New SIGN guidance emphasises that treating hypertension in the over-60s effectively can significantly reduce cerebrovascular and cardiovascular events, explains Dr Ron MacWalter

The prevention and treatment of hypertension and target organ disease are important public health challenges. Although many patients with hypertension are detected, many do not continue with treatment or are not adequately controlled.1

The need to develop guidelines

Hypertension in older people is not managed optimally at present,2 and until now most guidelines on hypertension have had only a small section on the management of elderly patients.

In contrast, SIGN Guideline No. 49, Hypertension in Older People, is a comprehensive guide to the treatment of hypertension in those over 60 years of age. It is designed to dispel myths about hypertension being 'normal' in older people and to allay any fears about treating older people with hypertension.3

The guideline also provides guidance on the specific needs of special groups of the elderly – those with diabetes mellitus, cardiovascular disease, renal disease, strokes and transient ischaemic attacks (TIAs), dementia and the very elderly.

There is a continuously increasing risk associated with higher blood pressure. Older people are more likely than younger people to have hypertension and to benefit from treatment to reduce their blood pressure. Meta-analyses of trials in elderly people with hypertension have shown that the relative risk reduction achieved by antihypertensive treatment is about 40% for strokes and 20% for coronary events.4,5,6,7

The main determinants of hypertension-related risk are level of blood pressure, both diastolic and systolic, presence of other cardiovascular risk factors, age, target organ damage, and associated clinical conditions. Every patient deserves a multifactorial risk assessment for primary and secondary prevention, and the guideline details how this should be done.8

Older patients with hypertensive blood pressure levels have a higher risk of cardiovascular complications than younger hypertensives,9 and treatment that reduces diastolic4,10 and isolated systolic11,12 hypertension reduces this risk. Recent trials show a 50% reduction in heart failure in the elderly with antihypertensive treatment.13,14

Treatment of hypertension also reduces the incidence of fatal and non-fatal stroke, cardiovascular disease (major coronary events and chronic heart failure) and, in some studies, reduces cardiovascular and total mortality.15,16

Treatment to target levels below 140/90mmHg (unless specific disease conditions dictate a lower target level) is advised for most older people. This may mean the use of regimens with multiple drugs.17 Where possible, single daily dosing is advocated.

The guideline also highlights the importance of non-pharmacological methods in treating hypertension. A multidisciplinary team approach involving coordination between doctors, nurses, pharmacists and other health professionals is recommended.

How robust is the evidence?

The guideline development group comprised 16 individuals, including representatives from patient groups, practice nurses, GPs, physicians and geriatricians with experience of treating older people with hypertension, public health specialists, pharmacists and a health economist. The group therefore reflected those responsible for primary and secondary prevention as well as those with experience in dealing with the consequences of hypertension.

As with other SIGN guidelines, a highly structured development methodology was used.18 The evidence base was carefully evaluated, and identified in collaboration with members of the development group by the SIGN information team.

The evidence base consisted mainly of randomised controlled trials, meta-analyses4–7 and systematic reviews, together with other studies such as longitudinal and cross-sectional studies.

Searches were carried out on Medline, Embase and Pascal and The Cochrane Library was consulted. The literature search was not restricted to trials in elderly people as many hypertension trials have included patients up to and beyond 80 years of age. Other hypertension guideline documents were obtained and evaluated. 19–22

Critical appraisal of the evidence base was carried out by small groups of the development team working in areas of special interest. The levels of evidence and grades of recommendations have been published previously in Guidelines in Practice (April 2001, Vol. 4(4) p.20). The guideline also includes 'Good Practice Points' agreed by the multidisciplinary development group. All of these details can be found in the guideline8 and on the SIGN website: www.sign.ac.uk.

How will the guideline improve patient care?

The main recommendations in the guideline are set out in the Summary of recommendations (see Figure 1, below).

Figure 1: First page of the summary of recommendations from SIGN Guideline No.49
Summary of recommendations p1
Summary of recommendations p2
Summary of recommendations p3
Summary of recommendations p4
© Scottish Intercollegiate Guidelines Network 2001

The guideline suggests how frequently blood pressure should be monitored. Setting thresholds for therapy and targets for blood pressure control should lead to a reduction in the serious consequences of hypertension (see Table 1, below). This is especially important in the groups of elderly patients with diabetes and renal disease, in whom the targets are set at a lower level.

Table 1: Potential consequences of inadequate treatment of hypertension
  • Cerebrovascular disease
    • Ischaemic stroke
    • Haemorrhagic stroke
    • Transient ischaemic attacks
    • Dementia
  • Cardiovascular disease
    • Myocardial infarction
    • Angina
    • Congestive cardiac failure
    • Left ventricular hypertrophy
    • Left ventricular dysfunction
  • Renal disease
  • Peripheral vascular disease
  • Aortic aneurysm
  • Retinopathy
  • Accelerated (malignant) hypertension

A full risk assessment using the Joint British Societies Coronary Risk Prediction Chart for primary prevention of cardiovascular disease is advised. For those who already have cardiovascular disease or are over 75 years of age (and therefore excluded from the Joint British Chart), use of the WHO table for assessing risk is recommended. Both charts are contained in the guideline.

The treatment initiation plan is shown in Figure 2 (below).

