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Therapeutics

Antihypertensive treatment reduced morbidity and mortality in elderly patients with hypertension

ACP J Club. 1992 Mar-April;116:35. doi:10.7326/ACPJC-1992-116-2-035


Source Citation

Dahlöf B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet. 1991 Nov 23;338:1281-5.


Abstract

Objective

To determine the effect on cardiovascular morbidity and mortality of treating elderly patients (70 to 84 years of age) for elevated diastolic blood pressure (BP).

Design

Randomized, double-blind, placebo-controlled trial.

Setting

116 health centers throughout Sweden.

Patients

The study included 1627 patients with treated or untreated essential hypertension, who, during a 1-mo placebo run-in period had diastolic BP between 105 and 120 mm Hg or systolic BP from 180 to 230 mm Hg with diastolic BP ≥ 90 mm Hg. 812 patients were randomized to active treatment and 815 patients to placebo. Reasons for exclusion were orthostatic hypotension, recent myocardial infarction or stroke, and other severe illnesses. Follow-up included all patients and was for a mean of 25 mo.

Intervention

Each center chose 1 of 4 basic, once-daily oral regimens: atenolol, 50 mg; metoprolol, 100 mg; pindolol, 5 mg; or hydrochlorothiazide, 25 mg, plus amiloride, 2.5 mg. If systolic BP was ≥ 160 mm Hg or diastolic BP was ≥ 95 mm Hg after ≥ 2 mo of treatment, then the diuretic was added to any of the β-blockers or vice versa. Patients were changed to open treatment if mean BP exceeded 230/120 mm Hg.

Main outcome measures

Fatal and nonfatal stroke or myocardial infarction, and other cardiovascular mortality.

Main results

At the last follow-up the active treatment group's mean BP was 167/87 mm Hg (SD 21/9 mm Hg) compared with 186/96 mm Hg (SD 22/10 mm Hg) for the control group. 84% of the treatment group and 77% of the placebo group were still taking study medication. There were 58 fatal or nonfatal cardiovascular events among the treatment group compared with 94 events among the placebo group {relative risk reduction (RRR) 40%, 95% CI 15% to 57%}*. Risk was reduced for stroke {RRR 47%, CI 14% to 67%}*; fatal stroke {RRR 76%, CI 9% to 96%}*; and other cardiovascular death {RRR 70%, CI 3% to 93%}*; but not for myocardial infarction {RRR 13%, CI -56% to 51%}*. Overall mortality (36 deaths among the treatment group and 63 deaths among the placebo group) was also reduced {RRR 43%, CI 13% to 63%}*.

Conclusion

Treating hypertension in patients between 70 to 84 years of age led to a reduction in cardiovascular morbidity and mortality.

Sources of funding: Astra/Hässle; ICI Pharma; Merck Sharp & Dohme; Sandoz; Swedish County Councils.

Address for article reprint: Dr. L. Hansson, Department of Medicine, University of Göteborg, Östra Hospital, S-416 85 Göteborg, Sweden.

*Numbers calculated from data in article.


Commentary

This study and the recently reported Systolic Hypertension in the Elderly Program (SHEP) have made abundantly clear the benefits of treating hypertension in older patients (1). Whereas SHEP showed that treating systolic hypertension reduced the incidence of stroke and cardiovascular events, this study completes the picture for diastolic hypertension as well.

The study is robust in design and execution with complete follow-up. The age range of selected patients ensured frequent clinical events. Although diastolic hypertension was the primary entry criterion, most patients had combined hypertension. The clinical impact of therapy was impressive, with 14 strokes and 15 deaths prevented for every 1000 patients treated for 1 year, and a total reduction in mortality of 43%. Secondary end points such as congestive heart failure, transient ischemic attacks, and angina were reduced by 67% with treatment. The frequency of myocardial infarction was reduced by 13% (nonsignificant). There were no differences in treatment-related morbidity, and the benefits of treatment extended throughout the full age range of the participants.

In clinical practice, STOP-Hypertension means that elderly patients with sustained diastolic blood pressures > 100 mm Hg should be treated and that the advantages of treatment extend to at least 84 years of age and probably older. The reductions in primary and secondary events were greater in the current study than in SHEP, indicating the important role that diastolic hypertension has in the pathogenesis of these events. Although only diuretics and β-blockers were used in this study, one can expect that other agents will yield similar results.

David L. Bronson, MD
University of VermontBurlington, Vermont, USA

David L. Bronson, MD
University of Vermont
Burlington, Vermont, USA


Reference

1. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final result of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265:3255-64.