Send Orders for Reprints to reprints@benthamscience.

ae
Cardiovascular & Hematological Agents in Medicinal Chemistry, 2014, 12, 146-151

146

Recommendations for the Treatment of Hypertension in Elderly People

Alberto F. Rubio-Guerra* and Montserrat B. Duran-Salgado
Clinical Research Unit, Hospital General de Ticoman, Mxico DF, And Mexican Group for Basic and Clinical Research
in Internal Medicine, Mexico City, Mexico
Abstract: High blood pressure is a major cardiovascular risk factor. The prevalence of hypertension increases with aging.
As a consequence of changes in arterial wall that leads to arterial stiffness, the majority of elderly patients suffer isolated
systolic hypertension. The evidence strongly supports that hypertension in the elderly is associated with an increase in
stroke risk and cardiovascular mortality and morbidity. Several trials have shown the benefits of treating hypertension in
elderly patients. Even in the very old patients, the use of antihypertensive agents such as calcium channel blockers,
thiazide and thiazide-like diuretics, and inhibitors of the renin-angiotensin system reduce the risk of complications in
those patients. However, most patients will need two or more drugs to reach the recommended goals.
Hypertension in the elderly has special conditions that must be assessed in the evaluation of the patient (as
pseudohypertension and white coat hypertension), and issues that may affect the therapeutic choice and the response to
treatment, as comorbidities and polypharmacy.

Keywords: Elderly, hypertension, isolated systolic hypertension, recommendations, treatment.

INTRODUCTION
The proportion of elderly individuals ( 65 years) is
growing rapidly. It is expected that in the United States, 20%
of population will reach this group of age by 2030 [1]. With
the aging, the prevalence of hypertension increases. In fact,
an age-dependent increase in both systolic and diastolic
blood pressure up to the 6th decade of life has been
described. It has been estimated that 67% of individuals aged
between 60 older are hypertensive [2], whereas in people
above the age of 70, the prevalence increases to 60-70% [3].
Hypertension in the elderly has several differences when
compared with younger hypertensive patients, as increased
blood pressure lability, and a greater risk of orthostatism. In
elderly subjects, a rise in systolic blood pressure (SBP)
occurs whereas diastolic blood pressure (DBP) slowly
decreases; then, the majority of elderly subjects suffers
isolated systolic hypertension. In elderly people, high SBP is
a more reliable marker of cardiovascular risk than elevated
DPB. Also in elderly people, pulse pressure (difference
between SBP and DBP) has more impact on cardiovascular
outcomes than DPB [3-7].
CONSEQUENCES OF HYPERTENSION IN THE
ELDERLY
Isolated systolic hypertension and elevated pulse pressure
are associated with left ventricular hypertrophy, and increases
the risk for fatal and nonfatal coronary events and stroke,
and also for end-stage renal disease [6].
*Address correspondence to this author at the Clinical Research Unit,
Hospital General de Ticoman, Mxico DF, and Mexican Group for Basic and
Clinical Research in Internal Medicine, Motozintla # 30. Col Letran valle
Mxico D.F. C.P. 03600, Mexico City, Mexico; Tel/Fax: (52 555) 539 35 84;
E-mail: clinhta@hotmail.com
187-/14 $58.00+.00

Hypertension is accompanied by remodeling in small

arteries, that raises vascular resistances, compromises
arteriolar dilatory capacity and increases the risk of organ
ischemia [7].
In the kidney, hypertensive changes in small arteries lead
to nephroangiosclerosis, which contributes to the development
of chronic kidney disease [8]. The Framingham study showed
a greater cardiovascular risk for elderly patients than for
younger patients at all levels of blood pressure [9].
Finally, some studies have shown that there is a
dependent relationship between the occurrence of arterial
hypertension and the risk of developing dementia in
elderly individuals; in fact both; vascular dementia and
Alzheimer disease are more common in hypertensive than in
normotensive patients [10]. High pulse pressure increase the
risk of dementia in elderly [3, 10].
DIAGNOSIS AND PATIENT EVALUATION
All international guidelines define hypertension when
systolic blood pressure 140 mm Hg, and diastolic blood
pressure 90 mm Hg on at least 3 different measurements
taken in at least two separate office visits [11, 12]. Isolated
systolic hypertension is defined as systolic values 140 mm
Hg, and diastolic blood pressure < 90 mm Hg [11, 12]. Clinical
evaluation of elderly patients with hypertension is quite
similar to the evaluation of younger patients, however, is
important to bear in mind three issues when attending elderly
patients for hypertension; pseudohypertension, white coat
hypertension, and postural and postprandial hypotension
[8].
Pseudohypertension is defined as falsely elevated
pressures that occur by indirect cuff measurements. This
condition is due to medial sclerosis, which prevents
compression of brachial artery; under those circumstances,
2014 Bentham Science Publishers

