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INVESTing In th..

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Atherosclerotic coronary artery disease (CAD) is the most prevalent cardiac disease in the elderly.1 More than 80% of deaths are due to CAD in patients 65 years and older.1 By 2030, there will be approximately 72.1 million older persons living in the United States.We will see more patients at increased risk for cardiovascular (CV) events as the population continues to live longer. Although we are unable to control age, race, or gender, we can control several risk factors associated with CAD.1 Successful hypertension treatment decreases the risk for CV adverse events in young patient populations, but evidence is lacking for the elderly.3

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Denardo and collegues3 completed a recent secondary analysis of the International Verapamil SR – Trandopril Study (INVEST) to assess hypertension management strategies in the very old and the relationship between treatment goals and adverse outcomes. The study included adults (> 50 years of age) with essential hypertension requiring drug therapy and stable CAD. Patients with unstable angina, angioplasty, coronary bypass or stroke within the previous month; beta-blocker use in the past 2 weeks or past year for post-MI patients; sinus bradycardia, sick sinus syndrome, or atrioventricular block of more than first degree in the absence of a pacemaker; severe heart failure (NYHA class IV), severe renal failure or hepatic failure; or contraindications to verapamil were ineligible for the study.4,5 

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The investigators stratified patients by age in 10-year increments (<60 n= 6668; 60-<70 n=7602; 70-<80 n=6126; >80 n=2180) and randomly assigned to receive either verapamil SR (calcium antagonist strategy, CAS) or atenolol (non-calcium antagonist strategy, NCAS) to achieve blood pressure (BP) goals. Patients with diabetes, heart failure, or renal insufficiency should take trandolapril, despite randomization.4 Target BP goals were <140/90 mm Hg or <130/85 mm Hg for patients with diabetes or renal insufficiency. The primary outcome was the first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. Secondary outcomes consisted of all-cause death, total myocardial infarction (fatal and nonfatal), total stroke (fatal and nonfatal), and revascularization (coronary bypass or percutaneous intervention).3

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After 2 years of follow-up (61,835 total patient-years), 23.6% (p < 0.001) of the very old (> 80 years) had the primary outcome, the other age groups ranged from 5.2% to 13.2%. The frequency of both the primary and secondary outcomes increased with age. However, revascularization remained similar between all age groups.3 For hypertension control, results were consistent with the original INVEST study; there was no difference in morbidity or mortality between CAS or NCAS treatment strategies.4 However, at baseline this analysis showed increasing age was associated with higher systolic and lower diastolic blood pressure. The very old had the largest decrease in systolic and smallest decrease in diastolic blood pressure. Data for the very old indicated “J-shaped” curves for the relationships between systolic and diastolic blood pressures and adverse events. The diastolic J-curve appeared much more prominent than the systolic J-curve.3 

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In this secondary analysis focusing on the very old (> 80 years) with coronary artery disease and hypertension, the authors concluded lower blood pressure goals increase the risk of CV events. These findings will significantly impact the growing population. The “J curve” phenomenon has been a controversial issue for many years and other studies have had similar results. As new evidence continues to emerge from large randomized trials, clinicians should be cautioned that strict BP control may ...

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