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Editor's Correspondence
July 26, 1999

Antihypertensive Therapy in the Elderly: Evidence-Based Guidelines and Reality

Arch Intern Med. 1999;159(14):1621-1622. doi:

In their thorough analysis of the treatment of hypertension in elderly nursing home residents, Gambassi and colleagues1 concluded that the current prescription pattern with a predominance of calcium antagonists and angiotensin-converting enzyme inhibitors at the expense of β-blockers did not follow recommended guidelines. As an explanation for this discrepancy, they suggest that "the present findings may reflect appropriate prescribing by an enlightened physician facing the difficult applicability of the guidelines to the frail, very old nursing home resident with multiple comorbid conditions and concomitant, complex pharmacological regimens." We can only reemphasize these thoughts. As can be seen in Table 1,26 there is a distinct difference between the "healthy" elderly patients with hypertension (such as those included in the SHEP [Systolic Hypertension in the Elderly Program], Syst-Eur [Systolic Hypertension in Europe], or Syst-China [Systolic Hypertension in the Elderly Chinese Trial] studies) and even the normotensive elderly population, not to speak of nursing home residents. It must be remembered that in the SHEP trial, of each 100 screened patients with isolated systolic hypertension, only 1 was randomized. Thus, most of the clinical trials in the elderly are not dealing with populations that are representative of the general elderly population with hypertension. In addition, the previous Joint National Committee (JNC), the JNC V,7 has erroneously promoted β-blockers as first-line therapy in the elderly, although since then it has become clear that, in the elderly, β-blockers are inappropriate and should no longer be used as initial antihypertensive therapy.8 This means that in the United States alone more than 7 million elderly patients with hypertension still are exposed to the cost, inconvenience, and adverse effects of β-blockers without having any benefits whatsoever. This also means, "mirabile dictu," that we are currently unable to provide evidence-based therapy in the majority of elderly patients with hypertension. The evidence on which the JNC guidelines are based originates from a completely different patient subset and therefore cannot be extrapolated to the 99% of patients who were for one reason or another excluded from participating in the SHEP study. It is perhaps reassuring to note that in the study of Gambassi and colleagues,1 the percentage of patients (8%) receiving β-blockers was remarkably small. Perhaps physicians in that study are trying to teach physicians who write guidelines a lesson on how to more appropriately treat hypertension in the elderly.

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