Recommendations for the Treatment of Hypertension

Cardiovascular & Hematological Agents in Medicinal Chemistry, 2014, Vol. 12, No. 3

the registers obtained with the sphygmomanometer are

higher than those obtained by intra-arterial registers [8].
Pseudohypertension should be suspected in patients with
high pressure values but without end organ damage, or in
those with hypotension symptoms in spite of the indirect
values of blood pressure remains high [8]. Although the gold
standard for pseudohypertension is the measurement of intraarterial blood pressure, this invasive method is not available
in most facilities. Differential diagnosis is usually performed
with the Osler maneuver, which consists of inflating the cuff
over the systolic level of pressure, meanwhile the radial
artery is palpated, the maneuver is positive if the artery
remains palpable but no arterial pulsations are present [8].
White coat hypertension is defined as high blood
pressure measurements at office but with normal ambulatory
registers. It is due to a sympathetic response during the
measurement, secondary to stress [13]. The prevalence of
white coat hypertension increases with aging. We found it in
25% of elderly patients referred to our unit with diagnosis of
uncontrolled isolated blood pressure (whereas in younger
patients in our country, the prevalence is around 16-20%),
and we also found that 75% of patients with white coat
hypertension were women [13]. In order to avoid white coat
hypertension, several out-of-office readings of blood
pressure are needed. Self-measurement or ambulatory
monitoring of blood pressure is effective to confirm or refute
the diagnosis of white coat hypertension, and to avoid
unnecessary antihypertensive treatments that may produce
side effects in these patients [8, 13].
Postural and postprandial hypotension: Both conditions
are common due to venous pooling, in the legs (postural) or
mesenteric (postprandial) beds, the reduction of baroreceptor
sensitivity may be involved too [3]. Postural hypotension is
defined as a decrease in SBP 20 mm Hg or DPB 10 mm
Hg within 3 minutes of standing. It is a common feature in
elderly patients and may limit antihypertensive therapy.
Therefore, it is recommended in older patients, to measure
blood pressure in the sitting position and after standing in
each visit [1].
Patients must be evaluated for postprandial hypotension
when they suffer, within 2 hours after meal, syncope or falls.
The measurement of blood pressure after meal when
symptoms are present is recommended. In this regard, selfmeasurement or ambulatory monitoring of blood pressure is
a good option. Whereas drugs that depleted volume should
be avoided in those patients, we lack of an effective
treatment for this disorder, -glucosidase inhibitors have
shown are useful but poorly tolerated [1].
In elderly hypertensive patients, a silence between the
first and the third Korotkoff sound may occur, it is called the
auscultatory gap, and may lead to errors if the evaluation of
Korotkoff sound begins during the auscultatory gaps. A
preliminary determination of systolic blood pressure by
palpation helps to avoid the mistake of a false low systolic
blood pressure record [14].
Masked Hypertension
Masked uncontrolled hypertension (normal seated clinic
blood pressure but an elevated out-of-office blood pressure

