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Geri pres
1. Ahad Lodhi, M.D.
PGY-2 Internal Medicine
Dept of Geriatrics
Crozer-Chester Medical Center
2.
3.
4.
5. BP Classification SBP mmHg DBP mmHg
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 Hypertension 140–159 or 90–99
Stage 2 Hypertension >160 or >100
6. The HYpertension
in the
Very Elderly Trial
N. Beckett, R. Peters, A. Fletcher, C. Bulpitt
on behalf of the HYVET committees and
investigators
N Engl J Med
Volume 358(18):1887-1898
May 1, 2008
7. • In this study, patients 80 years of age or older with sustained
systolic hypertension were randomly assigned to receive either
the diuretic indapamide, with or without the angiotensin-
converting-enzyme inhibitor perindopril, or matching placebos,
for a target blood pressure of 150/80 mm Hg
• Active treatment resulted in a nearly significant reduction of the
risks of fatal or nonfatal stroke and death from cardiovascular
causes and a significant reduction in the rates of death from
stroke and death from any cause, suggesting that
antihypertensive treatment in these persons may be beneficial
8. The Trial:
International, multi-centre, randomised double-blind placebo controlled
Inclusion Criteria: Exclusion Criteria:
Aged 80 or more, Standing SBP < 140mmHg
Systolic BP; 160 -199mmHg Stroke in last 6 months
+ diastolic BP; <110 mmHg, Dementia
Informed consent Need daily nursing care
Primary Endpoint:
All strokes (fatal and non-fatal)
15. Baseline data
(Cardiovascular Risk factors)
Placebo Active
Current smoker 6.6% 6.4%
Diabetes
(Known DM/ DM treatment/glucose>11.1mmo/l) 6.9% 6.8%
Total cholesterol (mmol/l) 5.3 5.3
HDL Cholesterol (mmol/l) 1.35 1.35
Serum Creatinine (μmol/l) 89.2 88.6
Uric acid (µmol/l) 279 280
Body Mass Index (kg/m2) 24.7 24.7
16. Mean Blood Pressure, Measured while Patients Were Seated, in the Intention-to-Treat
Population, According to Study Group
Beckett NS et al. N Engl J Med 2008;358:1887-1898
17. 180
170 15 mmHg
160
150
Blood Pressure (mmHg)
140
Placebo
130
120 Indapamide SR +/-
Median follow-up 1.8 years
I perindopril
110
100
6 mmHg
90
80
70
0 1 2 3 4 5
Follow-up (years)
18. Main Fatal and Nonfatal End Points in the Intention-to-Treat Population
Beckett NS et al. N Engl J Med 2008;358:1887-1898
25. •In 2 year cohort there were no significant
differences between the groups with regard to
change in serum….
•Potassium
•Uric acid
•Glucose
•Creatinine
26. Reported serious adverse events
(after randomisation)
448 in the placebo group vs 358 in active (p=0.001)
27. Antihypertensive treatment based on indapamide
(SR) 1.5mg (± perindopril) reduced stroke mortality
and total mortality in a very elderly cohort.
NNT (2 years) = 94 for stroke and 40 for mortality
Large and significant benefit in reduction of heart
failure events and for combined endpoint of
cardiovascular events
Benefits seen early
Treatment regime employed was safe
28. Major Outcomes in High-Risk Hypertensive Patients
Randomized to Angiotensin-Converting Enzyme
Inhibitoror Calcium Channel Blocker vs Diuretic
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart
Attack Trial (ALLHAT)
29. Objective: To determine whether treatment with a calcium channel blocker or an
angiotensin-converting enzyme inhibitor lowers the incidence of coronary heart disease
(CHD) or other cardiovascular disease (CVD) events vs treatment with a diuretic.
Design: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
(ALLHAT), a randomized, double-blind, active-controlled clinical trial con- ducted from
February 1994 through March 2002.
