Key messages
• Blood pressure-lowering medications lower the chance of death and probably reduce heart attacks and strokes in people with hypertension (high blood pressure) 60 years of age or older.
• There may be more study withdrawals among those taking blood pressure-lowering medications than those receiving placebo (dummy treatment) or no treatment.
What is hypertension?
Hypertension is high blood pressure. It is common in adults 60 years or older. Having hypertension increases the chance of heart and blood vessel disease.
How is hypertension treated?
Hypertension is commonly treated with different blood pressure-lowering medications.
What did we want to find out?
We wanted to know the benefits and harms of using blood pressure-lowering medications in adults 60 years or older with hypertension. This is the third update of this review, which was first published in 1998 and previously updated in 2009 and 2019.
What did we do?
We searched for studies comparing treatment with blood pressure-lowering medications versus placebo (dummy treatment) or no treatment in adults 60 years or older with hypertension. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We found 16 studies involving a total of 26,795 adults 60 years or older with hypertension comparing blood pressure-lowering medications to placebo or no treatment for an average of 3.8 years. We found no new trials in this update. Blood pressure-lowering medications in people 60 years or older with hypertension lowered the chance of death and probably reduced strokes and heart attacks. The benefit was similar if both upper and lower blood pressure numbers were elevated and if only the upper number was elevated. The first treatment used in most studies was a thiazide. There may be more study withdrawals due to unwanted effects in the group receiving blood pressure-lowering medications.
What are the limitations of the evidence?
We are confident that blood pressure-lowering drugs lower the chance of death and are moderately confident that blood pressure-lowering drugs reduce the chance of heart attack or stroke. In cases where our confidence was lowered, this was because some of the trials may not have reported all the data they collected or may have been selective in reporting of their results.
How up-to-date is this evidence?
The evidence is current to June 2024. Given that it is unlikely any new studies addressing this research question will be conducted, we will not update this review in the future.
อ่านบทคัดย่อฉบับเต็ม
This is the second substantive update of this review. It was originally published in 1998 and was previously updated in 2009. Elevated blood pressure (known as 'hypertension') increases with age - most rapidly over age 60. Systolic hypertension is more strongly associated with cardiovascular disease than is diastolic hypertension, and it occurs more commonly in older people. It is important to know the benefits and harms of antihypertensive treatment for hypertension in this age group, as well as separately for people 60 to 79 years old and people 80 years or older.
วัตถุประสงค์
Primary objective
• To assess the effects of antihypertensive drug treatment as compared with placebo or no treatment on all-cause mortality for people 60 years and older with hypertension defined as systolic blood pressure (SBP) > 140 mmHg or diastolic blood pressure (DBP) > 90 mmHg, or both.
Secondary objectives
• To assess the effects of antihypertensive drug treatment as compared with placebo or no treatment on cardiovascular-specific morbidity and mortality in people 60 years and older with hypertension defined as SBP > 140 mmHg or DBP > 90 mmHg, or both.
• To assess the rate of withdrawal due to adverse effects of antihypertensive drug treatment as compared with placebo or no treatment in people 60 years and older with hypertension defined as SBP > 140 mmHg or DBP > 90 mmHg, or both.
วิธีการสืบค้น
The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to June 2024: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, WHO ICTRP, and ClinicalTrials.gov. We contacted the authors of relevant papers regarding further published and unpublished work.
เกณฑ์การคัดเลือก
Randomised controlled trials of at least one year's duration comparing antihypertensive drug therapy versus placebo or no treatment and providing morbidity and mortality data for adult patients (≥ 60 years old) with hypertension defined as blood pressure greater than 140/90 mmHg.
การรวบรวมและวิเคราะห์ข้อมูล
Outcomes assessed were all-cause mortality; cardiovascular morbidity and mortality; cerebrovascular morbidity and mortality; coronary heart disease morbidity and mortality; and withdrawal due to adverse effects. We modified the definition of cardiovascular mortality and morbidity to exclude transient ischaemic attacks when possible.
ผลการวิจัย
This update includes one additional trial (MRC-TMH 1985). Sixteen trials (N = 26,795) in healthy ambulatory adults 60 years or older (mean age 73.4 years) from western industrialised countries with moderate to severe systolic and/or diastolic hypertension (average 182/95 mmHg) met the inclusion criteria. Most of these trials evaluated first-line thiazide diuretic therapy for a mean treatment duration of 3.8 years.
Antihypertensive drug treatment reduced all-cause mortality (high-certainty evidence; 11% with control vs 10.0% with treatment; risk ratio (RR) 0.91, 95% confidence interval (CI) 0.85 to 0.97; cardiovascular morbidity and mortality (moderate-certainty evidence; 13.6% with control vs 9.8% with treatment; RR 0.72, 95% CI 0.68 to 0.77; cerebrovascular mortality and morbidity (moderate-certainty evidence; 5.2% with control vs 3.4% with treatment; RR 0.66, 95% CI 0.59 to 0.74; and coronary heart disease mortality and morbidity (moderate-certainty evidence; 4.8% with control vs 3.7% with treatment; RR 0.78, 95% CI 0.69 to 0.88. Withdrawals due to adverse effects were increased with treatment (low-certainty evidence; 5.4% with control vs 15.7% with treatment; RR 2.91, 95% CI 2.56 to 3.30. In the three trials restricted to persons with isolated systolic hypertension, reported benefits were similar.
This comprehensive systematic review provides additional evidence that the reduction in mortality observed was due mostly to reduction in the 60- to 79-year-old patient subgroup (high-certainty evidence; RR 0.86, 95% CI 0.79 to 0.95). Although cardiovascular mortality and morbidity was significantly reduced in both subgroups 60 to 79 years old (moderate-certainty evidence; RR 0.71, 95% CI 0.65 to 0.77) and 80 years or older (moderate-certainty evidence; RR 0.75, 95% CI 0.65 to 0.87), the magnitude of absolute risk reduction was probably higher among 60- to 79-year-old patients (3.8% vs 2.9%). The reduction in cardiovascular mortality and morbidity was primarily due to a reduction in cerebrovascular mortality and morbidity.
ข้อสรุปของผู้วิจัย
Treating healthy adults 60 years or older with moderate to severe systolic or diastolic hypertension, or both, with antihypertensive drug therapy reduced all-cause mortality and probably reduced cardiovascular mortality and morbidity, cerebrovascular mortality and morbidity, and coronary heart disease mortality and morbidity. Most of the evidence pertains to a primary prevention population using a thiazide as first-line treatment. Given that no new or ongoing trials were identified in this update, the certainty of existing evidence is moderate or high, and we do not expect new trials in the future, this review is considered stable and will no longer be updated.
แหล่งทุน
Internal sources. Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia. Office space.
External sources. BC Ministry of Health grant to the Therapeutics Initiative. Infrastructure.
การลงทะเบียน
Original review (1998): Mulrow CD, Lau J, Cornell J, Brand M. Pharmacotherapy for hypertension in the elderly. Cochrane Database of Systematic Reviews 1998, Issue 2.
First update (2009): https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000028/full
Second update (2019): https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000028.pub3/full