147

values) has a high prevalence in patients with treated and

well-controlled clinic blood pressure. A recent article shown
that this disorder is most frequently seen in subjects under 60
years [15]. However, the results of the study confirm the
utility of self measurement or ambulatory monitoring of
blood pressure in the valuation of hypertensive patients,
independently of their age.
In the elderly, a careful abdominal auscultation is strongly
recommended, because narrowing of the renal artery, usually
due to atherosclerosis, is relatively common in individuals
over 65 years. This complication must be suspected in
patients 65 years with new onset or accelerated diastolic
high blood pressure [3]. In patients with stenosis of renal
artery, an abdominal murmur is often present. A renal
Doppler ultrasound and an angiographic study may confirm
the diagnosis. The importance of the diagnosis is that
treatment with inhibitors of the renin angiotensin system in
patients with renal artery stenosis may lead to acute renal
failure or heart failure, and in some patients, the possibility
of a revascularization procedure [3].
SHOULD WE TREAT HYPERTENSION IN THE
ELDERLY?
For many decades, the value of treating hypertension in
the elderly was rejected, and the rise in blood pressure was
considered as an adaptation for aging or compensatory
changes to vascular stiffness. Even more, lowering blood
pressure in the elderly was considered as harmful because it
could cause vascular collapse.
Several trials, as The Systolic Hypertension in the
Elderly Program [16], the Systolic Hypertension in Europe
[17] and the Systolic Hypertension in China trial [18], have
shown that the treatment of hypertension in elderly patients
produces a significantly cardiovascular risk lowering,
specially the in risk of fatal and non-fatal stroke. Both, the
Systolic Hypertension in Europe (SYST_EUR) trial, and the
Systolic Hypertension in China (SYST-CHINA) trial, were
prematurely terminated for ethical reasons, due to the early
detection of a clinical relevant reduction in the primary endpoint.
In the 22-year follow-up of the participants in the
Systolic Hypertension in the Elderly Program (SHEP),
treatment of isolated systolic hypertension with chlorthalidone
(with or without atenolol), was associated with longer life
expectancy at 22 years of follow-up [19]. And in the SYSTEUR trial, active treatment with nitrendipine (with or
without enalapril) was associated with a lower incidence of
dementia [20].
SHOULD THE VERY ELDERLY PATIENT RECEIVE
PHARMACOLOGICAL TREATMENT?
The hypertension in the very elderly trial (HYVET),
evaluated hypertensive patients aged 80 years or older,
shown a significantly 30% reduction in stroke and a 21%
reduction in mortality after treatment with indapamide, and
perindopril added if needed [21]. The results of this trial
showed that the use of antihypertensive therapy in older
patients with hypertension was associated with a clear
reduction in cardiovascular risk. A meta-analysis based on

148 Cardiovascular & Hematological Agents in Medicinal Chemistry, 2014, Vol. 12, No. 3

6701 patients > 80 years, shown that treating hypertension in

very old patients reduces stroke and heart failure, with no
effect on total mortality [22], providing clear evidence about
the cardiovascular benefits of pharmacological treatment in
hypertensive patient 80 years age and older.
GOAL OF ANTIHYPERTENSIVE THERAPY
Previous guidelines recommended a blood pressure goal
< 140/90 mm Hg in most hypertensive patients, or < 130/80
in diabetic hypertensive patients. However, current evidence
suggest a BP goal of less 150/90 in elderly patients [2].
Recently, the Eighth Joint National Committee (JNC8) suggests
a goal of SBP < 150 mmHg and goal DBP < 90mmHg, as a
grade A recommendation [12].
The 2013 ESH/ESC Guidelines for the Management of
Arterial Hypertension (11), suggest initiating antihypertensive
treatments when SBP is 160 mm Hg, (Class 1, Level A),
and adds that treatment may be considered in elderly
(younger than 80 years) when SPB is between 140 and 159
mm hg if agents is well tolerated (Class IIb, level C).
In patients with isolated systolic hypertension an
excessive reduction of DBP should be avoided, because a
possible interference with coronary perfusion, especially in
subjects with coronary artery disease [2].
Large, prospective studies have shown that reductions
not only in isolated systolic hypertension, but as well as
combined systolic-diastolic hypertension, lead to a reduction
in morbidity and mortality in elderly hypertensive patients.
Both, the European Working Party on hypertension in the
elderly trial (EWPHE), and the Swedish Trial in Old Patients
with Hypertension (STOP-Hypertension) trial significantly
reduced cardiovascular and cerebrovascular mortality [6], in
the STOP-Hypertension, a significant reduction in total
mortality was also observed, although it was not a primary
endpoint [6].
SPECIAL
PATIENTS

CONSIDERATIONS

IN

ELDERLY

Two issue require special attention in the evaluation of

elderly hypertensive patients because may have implications
in the therapeutic plans, comorbidities and polypharmacy.
Comorbidities
Assessment of comorbidities is of great importance in
older patients, not only because issues as diabetes mellitus or
Table 1.

