BACKGROUND: Hypertension increases dramatically with age. In clinically stable nonagenarians, ESH guidelines would recommend lowering blood pressure (BP) to 140-150mmHg systolic (SBP) and <90mmHg diastolic (DBP) if it is higher, but it is not clear if all of the oldest old comply with or need these goals. We prospectively analysed antihypertensive treatment decisions and BP outcome in a rural primary care hospital.
METHODS: All patients aged >89 years with BP medication admitted to the medical ward were prospectively included over 12 months. Cardiovascular risk profiling was performed as a clinical routine in all elderly. Patients had sitting BP taken at hospital admission with an ECG and blood tests; fasting serum lipids were determined >2 days thereafter. Antihypertensive treatment followed ESH guidelines. Follow-up sitting BPs were obtained in the morning before drug intake. BP treatment was furthermore adapated, if necessary, to minimize side-effects as a discharge goal. Patients with septic infections, circulatory shock, acute stroke or ST-elevation myocardial infarction, and readmissions were excluded.
RESULTS: Fifty-eight patients aged 92±3 years (mean±SD; range 90-101) with a median of 11 hospital days (4-32) were included (77.6% female, 34.5% diabetics, 24.1% atrial fibrillation, 41.4% coronary heart disease). Main diagnoses were diabetes, non-septic infections, heart insufficiency, rhythm problems, orthopedic pain and neuro-cognitive impairment. Admission SBP was 149±29mmHg (<140mmHg, 36%; >159mmHg, 27.6%), DBP 88±31mmHg (>89mmHg, 18.4%), heart rate (HR) 87±15/min, weight 62±12kg, serum creatinine 112±48μmol/l, total cholesterol 4.9±1.2mmol/l, blood hemoglobin 7.8±1.2mmol/l. Mid-term SBP was 128±22 and DBP 72±9mmHg (HR 76±9/min). Discharge SBP was 128±17 (<140mmHg, 62%; >159mmHg, 0%), DBP 72±9mmHg (>89mmHg, 3.6%) and HR 73±6/min being -21±43/17±35mmHg and -16±22/min lower vs. admission (p<0.01). Antihypertensive drugs/patient (n, admission vs. discharge) without diuretics was 1.0±0.9 vs. 1.1±0.9 (p=NS), and including diuretics 1.5±1.2 vs. 1.7±1,1 (p<0.05): blockers of beta-adrenoceptors 22.4% vs. 25.9%, of Ca-channels 8.6% vs. 12.1%, of the renin-angiotensin system 63.8% vs. 63.8%; spironolactone 5.2% vs. 5.2%; others 1.7% vs. 3.4% (p=NS); diuretics 48.3% vs. 67.2% (p<0.05); percent treated patients 75.9 vs. 86.2, excluding diuretics 67.2 vs. 70.7 (changing medication 43.1%); all without sex differences (p=NS). Combinations were clinically well tolerated.
CONCLUSIONS: A substantial proportion of very old hypertensive patients reached well tolerated BP values below recommended goals following significantly increased use of diuretics. Co-morbidity dominated in-hospital treatment decisions rather than guideline BP targets.