JNC 7, seventh report of the Joint National Committee on Detection,
Evaluation, and Treatment of High Blood Pressure.
CCB, calcium channel blocker; ACE-I, angiotensin converting enzyme inhibitor;
ARB, angiotensin II receptor blocker.*Percentage of person-examinations
of men and women aged 80 years or older using ARB is 0% and 0.1%, respectively.
Goal blood pressure systolic <140 mm Hg and diastolic <90 mm Hg.
Differences across age groups are significant (P<.001)
for treated men, all women, and treated women with hypertension.
Lloyd-Jones DM, Evans JC, Levy D. Hypertension in Adults Across the Age SpectrumCurrent Outcomes and Control in the Community. JAMA. 2005;294(4):466-472. doi:10.1001/jama.294.4.466
Author Affiliations: Department of Preventive
Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
(Dr Lloyd-Jones); and the National Heart, Lung, and Blood Institute’s
Framingham Heart Study, Framingham, Mass (Drs Evans and Levy).
Context Data are sparse regarding current rates of hypertension treatment and
control, and risks associated with hypertension, among persons older than
Objective To determine the prevalence of blood pressure stages, hypertension treatment
and control, and cardiovascular risk among older patients with hypertension.
Design, Setting, and Participants A community-based cohort study in which data were collected during all
Framingham Heart Study examinations attended in the 1990s. Participants were
pooled according to age: younger than 60 years, 60 to 79 years, or 80 years
or older. There were 5296 participants who contributed 14 458 person-examinations
of observation, including 7135 hypertensive person-examinations (4919 treated).
Main Outcome Measures Prevalence of hypertension, its treatment, and its control were compared
across age groups. Risks for incident cardiovascular disease during follow-up
of up to 6 years were estimated as multivariate-adjusted hazard ratios (HRs)
and 95% confidence intervals (CIs) using Cox proportional hazards regression.
Results Prevalence of hypertension and drug treatment increased with advancing
age, whereas control rates were markedly lower in older women (systolic <140
and diastolic <90 mm Hg). For ages younger than 60 years, 60 to 79, and
80 years and older, respectively, control rates were 38%, 36%, and 38% in
men (P = .30) and 38%, 28%, and 23% in
women (P<.001). Relative risks for cardiovascular
disease associated with increasing blood pressure stage did not decline with
advancing age, and absolute risks increased markedly. Among participants 80
years of age or older, major cardiovascular events occurred in 9.5% of the
normal blood pressure (referent) group, 19.8% of the prehypertension group
(HR, 1.9; 95% CI, 0.9-3.9), 20.3% of the stage 1 hypertension group (HR, 1.8;
95% CI, 0.8-3.7), and 24.7% of the stage 2 or treated hypertension group (HR,
2.4; 95% CI, 1.2-4.6).
Conclusions Relative to current national guidelines, rates of blood pressure control
in the community are low, especially among older women with hypertension.
Short-term risks for cardiovascular disease are substantial, indicating the
need for greater efforts at safe, effective risk reduction among the oldest
patients with hypertension.
Elderly persons are among the fastest growing segments of the US population1 and they have the highest prevalence of hypertension.2 Despite numerous trials demonstrating the benefits
of blood pressure lowering among older individuals with hypertension,3- 9 available
data suggest that rates of treatment and control are suboptimal.10- 13 Studies
from national surveillance data, however, are typically limited to adults
younger than 75 years of age.10,14,15 Data
are sparse regarding current patterns of treatment and control of hypertension
among individuals 80 years of age and older. In addition, contemporary risks
associated with hypertension in this oldest age group are poorly characterized.
Therefore, we sought to determine the current prevalence, patterns, treatment,
control, and risks of hypertension in persons aged 80 years or older compared
with younger individuals with hypertension in the community.
Study design and entry criteria for the Framingham Heart Study have
been detailed elsewhere.16,17 All
examinations and procedures were approved by the institutional review board
of Boston Medical Center and all participants provided informed consent.