Rubio-Guerra and Duran-Salgado

dyslipidemia contribute to an increase in cardiovascular risk

but they may also lead to polypharmacy.
Diabetes mellitus increases the risk of postural hypotension and other complications as chronic kidney disease.
Nevertheless, the management of hypertension associated
with diabetes mellitus or chronic kidney disease in older
patients do not differ from those in younger patients [6].
Depression is a common problem in elderly subjects. The
disease may interfere not only with the blood pressure
control, but also with the prognosis of the patient. It is
recommendable to perform a screening test for depression in
hypertensive patients because this cost-effective tool may
improve outcomes [23]. Most antidepressant agents may
affect blood pressure: notriptyline, amoxapine and desipramine
may cause refractory hypertension, whereas amitriptyline,
doxepin and imipramine may cause postural hypotension [1].
Interestingly two studies reported no significant differences
in blood pressure when duloxetine was compared with
placebo, and may be a safe option in elderly hypertensive
patients with depression [24].
Osteoarthritis and chronic pain conditions that require
continuous use of non-steroidal antiinflammatory drugs
(NSAID) must be also assessed. All NSAID increase blood
pressure values, and may interfere with the action of
antihypertensive agents as ACE inhibitors and blockers,
but not with those of calcium channel blockers [25].
Physicians must bear this fact in mind when the hypertensive
patient also needs NSAID for a long time period.
Peripheral arterial disease is also very common. The
ankle/brachial index (ABI) is obtained dividing the systolic
pressure of each of the ankles (measured using a Doppler
device) by the highest brachial pressure of either arm. A
resting ABI value 0.90 not only defines the presence of
peripheral arterial disease. The level of ABI also correlates
with peripheral arterial disease severity (Table 1) [26, 27]. A
low ABI has been also identified as an independent predictor
of coronary heart disease, stroke and mortality. A very high
ABI (1.40) in relation to stiffened arteries is associated with
increased mortality too. In fact, there is an increase of 10.2%
in the relative risk for a cardiovascular event by each
reduction of 0.1 in the ABI [27]. The TASC II guidelines
recommend that ABI should be measured in all patients 70
years or older, regardless of risk factor status, and in all
patients between 50 and 69 years of age with at least one
cardiovascular risk factor (particularly diabetes or smoking)
[28].

Level of ankle/brachial index and peripheral arterial disease severity.

Resting ABI

Peripheral Arterial Disease Severity

1.4

Increased risk for a cardiovascular event (RR 1.78)

> 1.3

Calcification of arterial wall

0.9 a 1.3

Normal

0.41-0.9

Peripheral Arterial Disease Mild to moderate

< 0.4

Peripheral Arterial Disease Severe. High risk of Amputation

Recommendations for the Treatment of Hypertension

Table 2.

Cardiovascular & Hematological Agents in Medicinal Chemistry, 2014, Vol. 12, No. 3

drugs that may interfere with blood pressure control.

Nasal decongestants

Notriptyline, Desipramine

Monoamine-oxidase inhibitors

Amphetamines

Adrenal steroids

Sympathomimetics

Erythropoietin

Cyclosporine and tacrolimus

Non-steroidal antiinflammatory drugs

Specially Cox-2 inhibitors
Estrongens and progestins
Ginseng

Alcohol
Venfalaxine
Sibutramine

POLYPHARMACY
Several drugs that are usually been taken by elderly
patients may interfere with blood pressure control, and are
shown on Table 2 [29].
Even in hypertensive patients taking multiple antihypertensive drugs, Phosphodiesterase 5 inhibitors (PDE5)
did not cause any important effects on blood pressure. PDE5
are effective, safe and well tolerated in hypertensive patients,
and can be safely administered to elderly hypertensive
patients receiving antihypertensive agents. However, PDE5
are contraindicated in patients receiving nitrates because
coadministration of both drugs may cause severe hypotension and death [30].
TREATMENT
PATIENTS

