Quality Indicators For The Care Of Hypertension In Vulnerable Elders

INTRODUCTION

Providing high quality of care to older adults with hypertension is growing in importance due to improved survival of hypertensive patients into old age and a growing older population at risk for developing systolic hypertension. ¹ Hypertension, a condition associated with mortality and functional decline with age, ² affects 79% of those age greater than 80 years old. ³ Despite improved treatment of hypertension in the general US population, ⁴ the older hypertensive population continues to have inadequate blood pressure (BP) control in comparison to younger populations. ^{3 5}

This new proposed indicator set for the care of hypertension in vulnerable elders reflects two new themes. The first is a shift in emphasis towards the treatment of systolic hypertension (SH), rather than diastolic, because of known risk associated with SH ^6–10 and downstream cardiovascular and mortality benefits of treating SH in older adults. ¹¹ The second addresses systolic blood pressure (SBP) goals, including the goals of therapy for vulnerable elders and those in the oldest age groups that account for individual values and preferences and expected benefits of antihypertensive medications in the context of overall prognosis, multiple morbidities¹ and risk of adverse drug events. ¹²

METHODS

A total of 256 articles were considered in this review; 38 guidelines identified via the Web Search, 83 articles identified through reference mining, 135 identified through the ACOVE-3 literature searches.

RESULTS

Of the 22 potential quality indicators, 14 were judged valid by the expert panel process (see the quality indicators on pages XXX-XXY of this supplement). Eight indicators were rejected (www.mywebsiteforthis.org). We describe the literature summaries that support each of the indicators judged to be valid in the expert panel process.

Confirming Elevated SBP

1. IF an asymptomatic vulnerable elder without the diagnosis of hypertension has an elevated systolic blood pressure (BP) measurement, THEN a repeat BP measurement should occur as follows:

• 140–159 mmHg: within 6 months

• 160–179 mmHg: within 2 months

• ≥180 mmHg: within 1 month

BECAUSE reassessment of BP may improve the detection of hypertension in elderly patients and lead to treatment of hypertension, improvement in BP control, and reduction in cardiovascular events and mortality.

Supporting Evidence:

There is expert consensus that patients with uncontrolled blood pressure should have close follow-up. The Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7), ¹³ Veterans Health Administration (VHA), ¹⁴ and American College of Physicians (ACP) ¹⁵ recommend follow-up at 2 months for BPs of 140–159 mmHg, at 1 month for 160–179 mmHg, and 1 week for SBP above 180 mmHg. The recommended intervals from the international guidelines were relaxed for adaptation to quality indicator.

Documenting Diagnosis of Hypertension

2. IF a vulnerable elder without a diagnosis of hypertension has a systolic BP of ≥140 mmHg on two consecutive visits, THEN the diagnosis of hypertension should be documented OR home/24-hour ambulatory blood pressure monitoring should be ordered within 2 months or documented as done in the past 2 years BECAUSE diagnosing patients with persistently elevated BP with hypertension or ordering home BP monitoring may lead to improvement in treatment and for patients with hypertension, reduction in risk of cardiovascular events and all-cause mortality.

Supporting Evidence:

Although we did not identify any studies that demonstrated a link between documenting hypertension and improved patient outcomes, several guidelines (Canadian Health Education Program (CHEP) ¹⁶, ACP¹⁷, and VHA¹⁸) support this practice. In cases where white coat hypertension is suspected, the JNC, ¹³ ESH, ¹⁹ CHEP, ¹⁶ BHS, ²⁰ VHA, ¹⁸ and ACP¹⁷ guidelines discuss home or ambulatory BP monitoring. One small observational study²¹ found that an ambulatory BP of ≥ 135 mmHg independently predicts coronary artery disease (CAD) better than office BP.