Setting and Participants: A total of 33 357 participants aged 55 years or older with
hypertension and at least 1 other CHD risk factor from 623 North American centers
30. Primary outcome:
Combined fatal CHD or non-
fatal myocardial infarction,
analyzed by intent-to-treat
Secondary outcomes:
ll- cause mortality,
troke,
ombined CHD (primary outcome, coronary revascularization, or angina with hospitalization)
ombined CVD (combined CHD, stroke, treated angina without hospitalization,
heart failure [HF],
peripheral arterial disease
31. Mean follow-up was 4.9 years
The primary outcome occurred in 2956 participants, with no difference between treatments
All-cause mortality did not differ between groups.
Five-year systolic blood pressures were significantly higher in the amlodipine (0.8 mm Hg,
P=.03) and lisinopril (2 mm Hg, P<.001) groups compared with chlorthalidone
5-year diastolic blood pressure was significantly lower with amlodipine (0.8 mm Hg, P<.001)
Amlodipine vs Chlorthalidone, secondary outcomes were similar except for a higher 6-year
rate of HF with amlodipine (10.2% vs 7.7%; RR, 1.38; 95% CI, 1.25-1.52)
Lisinopril vs Chlorthalidone, lisinopril had higher 6-year rates of combined CVD (33.3% vs
30.9%; RR, 1.10; 95% CI, 1.05-1.16); stroke (6.3% vs 5.6%; RR, 1.15; 95% CI, 1.02-1.30); and
HF (8.7% vs 7.7%; RR, 1.19; 95% CI, 1.07-1.31)
32. Thiazide-type diuretics are superior in preventing 1
or more major forms of CVD and are less expensive.
They should be preferred for first-step antihyperten-
sive therapy.
33. Objective. To assess the ability of antihypertensive drug treatment to reduce the risk of
nonfatal and fatal (total) stroke in isolated systolic hypertension.
Design. Multicenter, randomized, double-blind, placebo-controlled.
Setting. Community-based ambulatory population in tertiary care centers.
Participants. 4736 persons (1.06%) from 447 921 screenes aged 60 years and above were
randomized (2365 to active treatment, 2371 to placebo).
Systolic blood pressure ranged from 160 to 219 mm Hg and diastolic blood pressure was
less than 90 mm Hg.
3161 were not receiving antihypertensive medication at initial contact, and 1575 were.
The average systolic blood pressure was 170 mm Hg; average diastolic blood pressure, 77
mm Hg. The mean age was 72 years, 57% were women, and 14% were black
34. Participants were stratified by clinical center and by antihypertensive medication status at
initial contact.
step 1 of the trial:
dose 1 was chlorthalidone, 12.5 mg/d, or matching placebo; dose 2 was 25 mg/d.
step 2:
dose 1 was atenolol, 25 mg/d, or matching placebo; dose 2 was 50 mg/d.
Main Outcome Measures
Primary. Nonfatal and fatal (total) stroke
Secondary. Cardiovascular and coronary morbidity and mortality, all-cause mortality, and
quality of life measures.
35. Average follow-up was 4.5 years
The 5-year average systolic blood pressure was 155mm Hg for the placebo group and
143mm Hg for the active treatment group, and the 5-year average diastolic blood
pressure was 72 and 68mmHg, respectively.
The 5-year incidence of total stroke was 5.2 per 100 participants for active treatment
and 8.2 per 100 for placebo
The relative risk by proportional hazards regression analysis was 0.64 (P=.0003).
For the secondary end point of clinical nonfatal myocardial infarction plus coronary
death, the relative risk was 0.73. Major cardiovascular events were reduced (relative
risk, 0.68). For deaths from all causes, the relative risk was 0.87.
36. In persons aged 60 years and over with isolated systolic
hypertension, antihypertensive stepped-care drug treatment
with low-dose chlorthalidone as 1 medication reduced the
incidence of total stroke 36%, with 5-year absolute benefit of 30
events per 1000 participants
Major cardiovascular events were reduced, with 5-year absolute
benefit of 55 events per 1000
Editor's Notes
Lowest rates of BP control
Figure 2. Mean Blood Pressure, Measured while Patients Were Seated, in the Intention-to-Treat Population, According to Study Group.
Table 2. Main Fatal and Nonfatal End Points in the Intention-to-Treat Population.