OF

ELDERLY

HYPERTENSIVE

As in all hypertensive patients, in the elderly patient

treatment must begin with life-style changes such are
reduced salt intake and increased physical exercise [11].
The NICE guidelines for clinical management of
hypertension in adults [31], recommends pharmacologic
treatment for patients < 80 years old with stage 1
hypertension (BP 140-159/90-99 mm Hg) and the presence
of target organ damage, history of coronary heart disease,
chronic kidney disease diabetes or a 10 years CVD 20%,
and also pharmacologic treatment in patients with stage 2
hypertension (BP 160/90mmHg) at any age. In this point,
its important to remember the possible existence of
peripheral arterial disease, then, the measurement of ankle
brachial index may modified the cardiovascular risk and be
determinant in the initiation of antihypertensive agents [27].
According to the 2013 ESH/ESC Guidelines for the
Management of Arterial Hypertension, in elderly hypertensive
patients, drug treatment is recommended when SBP is 160
mmHg. Pharmacologic treatment may also be considered in
the elderly (at least when younger than 80 years) when SBP
is in the 140159 mmHg range, provided that antihypertensive
treatment is well tolerated. (11) JNC8 suggest that patients
aged 60 years or older, to initiate pharmacologic treatment at
SBP 150 mmHg or DBP 90mmHg.
WHICH
ANTIHYPERTENSIVE
COMBINATION SHOULD BE USED?

DRUG

OR

The choice of an antihypertensive drug is influenced by

the presence of medical history, comorbidities, adverse

149

events to medication, intake of other drugs, cost and patient

preferences [3]. The principal benefits of treatment derives
from blood pressure reduction, and most guidelines do not
shown preference for any specific drug family on the basis of
age [11, 12], although beta blockers are not recommended in
elderly patients as first choice drugs [12, 32].
NICE guidelines recommend that calcium channel
blockers or thiazide-like diuretics (in patients intolerant to
calcium channel blockers) should be preferred in patients >
55 years, and that indapamida and chlorthalidone should be
used instead of hydrochlorothiazide, and that beta blockers
not be used as a first-line option [31].
Most of the patients will need two or more antihypertensive agents to reach the therapeutic goals. The use
of combinations with drugs with complementary mechanisms
of action allows utilizing lower doses, with more effective
and more prompt BP lowering, less adverse effects and a
greater reduction of cardiovascular risk than monotherapy. It
is desirable that both drugs be administered in the same pill
(fixed-dose), because this formulation improves adherence
and potentially reduces costs [33].
Acceptable combinations in the elderly hypertensive
patient include a renin angiotensin inhibitor plus a diuretic
or a calcium channel blocker. In the SYST-EUR study
(17), 80% of patients were in combination therapy with
nitrendipine plus enalapril and hydrochlorothiazide. The
Avoiding Cardiovascular Events Through Combination
Therapy in Patients Living With Systolic Hypertension
(ACCOMPLISH) trial [34], demonstrated that the fixed-dose
combination benazepril-amlodipine was superior to the
combination benazepril hydrochlorothiazide in reducing
cardiovascular death, stroke, myocardial infarction and
chronic kidney disease, in spite of a similar blood pressure
reduction. Although the ACCOMPLISH trial did not involve
solely elderly patients, included predominantly patients with
a mean age of 68 years, and the results were independent of
age. The results of the ACCOMPLISH study suggest that
cardiovascular risk reduction not only depends on blood
pressure reduction.
The HYVET trial shown the advantages of the
combination of the angiotensin converting enzyme inhibitor
(ACEI) perindopril, plus indapamide in old and very old
patients [21].
LACK OF RESPONSE TO TREATMENT
This is a relatively common problem in elderly
hypertensive patients. The first issue to asses in these
patients is adherence to therapy. If this is the case, fixed dose
combinations and to ask a relative or to the patients career
for support may help to solve the problem. It is also
necessary to asses that the patient is not receiving any of the
drugs listed on Table 2 [29].
In elderly hypertensive patients, the amplitude of the
reflected wave component of the pulse wave is increased,
perhaps as a result of the arterial stiffness and endothelial
dysfunction. Although calcium channel blockers, inhibitors
of the renin-angiotensin system and diuretics reduce pulse
wave reflection, their effect is usually not enough to reach an
adequate blood pressure control [35].