Identifying cardiovascular disease (CVD) and Co-Existing cardiovascular (CV) Risk Factors

3. IF a vulnerable elder is newly diagnosed with hypertension, THEN cardiovascular disease/risk assessment should be performed within 3 months (if not done in the prior 3 months) including:

1. History: Myocardial infarction, angina, cardiomyopathy, aortic aneurysm, peripheral arterial disease, stroke, transient ischemic disease, hypercholesterolemia, family history of early coronary artery disease, smoking

2. Exam: Murmurs or gallops, peripheral arterial exam, peripheral edema, weight, BMI, waist circumference

3. Review of systems: Chest pain, shortness of breath, transient vision/neurologic symptoms, nocturnal dyspnea, leg pain

4. Laboratory: Blood glucose and serum lipids

5. Electrocardiogram

BECAUSE identifying co-existing cardiovascular risk factors may improve treatment of these cardiovascular risk factors and reduce the risk of cardiovascular events and may lead to a lower BP target (e.g., if diabetes is diagnosed).

Supporting Evidence:

No studies have focused on the long-term health outcomes of performing a targeted history, physical exam, review of symptoms, or ordering tests for risk stratification (bloodwork, electrocardiograms, etc) for older newly-diagnosed hypertensive patients. Attention to these items, however, leads to identifying co-morbidities that are associated with increased mortality and/or functional decline among older individuals: diabetes, ^{2 22 23} heart failure, ^24–27 ischemic heart disease, ^{2 26 28 29} stroke, ^{2 26 30 31} and atrial fibrillation. ³² Several guidelines (JNC, ¹³ ESH, ¹⁹ CHEP, ¹⁶ BHS, ²⁰ VHA, ¹⁸ and ACP¹⁷) recommend performing history, physical examination, review of symptoms, laboratory tests, and ECG to identify (1) cardiovascular risk, (2) modifiable risk factors, (3) and guide therapy in patients newly diagnosed with hypertension.

Assessment of Renal Function

4. IF a vulnerable elder is newly diagnosed with hypertension, THEN an assessment of renal function should be performed within 3 months (if not done in the prior 3 months) BECAUSE identification of chronic kidney disease (CKD) may guide further antihypertensive therapy (compelling indication for angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy and lower BP target) and early recognition of CKD, which is associated with increased mortality and disability among older adults, may lead to interventions that reduce progression of CKD.

Supporting Evidence:

Although no studies specifically link the effect of assessing renal function (by measuring serum creatinine alone or by calculating estimated glomerular filtration rate) in newly diagnosed hypertensive vulnerable elders with morbidity or mortality, identifying CKD in these patients guides further antihypertensive therapy (e.g., lower BP goals and use of ACEIs). Early recognition of CKD, which is associated with increased mortality and disability among older adults, ^{33 34} may lead to interventions that reduce progression of CKD.

The JNC, ¹³ ESH, ¹⁹ CHEP, ¹⁶ BHS, ²⁰ VHA, ¹⁸ and ACP¹⁷ guidelines recommend obtaining a serum creatinine as a routine lab evaluation for all hypertensive patients. The National Kidney Foundation (NKF) ³⁵ recommends measuring serum creatinine for calculation of the estimated GFR using the Modified Diet in Renal Disease equation³⁶ in patients at increased risk (including those with hypertension and age>60) for CKD. The JNC and VHA guidelines reserve calculation of estimated GFR as an option to better estimate risk of cardiovascular disease and CKD.

Identifying Secondary Causes of Hypertension

5. IF a vulnerable elder is newly diagnosed with hypertension THEN the quantity and frequency of alcohol intake should be documented within 3 months (if not done in the prior 3 months) BECAUSE screening for alcohol use in newly diagnosed hypertensive elders may lead to reduction in alcohol use and improvement in BP control.

6. IF a vulnerable elder is newly diagnosed with hypertension AND is taking a non-steroidal anti-inflammatory drug (NSAID) or cyclooxygenase-2 (COX-2) inhibitor, THEN there should be documentation within 6 months of dose reduction, an attempt to use an alternative medication, or justification for continued use BECAUSE chronic NSAIDs can cause/exacerbate hypertension and alternative treatments for pain are effective and safe for treatment of chronic pain in older patients..