For the present study, we considered each routine examination a participant
attended to be a discrete observational unit; thus, any single participant
could contribute 1 or more person-examinations to the study base. Our sample
comprised examination data collected between January 1, 1990, and December
31, 1999, from Framingham Heart Study original cohort members (enrolled 1948-1952
and reexamined at 2-year intervals) and offspring cohort members (enrolled
1971-1973 and reexamined at 4-year intervals). Participants with prevalent
cardiovascular disease (CVD) at the time of their examination were excluded
from analysis. Since the original cohort was reexamined twice as often as
the offspring cohort, we compensated by taking person-examination data from
every offspring cycle but from only every second cycle in the original cohort.
We stratified participants into 3 age groups based on their age at examination:
younger than 60 years, 60 to 79, or 80 years and older.
At each examination, blood pressure was measured twice in the left arm
by a physician, and the average of the 2 values was used as described previously.13 Hypertension was defined as systolic blood pressure
(SBP) greater than or equal to 140 mm Hg or diastolic blood pressure (DBP)
greater than or equal to 90 mm Hg, or receiving medication specifically for
the indication of hypertension. Control to goal blood pressure was defined
as SBP less than 140 mm Hg and DBP of less than 90 mm Hg among treated hypertensive
participants. Levels of other cardiovascular risk factors were obtained concurrently
with blood pressure. After review of all participant medical records by a
panel of 3 trained physicians using previously published Framingham Heart
Study criteria,18 we defined a major cardiovascular
event as the occurrence of a major coronary heart disease event (coronary
death, myocardial infarction, or coronary insufficiency), stroke, hospitalized
congestive heart failure, or other CVD cause of death. Hospitalized congestive
heart failure was defined according to the Framingham criteria.19
All analyses were performed using SAS statistical software version 8
(SAS Institute, Cary, NC).20 The period of
follow-up for incident CVD began on the date of examination and continued
until another examination was attended, or for a maximum of 6 years, after
which follow-up was censored. Each eligible examination attended prior to
December 31, 1999, ended the follow-up period from the prior examination and
initiated a new person-examination with the age group reclassified as appropriate.
Also at each eligible examination attended during this time, the Seventh Report
of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7) hypertension stage was reclassified,
medication use and other covariate data were collected, and follow-up for
incident CVD was begun at the time of the new examination date. Follow-up
for CVD events was continued through December 31, 2004, at which time all
remaining observations were censored. This method of pooling person-examinations
allows covariate data to be updated as collected while avoiding overlapping
periods of follow-up. It has been used extensively and has yielded estimates
of effect comparable to Cox proportional hazards regression analyses with
We determined the prevalence of JNC 7 blood pressure categories14,22 in each age group by sex, classifying
participants into the following mutually exclusive categories: normal blood
pressure (<120/<80 mm Hg), prehypertension (SBP 120-139 and/or DBP 80-89
mm Hg), stage 1 hypertension (SBP 140-159 and/or DBP 90-99 mm Hg), or stage
2 hypertension or treated (untreated SBP ≥160 and/or DBP ≥100 mm Hg
or receiving antihypertensive therapy). We determined the prevalence of antihypertensive
treatment, the number of agents used, the types of antihypertensive agents
used, and control of hypertension to goal levels (<140/<90 mm Hg) by
sex and age group. Finally, we determined the incidence of the 3 CVD outcomes
(major cardiovascular events, major coronary heart disease events, and hospitalized
congestive heart failure as defined previously) for up to 6 years following
each examination by sex and age group. Sex-specific prevalence of hypertension
therapy, hypertension control, and CVD incidence were compared across age
groups using the Cochran-Mantel-Haenszel statistic. Cox proportional hazards
regression analysis was used to estimate the influence of blood pressure stage
on CVD risk within age groups by sex, with participants in the normal blood
pressure group serving as the referent. Models were adjusted for age and sex,
or age, sex, smoking status, diabetes status, and total/high-density lipoprotein
cholesterol ratio. A 2-tailed P value ≤.05 was
considered statistically significant.
There were 5296 eligible participants (2317 men and 2979 women) who
contributed 14 458 person-examinations during the study period. Participants
with hypertension contributed 7135 (49.3%) person-examinations and were receiving
antihypertensive therapy at 4919 of these examinations. Characteristics of
the study sample are shown in Table 1.
Consistent with prior observations,15,23 SBP
was higher at more advanced ages, whereas DBP decreased in participants aged
60 years or older.
