Immediate and late benefits of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.d7541 (Published 04 January 2012) Cite this as: BMJ 2012;344:d7541
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Dear Editor,
We congratulate Dr. Beckett et al. for a high quality randomized controlled trial (RCT) on HYVET, which has given a new direction for management of hypertension in the elderly and very elderly patients. That said, we would like to point out the occasional instances of the condition 'Pseudo-hypertension' in the elderly, where the blood pressure may just be normal, but may still lead to unwarranted treatment to bring down and maintain the blood pressures at satisfactory levels. Arteriosclerosis can result in pseudo-hypertension. Both the systolic and diastolic pressures are affected.
Very high blood pressure with no significant target organ impairment should raise the suspicion of pseudo-hypertension in an elderly. Treatment efforts may result in adverse effects and such symptoms like dizziness, confusion, and decreased urine output, etc. A simple bedside procedure which goes by the name of 'Osler's maneuver'. In this, if the radial artery can still be palpated despite the blood pressure cuff being inflated over the arm, it denotes a positive Osler's sign, which is a likely pointer towards pseudo-hypertension.
In today's time, when automatic blood pressure instruments are freely available, and are in rampant use as well for home blood pressure monitoring, we possibly need to be a bit more cautious so as to prevent unnecessary treatment or over-treatment. Gold standard remains the measurement of intra-arterial pressure, which shall provide the definitive diagnosis.
Best regards.
Dr. Ajay Kumar Singh Parihar
Dr. Shruti Chauhan
Dr. Rajesh Chauhan
Competing interests: No competing interests
Louisa Polak makes a good point succinctly - that only 1 of 35 octogenarians treated for five years will benefit by avoiding a stroke..
But the suggestion from Gabriel that octogenarians might prefer to be left alone, or that strokes matter less, or that their limited life expectation should be weighed, needs to be better justified. Even though life may not be prolonged Engelaer should acknowledge that stroke is one avoidable ( in 1 in 35 octogenarians treated ) reason why health and vigour may be curtailed !
To put it in perspective -
In the trials conducted with younger patients with relatively nonsevere hypertension (entry DBP 90-110 mm Hg), the NNT to prevent one stroke is 118.
The NNT estimates from trials of more severely hypertensive younger patients are substantially lower (NNT=52 for entry DBP at or below 115 mm Hg, and NNT=29 for entry DBP above 115 mm Hg). I feel sure that Louisa treats many such younger patients.
My conclusion from this new evidence is that the NNT is even more favourable than in younger patients , principally I suspect because the risk of stroke is so much higher perhaps. Thus ABSOLUTE RISK should also be quoted, and considered in decisions to treat, just as in the decision to prescribe a Statin.
My practice will now change - I already offer healthy octogenarians antihypertensives because I saw no reason why antihypertensives would stop working at age 80. I will now add the encouragement that they are MORE likely to benefit the octogenarian than many of my younger treated hypertensives... and as usual the competent patient will then decide.
Competing interests: No competing interests
Evidence-based shared decision-making.
Beckett et al[1] state that their paper supports “the need to start treatment” in octogenarians with raised BP. Since shared decision-making is widely accepted nowadays as the way to practice, it would be more accurate to talk of supporting the need to offer such people treatment. Few would disagree that this offer should be made in such a way as to maximise patients’ understanding of what the trial’s results mean to them.
Gigerenzer’s article in the same issue[2] reminds us of the likelihood of misunderstandings between clinicians and patients when talking about risk, and Misselbrook[3] has shown the marked difference made to patients’ decisions about antihypertensive treatment by offering the same information in different ways, with a personalised estimate of risk giving the clearest picture. I shall therefore be giving my patients such an estimate when I inform them about the HYVET trial.
The main trial found that treatment reduced risk of stroke by 5.6 per 1000 patient years. Given this information in the form “if 36 people exactly like you take these pills for 5 years, the pills will stop one person having a stroke during that time, while making no difference either way to the other 35”, many people will decline treatment . It would be useful to both clinicians and policy-makers if authors of such trials could translate their findings into this form in future, to save us doing our own arithmetic.
[1]Beckett, N et al Immediate and late benefits of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial. BMJ 2012;344:d7541
[2]Gigerenzer, G, Galesic, M. Why do single event probabilities confuse patients? BMJ 2012;344:e245
[3]Misselbrook D, Armstrong D. Patients' responses to risk information about the benefits of treating hypertension.Br J Gen Pract 2001; 51:276–279
Competing interests: LP is doing an MPhil about attitudes to preventative medication
F.M. Engelaer, D. van Bodegom and R.G.J. Westendorp
Leyden Academy on Vitality and Ageing, the Netherlands
Leiden University Medical Centre, the Netherlands
The open label treatment extension of the original HYVET study by Beckett and colleagues received enthusiastic applause as further evidence for direct and long term benefits when hypertension is treated in very old people.(1) However, we have to be cautious to extrapolate these favorable outcomes as strict guidelines in clinical practice.