Overview

Because essential hypertension usually occurs in the 5^th decade of life, new-onset hypertension in the very old should prompt clinicians to consider secondary causes. ^{13 37} The JNC, ¹³ ESH, ¹⁹ CHEP, ³⁸ BHS, ²⁰ VHA, ¹⁸ and ACP¹⁷ guidelines all support screening and performing further investigations to determine underlying causes of hypertension. In addition to identifying CKD, two other secondary causes of hypertension (alcohol use and NSAID use) were selected from among those recommended by the JNC based upon their prevalence among older patients.

Alcohol use

Supporting Evidence:

We did not identify any studies that focus on long-term cardiovascular or mortality outcomes of screening older hypertensive patients for problem alcohol use. Among non-elders who consume alcohol, however, two recent meta-analyses demonstrate that behavioral or pharmacological interventions to reduce alcohol intake may have a modest effect (1 to 6 mmHg) on SBP. ^{39 40} Subjects with higher baseline SBP and those with greater reductions in alcohol intake had greater reduction in BP. ³⁹ The JNC, ¹³ ACP, ¹⁷ and BHS²⁰ specifically mention screening for excessive alcohol consumption as a modifiable or secondary cause of hypertension, and all these guidelines suggested definitions of excessive consumption (ranging from 2 daily servings for men and 1 daily serving for women ¹⁷, ¹⁹ to 3 daily servings for men and 2 daily servings for women ²⁰).

Non-steroidal anti-inflammatory drugs and COX-2 inhibitors

Supporting Evidence:

We identified one meta-analysis and 3 randomized controlled trials (RCTs) that evaluated the association between NSAID use and BP. The meta-analysis⁴¹ found that NSAID use was associated with a mean SBP increase of 5 mmHg (95% CI, 1.2 to 8.7 mm Hg). Patients with hypertension taking antihypertensive medications were affected the most. The RCTs compared different classes of NSAIDs, but all resulted in increased SBP. In the SUCCESS VI ⁴² and VII ⁴³ trials, elders with hypertension and osteoarthritis who were administered rofecoxib had higher incidence of increased SBP (≥20 mmHg above baseline or >140 mmHg SBP) than those administered celecoxib (15–17% versus 7–11%) over the 6 weeks (P<.01). In the third RCT⁴⁴, 74 patients with diabetes, hypertension and osteoarthritis were randomized to rofecoxib, celecoxib, or naproxen. Thirty percent of the patients given rofecoxib had elevated SBP (mean 24-hour SBP > 135 mmHg) versus only 16% for the celecoxib and 19% for naproxen groups (P=.05). The JNC, ¹³ ESH, ¹⁹ CHEP, ¹⁶ VHA, ¹⁸ and BHS²⁰ recommend identifying screening for all non-aspirin NSAID (including COX-2 inhibitor) use as a cause of secondary hypertension.

Patient-Centered Education

7. IF a vulnerable elder is newly diagnosed with hypertension, THEN a discussion of goal BP OR risks of prolonged hypertension should be documented within 3 months BECAUSE discussion of goals of therapy and physician education results in better adherence to prescribed medications and BP control.

Supporting Evidence:

A growing body of literature, summarized recently in a systematic review on shared decision-making, supports a patient collaborative approach to the consultative process, including goal-setting with the patient and provision of information to the patient about their chronic condition. ⁴⁵ In addition, a meta-analysis reported that educational interventions, with or without behavior interventions such as pill boxes, increases adherence rates by 12% (95% CI, 8.0 to 16.0%) among hypertensive patients. ⁴⁶ Patient-centered goal setting and behavior change are now emphasized in the latest JNC and VA recommendations. ^{13 18} The JNC recommends assessing a patient’s understanding of his/her diagnosis, clarifying concerns and misunderstandings, coming to an agreement about the goal BP, moving through the stages of behavior change (precontemplation, contemplation, preparation, action and maintenance), providing written materials, involving patients in making plans, and emphasizing the importance of continuous treatment, lack of cure for hypertension, and asymptomatic nature of the disease. ¹³

