Letters Hypertension in octogenerians

Hypotension is more risky than hypertension in very old people

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e721 (Published 31 January 2012) Cite this as: BMJ 2012;344:e721
  1. Frouke M Engelaer, PhD student1,
  2. David van Bodegom, assistant professor of medicine at Leiden University Medical Centre1,
  3. Rudi G J Westendorp, professor of medicine at Leiden University Medical Centre1
  1. 1Leyden Academy on Vitality and Ageing, 2333 AA Leiden, Netherlands
  1. engelaer{at}leydenacademy.nl

The open label treatment extension of the original HYVET study received enthusiastic applause as further evidence for direct and long term benefits of treating hypertension in very old people (≥80 years).1 However, we should be cautious in extrapolating these findings to clinical practice.

It has repeatedly been shown that hypotension, not hypertension, carries the greatest risk in very old people.2 Low blood pressure may be a consequence of imminent heart failure, drug treatment, or both, whereas raised blood pressure may be reactive and can have survival benefits by ensuring perfusion in critical organs.3 It is therefore important to estimate the net benefit of blood pressure lowering treatment. The latest Cochrane review on treatment of hypertension in octogenarians weighs all the available evidence, including the HYVET study, but does not show a survival benefit for treatment, the hazard ratio being close to unity.4 The HYVET study may be the only trial to show a survival benefit because it recruited healthy octogenarians, as shown by the low levels of comorbidity at baseline and low fatality rate in the placebo group.5

The benefits of treating very healthy octogenarians with hypertension definitely outweigh the side effects. But it would be a daunting task for clinicians to correctly identify these older people in clinical practice.


Cite this as: BMJ 2012;344:e721


  • Competing interests: None declared.