Letter Hypertension in comorbidity

Authors’ reply to Ninan and Millar and Abou-saleh

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2253 (Published 26 April 2016) Cite this as: BMJ 2016;353:i2253
  1. Kevin M O’Shaughnessy, consultant, reader in clinical pharmacology1,
  2. Lucinda Kennard, specialist registrar in clinical pharmacology1
  1. 1Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK
  1. kmo22{at}medschl.cam.ac.uk

Ninan highlights the importance of frailty in the context of treatment for hypertension.1 2 We did not intend to give the impression that “one size fits all.” We agree that an individualised approach is needed in all cases, with a balance being struck between the need to reduce cardiovascular risk versus the risk, for example, of falls from postural hypotension.

With respect to evidence for treatment of hypertension in the frail elderly, we highlight the following:

  • The HYVET study found lower cardiovascular mortality and a lower risk of stroke and heart failure in elderly patients treated to systolic and diastolic blood pressure targets <150 mm Hg and <80 mm Hg, respectively3

  • The recent PARTAGE study showed that nursing home residents aged over 80 years with systolic blood pressure <130 mm Hg taking two or more antihypertensives had a higher risk of mortality than those who had a similar blood pressure but were taking fewer antihypertensives. However, patients with a low systolic blood pressure receiving multiple drugs had lower activity of daily living scores, a greater prevalence of cardiovascular disease (including heart failure), and higher Charlson comorbidity index scores than other participants. This illustrates the difficulty in ascertaining the best blood pressure range in this age group4

  • For those aged over 80 years, National Institute for Health and Care Excellence (NICE) guidance recommends a target blood pressure of <150/90 mm Hg on ambulatory blood pressure monitoring or <145/85 mm Hg on home blood pressure monitoring during waking hours.5

We agree the difficulty arises when trying to establish how far below a target of <150 mm Hg systolic blood pressure a patient should be treated. Not only is there a paucity of data for the very elderly but other confounding factors such severe cardiac failure (and hence shorter survival) may drive a low systolic blood pressure.

Clinicians must ultimately use their clinical judgment to weigh up the risks and benefits of antihypertensive treatment for their elderly frail patients. We would never suggest that one size fits all.

We agree with Millar and Abou-saleh that psychiatric disorders are an important comorbidity that we did not cover, basically because of space limitations.6 The article was intended to merge NICE and other guidance on hypertension and highlight the most common areas of difficulty for prescribers. The patient’s mental state should obviously be considered before starting any drug both with regard to the patient’s capacity to give consent and whether drug adherence is likely to be affected.


  • Competing interests: None declared.


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