It has repetitively been shown that hypotension, not hypertension carries the greatest risk in the oldest old.(2) Low blood pressure may be a consequence of imminent heart failure, drug treatment or both, whereas elevated blood pressure may be reactive and can have survival benefits while ensuring perfusion in critical organs.(3,4) It is therefore of utmost importance to estimate the net result of benefits and side effects 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, the hazard ratio being close to unity.(5) The reason for the HYVET study being the only trial showing a survival benefit may lie in the recruitment of healthy octogenarians as represented by the very low levels of co-morbidity at baseline, and low fatality rate in the placebo group.(6)
There seems no doubt that the benefits of treating very healthy octogenarians with hypertension outweigh the side effects. It is however, a daunting task for clinicians to correctly identify these older people in clinical practice.
1. N. Beckett et al. Immediate and late benefits of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial BMJ 2012;344:d7541
2. T. van Bemmel et al. In a population-based prospective study, no association between high blood pressure and mortality after age 85 years Journal of Hypertension: February 2006 - Volume 24 - Issue 2 - p 287-292
3. T. van Bemmel et al. Low blood pressure in the very old , a consequence of imminent heart failure: the Leiden 85-plus Study Journal of Human Hypertension 2009;23, 27-32
4. S.M. Euser et al. The effect of age on the association between blood pressure and cognitive function later in life Journal of the American Geriatrics Society 2009 : Volume 57, Issue 7 ;1232-1237
5. N. Beckett et al. Treatment of hypertension in patients 80 years of age or older N ENGL J MED 2008; 358;18
6. V.M. Musini, Tejani A.M., Basset K. and Wright J.M. Pharmacotherapy for hypertension in the elderly Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD000028. DOI: 10.1002/14651858.CD000028.pub2.
Competing interests: No competing interests
Re: Immediate and late benefits of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial
Dear Editor,
Wide spread and unchecked dietary supplementation of iodine may possibly be leading to some adverse consequences, which might be passing off unnoticed. There are definitely defined geographical areas like for instance the Himalayan belt that has been confirmed as having a deficiency of iodine. In the context of India, is that the deficiency exists all over, and even for all the persons who are taking a balanced diet? Possibly there needs to be a concerted effort now on the part of national health and nutrition monitoring agencies, as well as international agencies like the WHO, etc, to check if the continuous and so far unrestricted fortification of common salt and other dietary stuff, consequent to their advise and directions, is not causing any unrecognized harm to humans who are not staying in iodine deficient geographical areas, and when their balanced diet does provide to them enough iodine every day.
Looking at the distinct increase in number of cardiovascular events, conduction defects, as well as rising numbers of individuals suffering from hypertension, any incidental or potentiating role of excess of iodine should be checked thoroughly. Along with this, there is a need to cross check if there is any correlation between increasing numbers of thyroid related issues, and the rising incidence of obesity in relatively well off individuals and their families. We certainly feel that a reality check is the need of the hour, in India at least, if not worldwide. If our possibility turns out to be true, then perhaps many individuals having “essential hypertension” may start having better control of blood pressures, if they switch over to using common salt that is not supplemented with iodine.
We definitely feel that common salt NOT FORTIFIED with iodine, should also be made available forthwith for all those patients having problems like high blood pressure. Possibly, if our assessment is true, many of these patients may have been inadvertently accounted so far in the essential hypertension group, rather than in secondary hypertension group where they should belong. And especially so, if they have associated unexplained high resting heart rate and signs of raised BMR (basal metabolic rates), which could be easily detected and identified clinically. If it is true, then possibly it could lead to bringing down the dosages required, as well as the number of drugs being used for control of hypertension in those thus identified by the features described afore by us.
While at it, as a wild guess, we also feel that the children who are labeled as having ADHD (attention deficit hyperactivity disorder), should also be assessed for iodine excretion in their urine, besides the thyroid function tests, and other clinical parameters. Any role of excess iodine during their entire development from their period in womb, to the present day, should be scrutinized. It shall definitely be very reassuring if these problems are found to be unrelated to excess of dietary iodine provided through supplementation of iodine in common salt. Finally, since iodine is a trace element that is required by human body only in very minor amounts, any excess may possibly manifest rapidly in elderly, and therefore there is a definite need to rule out if any excess iodine intake is happening inadvertently.
Best regards.
Dr. Ajay Kumar Singh Parihar
Dr. Shruti Chauhan
Dr (Lt Col) Rajesh Chauhan
Competing interests: No competing interests