Non-Pharmacologic Intervention

8. IF a vulnerable elder is newly diagnosed with hypertension, THEN a non-pharmacologic intervention (e.g. diet, exercise, weight loss, reduced alcohol) should be recommended within 3 months (if not done in the prior 3 months) BECAUSE non-pharmacologic interventions can lower BP in hypertensive patients.

Supporting Evidence:

Low-sodium diet

We identified 2 meta-analyses and 1 RCT that examined the effect of a low-salt diet on hypertension among older patients. The first meta-analysis of 11 RCTs reports that low sodium diets are associated with decreased SBP by 5.6 mmHg (95% CI, 4.31 to 6.85). ⁴⁷ The second meta-analysis of 40 trials of low dietary sodium found that decreased sodium intake results in a reduction in SBP by 2.5 mmHg (95% CI, −3.16 to −1.92). A subgroup analysis showed that trials with mean age ≥45 experienced greater reduction of SBP (3.07 versus 1.77 mmHg, P=0.1) than those performed on younger adults. The trials with mean initial BPs ≥140/90 mmHg experienced greater decreases in BP than those whose subjects were on average normotensive (5.2 versus 1.3 mmHg, P < 0.001). ⁴⁸

The Trial of Nonpharmacologic Interventions in the Elderly (TONE) study⁴⁹, which enrolled older hypertensive patients with SBP <145 mm on one antihypertensive medication demonstrated that patients in the reduced sodium diet arm had a mean decrease in systolic BP of 3.6 mmHg compared to only 0.8 mmHg for patients in the control arm (P<0.001). Furthermore, a low-sodium diet was associated with a reduction in need for antihypertensive medication. The JNC, ¹³ ACP, ¹⁷ VHA, ¹⁸ and BHS²⁰ all recommend no more than 6 grams of sodium chloride (2.4 grams of sodium) per day for hypertensive patients.

A RCT⁵⁰ found that a “Dietary Approaches to Stop Hypertension” (DASH) diet rich in whole grains, vegetables and fruit, low-fat dairy products, lean meats, and legumes/seeds lowered BP among younger adults (mean age 48 years) by 2.2–5.9 mmHg (P<0.01). Participants who were restricted to low sodium (<1g daily) in addition to the DASH diet had a mean SBP of 8.9 mmHg less than the individuals assigned to a high-sodium (3.5 g daily) non-DASH diet (P<.01). Multiple guidelines recommend a DASH diet as a non-pharmacologic intervention to lower BP. ^{13 17–20 38}

Weight loss

The TONE⁵¹ study evaluated the effects of a multicomponent intervention (multidisciplinary lifestyle change counseling, small group and individual meetings, and goal weight loss of ≥4.5 kg) with or without a low-sodium diet in older obese patients on the endpoints: high BP at a TONE follow-up visit, continued use or resumption of antihypertensive medication, or a cardiovascular disease event. The risk over the 28 month study was reduced by 36% (95% CI, 51 to 15%) for the obese participants assigned to the weight loss group; risk was reduced by 53% (95% CI, 65 to 36%) for those assigned to weight loss plus sodium reduction. Multiple guidelines recommend maintaining a healthy weight (BMI between 18–25 kg/m² or <20% above ideal body weight). ^{13 17–20 38}

