Does Treating Hypertension In The Very Elderly Equally Reduce Mortality In All Subgroups?

There is already a large body of evidence suggesting that hypertension among the youngest-old (65-80 years-old) should be treated no differently from that of younger adults. This includes the current definition of hypertension (>= 140 mmHg for systolic or >= 90 mmHg for diastolic Blood Pressure [BP]) also for this age group. Even though orientations from the 'VII Joint on Hypertension' have recommended the extrapolation of this evidence also for the oldest-old group (>= 80 y.o), until recently there was no definite evidence that treating hypertension in this age group would reduce overall mortality. In fact, a meta-analysis of several mega clinical trials, which have included small subgroups of very elderly people, has found a reverse relationship between treating hypertension and overall mortality. Very recently, the HyVET study has found that treating otherwise healthy very elderly hypertensive (systolic BP 160-210 mmHg as inclusion criteria) people at a goal of 150 x 80 mmHg of systolic and diastolic BP, respectively, reduces overall mortality over an average 1.8 year period. However, several considerations should arise when interpreting data from this study. First, this study included vastly healthy elderly people, having excluded subjects with heart failure (HF), dementia, and frail, institutionalized, elderly people. HF and dementia are possibly the two main confounders of the relationship between BP and mortality among the very elderly. BP tends to decrease in dilated hypertensive myocardiopathy, as it does in malnutrition states associated with advanced dementia. In fact, a study has found that, in the general very elderly population, hypertension was only associated with increased overall mortality after excluding people who have deceased within a 3-year period from baseline, a disproportional part of them apparently from HF and dementia. Aging is a heterogeneous process, and considering only chronological age may not be adequate in analyzing the relationship between BP and mortality in the very elderly. For instance, the relationship between BP and risk of ischemic stroke is the inverse among people with bilateral carotid stenosis >= 70%, regardless of age. As a general rule, it may be reasonable deciding to treat otherwise healthy very elderly hypertensive people (without HF, significant carotid stenosis, or moderate-to-advanced dementia) with at least 2 consecutive systolic BP measures >= 160 mmHg. In this specific age group, the therapeutic goal should be 150 x 80 mmHg, as evidenced by the HyVET study. Lower BP levels might be associated with an increased risk of hypoperfusional stroke even among otherwise healthy very elderly people, since cerebral blood flow autoregulation is lost in the presence of significant cerebrovascular disease - a finding not uncommon in this age group.