150 Cardiovascular & Hematological Agents in Medicinal Chemistry, 2014, Vol. 12, No. 3

Table 3.

Rubio-Guerra and Duran-Salgado

Recommendations for the treatment of resistant hypertension.

Improve adherence.
Withdrawal of interfering medication.
Perform Ambulatory Blood Pressure Monitoring
Administering one of the agents at night.
If the diuretic that the patient receives is hydrochlorothiazide, change it to chlorthalidone.
Use of antagonist of mineralocorticoids,
Addition of other drugs. (Direct vasodilators, Centrally acting agents)
Refer to a hypertension specialist.

Nitric oxide donors, as isosorbide mononitrate, may

reduce wave reflection by 40% or more, which results in
reduction on systolic and pulse pressure without change in
the diastolic values [36]. In patients with systolic values >
150 mm Hg, and/or pulse pressure > 60 mm Hg in spite of an
adequate antihypertensive regimen, the addition of 60-120
mg of extended-release isosorbide mononitrate once a day,
(starting with 30 mg in the morning, and increasing the dose
until 120 mg daily), without changes in the previous therapy,
is accompanied by a reduction in systolic blood pressure that
usually is enough to achieve therapeutic goal in most
patients [36]. The only contraindication to the use of
isosorbide mononitrateis in patients receiving PDE5 for
erectile dysfunction [30].

ACKNOWLEDGEMENTS
Declared none.
REFERENCES
[1]
[2]
[3]
[4]

[5]

RESISTANT HYPERTENSION
Truly resistant hypertension is defined as the lack of
response to a triple drug regimen that includes a diuretic. In
patients with a good adherence to therapy, in whom
pseudohypertension and white coat hypertension were
excluded, about 2% to 5% of hypertensive patients suffer
resistant hypertension [29].
The main causes of resistant hypertension in the elderly
are obstructive sleep apnea, renal artery stenosis,
pheochromocytoma, and nephropathy [29], these conditions
should be assessed, and, if is the case, treated, in these
patients.
Treatment includes (when apply), the recommendations
shown in Table 3 [29].
Although mineralocorticoid receptor antagonistsare nor
recommended as a first choice option in elderly hypertensive
patients, may be an effective therapy when added to
antihypertensive regimens in elderly patients with resistant
hypertension and normal renal function [35]. The addition of
spironolactone (12.5-50 mg daily) to the therapeutic
antihypertensive regimen reduces blood pressure with an
average of 25 mm Hg in systolic and 10 mm Hg on diastolic
blood pressure. The use of amiloride is accompanied by
greater reductions of blood pressure than spironolactone,
both drugs are safe and well tolerated, however, monitoring
potassium levels is recommended in elderly patients [29, 35].

[6]
[7]
[8]

[9]

[10]
[11]

[12]

[13]

CONFLICT OF INTEREST
The authors confirm that this article content has no
conflict of interest.

[14]

Pimenta, E.; Oparil, S. Management of hypertension in the elderly.