Exercise

We identified 3 meta-analyses that evaluated the effects of exercise on BP in older adults. The first meta-analysis⁵² reported that exercise intervention among older patients (baseline SBP 115–156 mmHg) resulted in a 2% reduction in SBP (2 mmHg; 95% CI, 4 to 1 mmHg reduction). A second meta-analysis⁵³ of younger and older patients (age18–79) reported that exercise was associated with a decrease in SBP by 4.0 mmHg (95% CI, 3.3 to 4.7) among trials whose participants were classified as hypertensive. A third meta-analysis⁵⁴ reported that aerobic exercise decreased SBP by 3.8 mmHg (95% CI, 2.72 to 4.97 mmHg) regardless of baseline BP. The JNC, VHA, and BHS recommend 30 minutes of any type of exercise on most days of the week. ^{13 18 20} The ESH recommends moderate aerobic exercise such as walking, jogging or swimming for 30–45 minutes 3–4 times per week, ¹⁹ CHEP makes this recommendation for 4–5 days per week. ³⁸ The ACP recommends walking 1 mile in addition to current activity level. ¹⁷

Intervening for Hypertension Above Goal SBP

9. IF a vulnerable elder with HTN has persistent (on 2 consecutive visits) elevation of systolic BP above goal*, THEN an intervention (pharmacologic, lifestyle, compliance, etc.) should occur or there should be documentation of a reversible cause or other justification for the elevation BECAUSE pharmacological treatment of hypertension improves BP and reduces risk of cardiovascular events, stroke, CKD, and mortality, and non-pharmacologic interventions aid in lowering BP.

• Goal systolic BP is:

• Diabetes or chronic kidney disease – 130mm Hg

• Home ambulatory monitoring – 135mm Hg

• All other patients – 140mm Hg OR any other specified goal.

Supporting Evidence:

Since non-pharmacologic and adherence-improving interventions are addressed elsewhere in this review, the evidence presented in his section focuses on pharmacologic interventions for elevated BP. Eight meta-analyses focused on treatment of older patients^{11 55–60} found that reducing SH decreased all-cause mortality, ^{11 56 57 60} cardiovascular events, ^{11 56 57 60} stroke, ^{11 55–58 60} and CKD. ⁵⁹ The results of three of these meta-analyses are presented here. In a meta-analysis¹¹ of 8 trials of the treatment of ISH among older subjects (mean age of 70), active treatment over (mean) 3.8 years resulted in a decreased SBP of 7–18 mmHg. The number needed to treat (NNT) to prevent 1 event over 5 years of treatment was: 59 [95% CI, 55 to 64] for all-cause mortality, 79 [95% CI, 72 to 89] for CV mortality, 26 [95% CI, 25 to 27] for CV (fatal or non-fatal) events, and 48 [95% CI, 45 to 51] for strokes. Stratification by advanced age (> 70), higher SBP, pulse pressure, prior CV complications, and smoking did not affect the relative benefits. A meta-analysis evaluating the effects of SH treatment among very old (age ≥ 80) subjects (7 SH trials) ⁵⁵ found that treatment of systolic hypertension was associated with a RR of 0.66 (P=0.01) for stroke (primary endpoint). Among the secondary endpoints, only CHF (RR 0.81, P=0.01) and major CV events (RR 0.78, P<0.01) favored treatment. A recent meta-analysis⁵⁷ of 29 trials of BP-lowering (mean age 65) evaluated the effects of various drug classes and strategies targeting different blood pressure goals on major cardiovascular events. The pooled difference in SBP between the more aggressive versus the less aggressive blood pressure targets was 4 mmHg. This resulted in an RR of 0.77 (95% CI, .63 to .95) for stroke and 0.85 (95% CI, .76 to .95) for major CV events. The benefit was seen regardless of class of drug used.