The distribution of JNC 7 blood pressure stages is shown in Figure 1, stratified by sex and age groups. As
expected, the prevalence of hypertension increased markedly with advancing
age: 27.3% among participants younger than 60 years of age, 63.0% in those
aged 60 to 79 years, and 74.0% in those aged 80 years or older, with 33.3%,
23.5%, and 19.1%, respectively, classified as prehypertension, and the remaining
39.4%, 13.5%, and 6.9%, respectively, in the normal blood pressure category.
The overall prevalence of treatment among participants with hypertension
was 68.9%. Treatment rates increased substantially from the younger than 60
years age group (55.7%) to the 60 to 79 years age group (72.5%) with no further
increase in the oldest group (74.2%). Among treated individuals, however,
the number of antihypertensive medications used was similar across age groups,
with approximately 60% of treated patients with hypertension using only 1,
30% using 2, and 10% using 3 or more antihypertensive medications.
Patterns of use differed for distinct classes of antihypertensive agents
across age groups and by sex (Figure 2).
Use of thiazide diuretic agents increased in patients older than age 60 years,
with women consistently using them more than men. Among treated patients with
hypertension who were older than 80 years, 23% of men and 38% of women were
using thiazide diuretic agents for antihypertensive therapy. Use of β-blocker
and calcium channel blocker medications were most prevalent in the 60 to 79-year-old
group, with somewhat lower rates among the younger and the oldest groups.
In contrast, angiotensin-converting enzyme (ACE) inhibitor use declined with
advancing age from 44% in the youngest treated patients with hypertension
to 33% in persons aged 80 years or older. As expected, use of angiotensin
receptor blockers was low among all ages, because these agents were first
introduced during the study period. Use of other classes of antihypertensive
agents increased steadily with advancing age, especially among men in whom
use of α-blockers increased from 6.5% in the youngest to 15.7% in the
oldest. The increase in α-blocker use among men was likely due to treatment
for concomitant hypertension and symptoms of prostatism.
Among all participants with hypertension, the prevalence of control
to blood pressure <140/<90 mm Hg was 32.4%. Overall prevalence of control
declined with advancing age, due entirely to substantially lower rates of
control in older women, as shown in Figure 3.
Among treated participants with hypertension, the overall prevalence of control
of SBP to less than 140 and DBP to less than 90 mm Hg was 47.0%, with significantly
lower rates of control with advancing age in both men and women.
The numbers of cardiovascular events during follow-up are presented
in Table 2, stratified by age. The absolute
rates and HRs for CVD end points during up to 6 years’ follow-up, including
major CVD events, major coronary heart disease events, and hospitalized congestive
heart failure, are shown in Table 3.
Compared with individuals with normal blood pressure, the relative risks (HRs) associated with hypertension increased with higher
blood pressure levels within each age group, and they were at least as high
among participants aged 80 years or older as among younger hypertensives.
However, absolute rates of CVD were substantially
higher among persons aged 80 years or older. Furthermore, absolute rates of
CVD increased much more markedly with increasing blood pressure stage among
persons aged 80 years or older compared with younger participants with hypertension.
When we analyzed outcomes by classifying blood pressure stage ignoring
antihypertensive therapy, treated individuals were included among those with
normal, prehypertension, and stage 1 hypertension categories. In this analysis,
the absolute and relative risks for CVD outcomes increased in these lower
blood pressure categories, whereas absolute and relative risks decreased in
the highest blood pressure group (data not shown). In a separate analysis,
we excluded treated participants with hypertension and examined outcomes only
among those who were untreated. In this analysis, from which the highest-risk
individuals were excluded, the findings were similar to those shown in Table 3 for the oldest age group, but absolute
and relative risks were lower among younger hypertensive participants.
In the current investigation of patterns of hypertension prevalence,
treatment, control, and outcomes in the community in the decade of the 1990s
and beyond, we observed the following: among those older than age 80 years,
the prevalence of hypertension exceeds 70% and fewer than 10% have normal
blood pressure levels; among the oldest participants with hypertension, only
38% of men and 23% of women were controlled to blood pressure levels of less
than 140/90 mm Hg; and among treated participants with hypertension in the
oldest age group, 62% were receiving only one antihypertensive medication
and only 23% of men and 38% of women were receiving a thiazide diuretic. With
regard to outcomes, the relative hazards for CVD events associated with hypertension
do not decline with advancing age and the absolute risks increase markedly,
especially among the oldest participants with hypertension.
