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Address for correspondence:
Stanley S. Franklin, MDAssociate Medical DirectorHeart Disease
Prevention ProgramUniversity of California, IrvineSprague Hall
112Irvine, CA [email protected]
Editorials
What Can We Learn From the American HeartAssociation and
American College ofCardiology Expert Consensus Document
on Geriatric Hypertension?Stanley S. Franklin, MDHeart Disease
Prevention Program, UCI School of Medicine, University of
California, Irvine,
Irvine, California
The expert consensus document in the elderly1 is designed
to cover topics that have incomplete evidence-based
information regarding clinical practice, and therefore often
must be altered significantly on the basis of future
randomized controlled trials (RCTs). Hence, it is not
uncommon for consensus documentsto have both strengths
and potential weaknesses.
For example, the guidelines stress the importance ofusing
24-hour ambulatory blood pressure (BP) measure-
ment as the ideal method of diagnosing both masked and
white-coat hypertension1; indeed, errors of detection are
magnified in the elderly population with isolated systolic
hypertension (ISH) because of increased BP variability con-
tributing to white-coat hypertension and white-coat effect.
The consensus statement1 emphasizes these points but
neglects to mention that recruitment of elderly subjects for
RCTs exclusively by clinic BP will perpetuate the inclu-
sion of those with white-coat hypertension and excessive
white-coat effect and exclude those with masked hyperten-
sion. These errors of recruitment may lead to mistakes in
defining optimal target BP treatment goals for the
elderlyhypertensive subjects in general and for specific
subgroups
in particular, such as those with diabetes, chronic kidney
disease, and cerebrovascular and cardiovascular disease.
Guidelines for initiating and defining the target goal of
antihypertensive therapy in the elderly have been updated.1
Indeed, to date, there have been no intervention trials
involving the elderly that used systolic BP (SBP) target
goals of
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Combination therapy is favored over monotherapy for
many reasons: increased efficacy, avoidance of side effects
because of lower dosage and reciprocal drug effects,
convenience when given in a single pill, and further
reduction in morbidity and mortality when compared
with single antihypertensive agents, as proven in RCTs.1
Indeed, most elderly hypertensives need combination
therapy to reach therapeutic goal; when goal therapy is
20/10 mm Hg above SBP/DBP target goal, it may be
preferable to start with combination therapy.1 Importantly,using
blockade of the renin-angiotensin-aldosterone-system
(RAAS) is a logical foundation for therapy; combining the
RAAS inhibitor with either a diuretic or calcium channel
blocker is scientifically logical, and tends to restore dose
responsiveness regardlessof theactivity of theRAAS and/or
the extent of salt sensitivity.
Elderly individuals with complicated hypertension (ie,
with associated coronary heart disease, left ventricular
hypertrophy, diastolic or systolic cardiac dysfunction,
heart
failure, atrial fibrillation, stroke, diabetes, or chronic
renal
failure) will require specific therapy for their primary
complication, in addition to antihypertensive medication.
Whether lowering BP to