Refractory Hypertension

10. IF a vulnerable elder with HTN has persistent (on 2 consecutive visits) elevation of systolic BP above goal* for > 6 months THEN there should be documentation of the suspected reason why the target was not reached AND efforts to address the limitation BECAUSE (1) persistently elevated systolic BP increases risk of stroke and CVD that increases with time among elders who are untreated or undertreated, (2) identifying causes of non-adherence may lead to improved treatment of hypertension, and (3) there may be justifiable reasons to prolong attainment of a specified BP goal

• Goal systolic BP:

• Diabetes or chronic kidney disease – 130mm Hg

• Home ambulatory monitoring – 135mm Hg

• All other patients – 140mm Hg OR any other specified goal

Supporting Evidence:

We did not identify any studies that specifically addressed the time frame within which SBP must be brought under control. Therefore, the support for this indicator is primarily derived from expert opinion. The ACP recommends that after one year, individuals who still have BPs above their goal should be referred to a hypertension specialist. ¹⁷ The CHEP, ¹⁶ JNC, ¹³ and VHA¹⁸ reiterate that if BP is not controlled to goal, then underlying reasons for hypertension should be addressed.

Hypertensive Urgency

11. IF a vulnerable elder without target organ damage has a diastolic BP ≥120 mmHg, THEN immediate therapy and/or referral to emergency room/hospital should occur BECAUSE hypertensive urgency can lead to target organ damage if not immediately addressed.

Supporting Evidence:

In a systematic review of the literature on treatment of hypertensive urgencies and emergencies, ⁶¹ the authors did not identify any high-quality studies that addressed the appropriate time interval or setting in which BP should be controlled, although the most consistent cutoff used to define hypertensive urgency was a diastolic BP of 120 mmHg.

The JNC, ¹³ ACP, ¹⁷ VHA, ¹⁸ European Society of Hypertension (ESH) ¹⁹ and Canadian Hypertension Education Program⁶² guidelines all recommend early triage and close follow-up of patients presenting with severe hypertension. The JNC suggested that after judicious use of short-acting oral BP medication and/or adjustment of existing regimens, patients should be observed for several hours, followed by another clinician visit within 1 to a few days of their initial visit to ensure improvement in BP control. ¹³

Monitoring For Adverse Antihypertensive Drug Events

12. IF a vulnerable elder’s hypertension medication regimen is changed (new medication or dose change) AND within 1 week s/he reports dizziness, syncope/near syncope, near-fall or fall, THEN s/he should be evaluated for orthostatic hypotension at the time of the report (or within 1 week if outside the office) OR the medication regimen changed BECAUSE postural hypotension is a common side effect of hypertension therapy in older patients and is a reversible cause of injurious falls.

Supporting Evidence:

Othostatic hypotension (OH) in elders is associated with increased risk of mortality. ⁶³ In a meta-analysis⁶⁴ of observational studies of cardiovascular medications and falls among older (age > 60) individuals, treatment with any type of diuretic therapy over ≥ 6 months was associated with an 8% (95% CI 2 to 16%) increased odds of falling, although none of the other classes of drugs (beta-blockers, calcium channel blockers, ACEIs, centrally-acting agents, or specific diuretics such as thiazides) were significantly associated with falls. Alpha-blockers were not evaluated. The JNC recommends “periodic checks” for OH in all individuals with hypertension ≥50 years old but does not specify a time frame. ¹³ The VHA recommends that all older persons should be evaluated for postural hypotension within one month of initiating antihypertensive therapy. ¹⁸ Last, the BHS recommends older patients should also have a standing BP measured after at least 2 minutes to determine whether there is significant orthostatic hypotension; if a fall in SBP ≥ 20 mmHg is accompanied by postural symptoms, antihypertensive medications should be titrated to standing SBP. ²⁰

Compelling Indications (beta-blocker)

13. IF a vulnerable elder with hypertension has ischemic heart disease, THEN treatment with beta blocker should be recommended OR documentation why not BECAUSE beta-blockers have been shown to have mortality benefit among younger patients with ischemic heart disease.