With the aging of the population, the burden of hypertension is expected
to increase significantly. The current data provide an important look at the
status of hypertension in the oldest individuals. The very elderly group is
one of the fastest growing segments of the US population.1 Thus,
urgent public health efforts are needed for patients and physicians to improve
awareness of risks of hypertension at older ages, strategies and benefits
of therapy, and importance of achieving blood pressure reduction, if possible
to goal blood pressure levels.
As expected, we observed that persons aged 80 years or older had the
greatest prevalence of hypertension. Whereas average DBP increases until approximately
age 55 years and then decreases throughout the remaining lifespan, average
SBP increases linearly with age until near the end of life.15,23 Thus,
elderly persons have a high incidence and prevalence of hypertension, which
is overwhelmingly due to isolated systolic hypertension. It is rare to escape
the development of hypertension with aging: even for individuals free of hypertension
at age 65 years, the remaining lifetime risk of developing hypertension is
Individuals who are susceptible to CVD as a result of hypertension would
be more likely to die or have CVD at younger ages, and therefore would have
been excluded from our study sample. Nonetheless, we observed relative hazards
for CVD that were similar among the oldest as among younger hypertensives.
Given the similar relative and very high absolute risks among those aged 80
years or older, our data suggest that this group may have the most to gain
from blood pressure reduction, even in the face of their shorter remaining
Our results confirm that the risks for CVD associated with prehypertensive
blood pressure levels (SBP 120-139 and/or DBP 80-89 mm Hg) are higher than
for normal blood pressure levels (<120/<80 mm Hg).25 Clinical
trial data are needed in all age groups to determine whether aggressive lifestyle
or other interventions can reduce CVD risk and also progression to hypertension.
Whether such a strategy would reduce CVD event rates among individuals with
hypertension aged 80 years and older is unproven, and may be worthy of study
in clinical trials in light of our findings.
Significant controversy exists regarding the relative risk/benefit ratio
of antihypertensive therapy for persons aged 80 years and older. Using data
from the European Working Party on High Blood Pressure in the Elderly (EWPHE)
study, Amery et al26 suggested that drug treatment
may be less effective or even harmful in patients with hypertension aged 80
years and older. Data from a pilot study suggested a 53% reduction in stroke
but a 23% increase in risk for total mortality with antihypertensive therapy
in persons aged older than 80 years.27 A meta-analysis
from the Individual Data Analysis of Antihypertensive intervention trials
(INDANA) group5 combined data on the subsets
of individuals aged 80 and older from 4 major double-blind placebo-controlled
trials: SHEP,4 SHEP-pilot,28 Syst-Eur,7 and STOP-Hypertension.3 Among
the 1670 trial participants aged 80 years and older, active treatment compared
with placebo was associated with a 34% reduction in stroke rates, 22% reduction
in major CVD, and 39% reduction in congestive heart failure. There was a nonsignificant
6% increase in risk for all-cause mortality among treated participants compared
with the placebo group.5 Thus, as recently
reviewed by Chaudhry et al,29 currently available
data suggest overall benefit for treatment in this age stratum, although data
are weak for treatment of stage 1 hypertension. The Hypertension in the Very
Elderly Trial, a large multicenter, placebo-controlled trial in hypertensive
patients aged 80 and older, is ongoing, and is comparing initial diuretic
therapy with initial ACE inhibitor therapy and placebo.30 This
trial should provide important, direct information regarding the benefits
and risks of antihypertensive therapy in the oldest age group.