Figure 2: Initiation of treatment for hypertension in older people, from Quick Reference Guide No.49
Algorithm from quick reference guide
© Scottish Intercollegiate Guidelines Network 2001

The guideline emphasises that even if target blood pressures are difficult to achieve, a small reduction in blood pressure is worthwhile. Combinations of drugs at low doses are recommended to minimise side-effects.

How will the guideline promote best practice?

Designed to be user-friendly to primary care teams, the guideline allows practices to discuss how they will achieve the goals set out, in terms of detecting, treating and monitoring older people with raised blood pressure.

The guideline also promotes better communication with patients, as well as providing an excellent basis for audit.

It is recognised that best practice, as advocated by the SIGN guideline, will result in members of the primary care team spending more time identifying and treating hypertensive patients, and also in increased prescribing. However, the evidence shows that this will be rewarded by a significant reduction in cerebrovascular and cardiovascular events in the future.

We hope that extra funding will be made available to meet the challenge set by the guideline. Coronary heart disease and stroke are priority diseases, and an analysis of the evidence in this area has shown that more effective treatment of hypertension, through the application of this guideline, will reduce such events.

  • Copies of Hypertension in Older People, Guideline No. 49, can be obtained from SIGN, Royal College of Physicians, 9 Queen Street, Edinburgh EH2 IJQ (tel 0131 225 7324) or can be downloaded from the website at www.sign.ac.uk

References

  1. Colhoun HM, Dong W, Poulter NR. Blood pressure screening, management and control in England: results from the health survey for England 1994. J Hypertens 1998; 16: 747-52.
  2. Dickerson JE, Brown MJ. Influence of age on general practitioners' definition and treatment of hypertension. Br Med J 1995; 310: 574.
  3. Dickerson JE, Garratt CJ, Brown MJ. Management of hypertension in general practice: agreements with and variations from the British Hypertension Society guidelines. J Hum Hypertens 1995; 9: 835-9.
  4. Thijs L, Fagard R, Lijnen P, Staessen J, Van Hoof R, Amery A. A meta-analysis of outcome trials in elderly hypertensives. J Hypertens 1992; 10: 1103-9.
  5. Insua JT, Sacks HS, Lau TS, Lau J, Reitman D, Pagano D, et al. Drug treatment of hypertension in the elderly: a meta-analysis. Ann Intern Med 1994; 121: 355-62.
  6. Pearce KA, Furberg CD, Rushing J. Does antihypertensive treatment of the elderly prevent cardiovascular events or prolong life? A meta-analysis of hypertension treatment trials. Arch Fam Med 1995; 4: 943-9.
  7. Holme I, Ekelund LG, Hjermann I, Leren P. Quality-adjusted meta-analysis of the hypertension/coronary dilemma. Am J Hypertens 1994; 7: 703-12.
  8. Scottish Intercollegiate Guidelines Network. Hypertension in Older People. Guideline No. 49. Edinburgh. SIGN. 2001.
  9. Lever AF, Ramsay LE. Treatment of hypertension in the elderly. J Hypertens 1995; 13: 571-9.
  10. Dahlof B, Lindholm LH, Hansson L, Schersten B, Ekbom T, Wester PO. Morbidity and mortality in the Swedish Trial in Old Patients with hypertension (STOP-Hypertension). Lancet 1991; 338: 1281-5.
  11. Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhager WH et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997; 350: 757-64.
  12. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991; 265: 3255-64.
  13. Kostis JB, Davis BR, Cutler J, Grimm RH, Berge KG, Cohen JD, et al. Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group. JAMA 1997; 278: 212-6.
  14. Levy D, Larson MG, Vasan RS, Kannel WB, Ho KK. The progression from hypertension to congestive heart failure. JAMA 1996; 275: 1557-62.
  15. Gueyffier F, Froment A, Gouton M. New meta-analysis of treatment trials of hypertension: improving the estimate of therapeutic benefit. J Hum Hypertens 1996; 10: 1-8.
  16. Hebert PR, Moser M, Mayer J, Glynn RJ, Hennekens CH. Recent evidence on drug therapy of mild to moderate hypertension and decreased risk of coronary heart disease. Arch Intern Med 1993; 153: 578-81.
  17. Hansson L, Zanchetti A, Carruthers SG, Dahlof B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998; 351: 1755-62.
  18. Scottish Intercollegiate Guidelines Network. An Introduction to SIGN Methodology for the Development of Evidence-based Guidelines. Guideline No. 39. Edinburgh. SIGN, 1999.
  19. The sixth report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure. Arch Intern Med 1997; 157: 2413-46.
  20. 1999 World Health Organization – International Society of Hypertension Guidelines for the Management of Hypertension. Guidelines Subcommittee. J Hypertens 1999: 17: 151-83.
  21. Ramsay L, Williams B, Johnston G, MacGregor G, Poston L, Potter J, et al. Guidelines for management of hypertension: report of the third working party of the British Hypertension Society. J Hum Hypertens 1999; 13: 569-92.
  22. Wood D, Durrington P, Poulter N, McInnes G, Rees A, Wray R, on behalf of the British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society, and British Diabetic Association. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998; 80 (Suppl 2): S1-S29.

Guidelines in Practice, June 2001, Volume 4(6)
© 2001 MGP Ltd
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