Supporting Evidence:

Expert opinion provides support for this indicator, since we did not identify any RCTs that tested beta-blockers as anti-hypertensive therapy specifically among older patients with prevalent CAD. The JNC recommends that the compelling indications listed for younger populations, i.e. beta-blockers for heart failure, CAD, and increased CV risk, should be applied to older populations. ¹³ CHEP recommends use of beta-blockers in selected older hypertensive patients with concomitant conditions or in the context of combination therapy. ⁶² The BHS recommends against the use of beta-blockers in older people unless there is a specific indication of post-myocardial infarction (MI), angina, or heart failure. ²⁰

Compelling Indications (ACEI, ARB)

14. IF a vulnerable elder with hypertension has a history of heart failure, left ventricular hypertrophy, ischemic heart disease, chronic kidney disease or CVA, THEN s/he should be treated with an ACE inhibitor or ARB OR documented why not BECAUSE the use of ACEIs and ARBs is beneficial among older patients with hypertension and compelling indications (CHF, LVH, CAD, CKD, and history of CVA).

Supporting Evidence:

Evidence from multiple trials supports the use of ACEIs in patients with heart failure, ischemic heart disease, CKD, or stroke. A meta-analysis of RCTs of ACEIs in patients with heart failure concluded that treatment with ACEIs are associated with a reduction in the combined endpoint of mortality or heart failure-related hospitalization. ⁶⁵ In subgroup analyses, the authors found that the benefits of ACEIs were comparable for older patients (age >60 OR 0.79, 95% CI 0.66 to 0.95) and younger patients (age < 60 OR 0.71, 95% CI 0.59 to 0.86). ⁶⁵

A recent meta-analysis of patients with coronary artery disease and preserved left ventricular function concluded that ACEI treatment is associated with decreased overall mortality (OR 0.86, 95% CI 0.79 to 0.93), cardiovascular mortality (OR 0.81, 95% CI 0.73 to 0.90), myocardial infarction (OR 0.82, 95% CI 0.75 to 0.89), and stroke (OR 0.77, 95% CI 0.66 to 0.88). ⁶⁶ One of the trials included in this meta-analysis was The Heart Outcomes Prevention Evaluation (HOPE) trial⁶⁷, which⁶⁸ enrolled 9297 elders (66% were age ≥ 65) at increased risk of CAD (history of CAD, CVA, PVD, or diabetes mellitus plus at least one other CV risk factor). Subjects who received ramipril over 5 years had a 22% (95% CI, 14 to 30%) reduced risk of having MI, stroke, or death from any CV cause. In pre-defined subset analyses, the benefit of ramipril was seen regardless of baseline hypertension status or age.

The HOPE^{67 69}, Losartan Intervention For Endpoint reduction in hypertension (LIFE) ⁷⁰, Prospective Randomized Enalapril Study Evaluating Regression of Ventricular Enlargement (PRESERVE), ⁷¹ and Left Ventricular Mass and Diastolic Function (E/A Ratio) (ELVERA) ⁷² studies all showed reduction in left ventricular hypertrophy (LVH) among elders with SH and LVH when ACEIs or ARBs were compared with other classes of medications (BBs and CCBs).

Although the prevalence of prior stroke was small (3.9%) in the Study on Cognition and Prognosis in the Elderly (SCOPE) study ^{73 74} investigators found that candesartan versus placebo was associated with a 64% (P=0.004) reduction in major cardiovascular events among those with a history of stroke.

We did not review any trials of antihypertensive therapies conducted specifically on older patients with CKD. Among younger patients with non-diabetic CKD, ACEIs have been shown to protect against progression of kidney disease compared to non-ACEI regimens, ⁵⁹ as have ARBs. ^{75 76} A recent systematic review that compared ACEI or ARBs with other antihypertensive drugs found a small benefit associated with ACEI or ARB use on end-stage renal disease (RR 0.87, 95% CI 0.75 to 0.99). ⁷⁷

The JNC recommends that older patients follow the same guidelines for using ACEIs/ARBs for compelling indications as in younger patients. ¹³ The ACP recommended that older patients with LVH and hypertension should receive ARBs. CHEP ⁶² and BHS²⁰ recommends consideration of drug classes among older people according to their specific co-morbidities. ²⁰