evaluate anti-hypertensive treatment specifically in CLI patients and most large outcome trials enrolling general hypertensive populations have not recruited the very elderly or only a few.³, ⁴ There is also relatively little data available on the effects of treating the type of hypertension, called Isolated Systolic Hypertension that is common in older patients.

One of these concerns is no longer an issue. At the end of March 2008 the hypertension in the very elderly trial (HYVET) reported that it was terminated early due to favorable results in one of its treatment arms and that it was unethical to continue. Simultaneously the results were published.⁵ HYVET enrolled 3845 patients mainly from Europe and Asia who were 80 years of age or older and had a sustained systolic blood pressure of 160mm Hg or more. The patients received either the diuretic indapamide or matching placebo. An angiotensin-converting–enzyme inhibitor was added in the active arm if necessary to achieve the target blood pressure of 150/80mm Hg and the study continued for five years.

The results emphasized the value of aggressive antihypertensive treatment also in the very elderly. It dismissed the suspicion that stroke prevention has an associated cost of increased mortality, as the incidence of fatal and non-fatal stroke was reduced by 30% in the active treatment arm and all cause mortality by 21%. A large reduction in congestive heart failure was also noted (hazard ratio 0.36 95% CI 0.22–0.58). The benefit was apparent already during the first year of treatment and despite the fact that the population was healthier than the PAD group we usually meet in our clinics, we should consider these results carefully.

Despite the high age and the limited life of span of our PAD patients there are now evidence that all should receive antihypertensive treatment if their systolic blood pressure is over 160mm Hg, and the tolerability of this treatment is probably good. Less heart failure opposes the “poor perfusion to the foot “concept. Those of you who already manage your patients this way should be commended, while the rest of us should be able to improve and split our attention between the vascular surgical view and a more medicine oriented approach in favour of our patients. Active therapy can even enhance blood flow by improving heart failure and thus be beneficial for the patency of the grafts we implant.⁶

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