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June 2, 1999

Should β-Blockers Be Used to Treat Hypertension in Elderly Patients?—Reply

Author Affiliations

Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthor

JAMA. 1999;281(21):1988-1989. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-21-jbk0602

In Reply: While it is true that both β-blockers and diuretics are recommended by JNC VI, the report states, "When compared with each other, diuretics (hydrochlorothiazide with amiloride hydrochloride) are superior to the β-blocker atenolol. In older patients with isolated systolic hypertension, diuretics are preferred because they significantly reduce multiple end-point events."1 One reason diuretics may be superior is that a major pathological component of hypertension in the elderly is decreased arterial compliance, which leads to a selective increase of systolic pressure as a result of accelerated reflection of the arterial pulse wave from the periphery.2 Peripheral resistance is increased, and cardiac output is low. β-Blockade lowers cardiac output; furthermore, in younger patients with systolic hypertension, acute β-blockade lowers blood pressure without affecting arterial compliance, whereas in older patients, compliance is decreased and blood pressure is unchanged.3 In elderly patients with systolic hypertension, diuretic treatment lowers peripheral resistance without affecting cardiac output.4 Thus, there are theoretical as well as practical reasons for believing that diuretic treatment is preferable to treatment with β-blockers in elderly patients with uncomplicated hypertension.

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