Perhaps due to the uncertainty regarding safety discussed previously,
our data suggest major gaps in the implementation of antihypertensive therapies
recommended by current clinical practice guidelines in the community. Individuals
aged 80 years and older, and particularly women in this group, had the lowest
rates of blood pressure control of any group. It appeared that poor control
was due in part to lack of use of combination therapy and perhaps, to poor
selection of drug classes. Despite a wealth of evidence suggesting that thiazide
diuretics are the most cost-effective agents for blood pressure reduction,31- 33 and that they are
particularly efficacious among the elderly,4 we
found overall low rates of thiazide use, particularly among men. We observed
high prevalence of use of more expensive agents such as ACE inhibitors and
other classes of drugs (eg, α-blockers), although data supporting their
efficacy in older hypertensive patients are limited. Our findings confirm
at the community level the trends that have been observed in national surveillance
data and large databases regarding underuse of thiazides and preferential
prescription of newer antihypertensive agents rather than thiazide diuretics.34- 37
Control of blood pressure is more difficult to achieve when starting
at a higher baseline blood pressure, as is often the case with older hypertensive
patients. Clinicians may be reluctant to treat older patients as aggressively
because of perceived lower benefits or possible increased risk of adverse
effects. Nonetheless, the treatment principles recommended by JNC V (1993),38 JNC VI (1997),39 and
JNC 7 (2003)14,22 have been essentially
the same for older as for younger hypertensive patients, including those with
isolated systolic hypertension. JNC 7 recommends that for the elderly, physicians
should start with low doses, add additional medications that can work synergistically
at low doses, and gradually continue to increase doses and add medications
to attempt to reach goal blood pressure levels.14,22 In
the recently completed Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT)40,41 of
antihypertensive therapies among hypertensive patients aged 55 years and older
(mean [SD] age, 66.9 [7.7] years), two thirds of those who achieved goal blood
pressure required 2 or more medications to do so, consistent with the findings
of other studies. Among older hypertensive patients, achieving goal levels
would be expected to require even more. Polypharmacy and medication expenses
for the elderly are of great concern, but there are a number of inexpensive,
highly effective, once-daily medications (including thiazide diuretics) that
have proven efficacy at lowering blood pressure and reducing CVD events. There
are also increasing numbers of combination pills available with variable doses
of standard agents.
Since the Framingham Heart Study original and offspring cohort participants
are, with few exceptions, whites of European extraction, the generalizability
of our findings to other racial groups may be limited. The prevalence of hypertension,
however, is known to be higher among some other races, including African Americans.11 The overall prevalence of blood pressure control
we observed (32.4%) is almost identical to the 34% observed in the NHANES
sample from 1999 to 2000,2,11 suggesting
that patterns in this community closely mirror national trends. We chose to
classify blood pressure according to the current JNC 7 staging scheme in individuals
examined in the 1990s. As several primary studies25,42,43 have
now documented extensively, there is a continuum of risk that increases linearly
from normal blood pressure through prehypertensive levels to frank hypertension.
Since we sought to define risk in the oldest group, we believe that using
the current understanding of blood pressure risk to classify individuals is
most appropriate. We may have underestimated the risks of CVD associated with
hypertension, given that hypertensive participants (and particularly treated
hypertensive participants) may have been more likely to receive other therapies
designed to reduce CVD risk during follow-up (eg, statins). If there was age-related
bias in such treatment, it may have skewed our results somewhat but we did
not directly compare hazard ratios across age groups. Thus, our results should
provide a representative contemporary picture of prevalence, treatment, control,
and risks associated with hypertension in the community.
Corresponding Author: Donald M. Lloyd-Jones,
MD, ScM, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern
University, 680 N Lake Shore Dr, Suite 1102, Chicago, IL 60611 (firstname.lastname@example.org).
Author Contributions: Dr Lloyd-Jones had full
access to all of the data in the study and takes responsibility for the integrity
of the data and the accuracy of the data analysis.
Study concept and design: Lloyd-Jones, Evans,
Analysis and interpretation of data: Lloyd-Jones,
Drafting of the manuscript: Lloyd-Jones.
Critical revision of the manuscript for important
intellectual content: Lloyd-Jones, Evans, Levy.
Statistical expertise: Evans.
Administrative, technical or material support:
Study supervision: Lloyd-Jones, Levy.
Funding/Support: Dr Lloyd-Jones is supported
by grant K23 HL04253 from the National Heart, Lung, and Blood Institute. The
Framingham Heart Study is supported by National Institutes of Health/National
Heart, Lung, and Blood Institute contract N01-HC-25195.
Role of the Sponsor: The National Heart, Lung,
and Blood Institute approved the final version of the manuscript. It sponsors
the Framingham Heart Study through a contract but had no direct involvement
in this analysis or the decision to publish.