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Posted: April 15, 2008

Lowering Blood Pressure in Oldest of the Old Extends Life: Study

Lowering blood pressure in the very elderly could cut their total death rate by more than 20% and slash the likelihood of non-fatal heart attacks, stroke and other cardiovascular incidents by a third, according to a new study.
There is a tendency for doctors to not aggressively treat high blood pressure, or hypertension, in the very elderly, fearing that aggressive treatment may do more harm than good. The practice, however, is not without its controversy, leading, in part, to this latest study.
The 3,845-patient Hypertension in the Very Elderly Trial (HYVET), which is coordinated by scientists from Imperial College London, is the largest ever clinical trial to study the effects of lowering blood pressure solely in those age 80 and older, the so-called oldest of the old.
As a part of the trial, participants were given either a placebo or the diuretic indapamide slow release (SR) 1.5mg, with the addition of the ACE inhibitor perindopril in tablet form once a day.
In turn, researchers found that the benefits of treatment include a 21% (p=0.02) reduction in total death rate, a 39% (p=0.05) reduction in stroke mortality rate, a 64% (p<0.001) reduction in fatal and non-fatal heart failures and a 34% (p<0.001) reduction in cardiovascular events. The benefits were apparent within the first year of follow-up.
The reduction in overall death was a novel and unexpected result. Earlier trials had demonstrated that reducing blood pressure in those younger than 80 reduces stroke and cardiovascular events. However, previous smaller and inconclusive studies also suggested that while lowering blood pressure in those 80 or older reduced the number of strokes, it did not reduce, and may have even increased, total mortality.
The findings in this latest study was so resounding that, the trial was stopped early, last July, on the recommendation of an independent data monitoring committee after they witnessed significant reductions in overall mortality and stroke in those receiving treatment.
Emeritus Professor Christopher Bulpitt, the lead investigator on the study from the Care of the Elderly Group at Imperial College London, said: "Before our study, doctors were unsure about whether very elderly people with high blood pressure could see the same benefits from treatment to lower their blood pressure as those we see in younger people. Our results clearly show that many patients aged 80 and over could benefit greatly from treatment. Populations are living longer and we have growing numbers of people living well into their 80s and beyond, so this is good news. We are very pleased that cardiovascular events were reduced safely with a reduction in total mortality."
The researchers hope their findings will clear up uncertainty among clinicians about the benefits of treating those 80 and older for high blood pressure.
"Many very elderly people with high blood pressure are not being treated for it at the moment, because doctors are unsure about whether or not treatment will help them,” said Dr. Nigel Beckett, the trial coordinator from the Care of the Elderly Group. “We hope that following our study, doctors will be encouraged to treat such patients in accordance with our protocol."
As the trial was stopped early, an extension involving patients receiving active-treatment is now underway to assess the longer term benefits of treatment.
Patients with high blood pressure (defined here as a systolic blood pressure between 160-199 mmHg), from 13 countries, were randomized for the double-blind, placebo-controlled trial, which began in 2001. The mean age of participants was 83 years and 7 months.
Patients were given either placebo or indapamide slow release (SR) with the addition of perindopril, in tablet form once a day as required, to achieve a target blood pressure of 150/80mmHg. The average follow-up of patients was just over two years by which time 20% of the placebo subjects and 48% of those taking medication had achieved the target blood pressure of 150/80 mmHg. In those patients who were followed up for longer, a larger number of patients receiving active treatment achieved the target blood pressure.
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The research findings were presented at the American College of Cardiology in Chicago and published in the New England Journal of Medicine.

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