Nat. Rev. Cardiol., 2012, 9, 286-296.
Oliva, R.V.; Bakris, G.L. Management of hypertension in elderly
population. J. Gerontol. Biol. Sci. Med. Sci., 2012, 67, 1343-1351.
Acelajado, C.Z. Optimal management of hypertension in elderly
patients. Int. Blood Press Control., 2010, 3, 145-153.
Mackey, R.H.; Sutton-Tyrrell, K.; Vaitkevicius, P.V.; Sakkinen,
P.A.; Lyles, M.F.; Spurgeon, H.A.; Lakatta, E.G.; Kuller, L.H.
Correlates of aortic stiffness in elderly individuals, a subgroup of
the Cardiovascular Health Study. Am. J. Hypertens., 2002, 15, 16-23.
de Ortiz, H.K.; de Quattro V.; Schoentgen, S.; Stephanian, E.
Raised plasma catecholamines in old and young patients with
disproportionate systolic hypertension. Clin. Exp. Hypertens. A.,
1982, 4, 1107-1120.
Meredith, P.A.; Trenkwalder, P. Therapy in the elderly hypertensive.
JRAAS, 2002, 3, S49-S56.
Rubio-Guerra, A.F.; Duran-Salgado, M.B. Anti-hypertensive
Treatment and Vascular Extracellular Matrix Remodeling. Cardiol.,
2014, 127, 245-246.
Macas, J.; Robles, N.R.; Herrera, J.; Ayus, J.C.; Calabria, F.;
Domnguez, A.; Sociedad Espaola para La Lucha Contra la
Hipertensin Arterial; Sociedad Argentina de Hipertensin
Arterial; Sociedad Espaola de Geriatra y Gerontologa; Sociedad
Espaola de Medicina Geritrica; Sociedad Espaola de
Nefrologa. Recomendaciones para la deteccin y el tratamiento del
anciano con hipertensin arterial. Nefrologia, 2007, 27, 270-278.
Franklin, S.S.; Larson, M.G.; Khan, S.A.; Wong, N.D.; Leip, E.P.;
Kannel, W.B.; Levy, D. Does the relation of blood pressure to
coronary heart disease risk change with aging? The Framingham
Heart Study. Circulation, 2001, 103, 1245-1249.
Igase, M.; Kohara, K.; Miki, T. The Association between
Hypertension and Dementia in the Elderly. Int. J. Hypertens. 2012,
2012, 320648.
Task Force for the management of arterial hypertension of the
European Society of Hypertension; Task Force for the management
of arterial hypertension of the European Society of Cardiology.
2013 ESH/ESC Guidelines for the Management of Arterial
Hypertension. Blood Press., 2013, 22, 193-278.
James, P.A.; Oparil, S.; Carter, B.L.; Cushman, W.C.; DennisonHimmelfarb, C.; Handler, J.; Lackland, D.T.; Le Fevre, M.L.;
MacKenzie, T.D.; Ogedegbe, O.; Smith, S.C. Jr.; Svetkey, L.P.;
Taler, S.J.; Townsend, R.R.; Wright, J.T. Jr.; Narva, A.S.; Ortiz, E.
Evidence-Based Guideline for the Management of High Blood
Pressure in Adults: Report >From the Panel Members Appointed to
the Eighth Joint National Committee (JNC8). JAMA, 2014, 311,
507-520.
Rubio, A.F.; Rodrguez, L.; Vargas, G.; Narvez, J.L.; Lozano, J.J.
Prevalencia de la hipertensin de bata blanca en poblacin
geritrica con diagnstico de hipertensin sistlica aislada. Rev.
Esp. Cardiol., 2001, 54, 1116-1118
Cavallini, M.C.; Roman, M.J.; Blank, S.G.; Pini, R.; Pickering,
T.G.; Devereux, R.B. Association of the auscultatory gap with

Recommendations for the Treatment of Hypertension

[15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

[23]

[24]

Cardiovascular & Hematological Agents in Medicinal Chemistry, 2014, Vol. 12, No. 3

vascular disease in hypertensive patients. Ann. Intern. Med., 1996,

124, 877-883.
Banegas, J.R.; Ruilope, L.M.; de la Sierra, A.; de la Cruz, J.J.;
Gorostidi, M.; Segura, J.; Martell, N.; Garca-Puig, J.; Deanfield, J.;
Williams, B. High prevalence of masked uncontrolled hypertension
in people with treated hypertension. Eur. Heart J., 2014 doi:10.
1093/eurheartj/ehu016. [Epub ahead of print].
SHEP Cooperative Research Group. Prevention of stroke by
antihypertensive drug treatment in older persons with isolated
systolic hypertension, final results of the Systolic Hypertension in
the Elderly Program (SHEP). JAMA, 1991, 265, 32553264.
Staessen, J.A.; Fagal, R.; Thijs, L.; Celis, H.; Arabidze, G.G.;
Birkenhger, W.H.; Bulpitt, C.J.; de Leeuw, P.W.; Dollery, C.T.;
Fletcher, A.E.; Forette, F.; Leonetti, G.; Nachev, C.; O'Brien, E.T.;
Rosenfeld, J.; Rodicio, J.L.; Tuomilehto, J.; Zanchetti, A. for the
Systolic Hypertension in Europe (Syst-Eur) trial Investigators.
Randomised double-blind comparison of placeboand active
treatment for older patients with isolated systolic Hypertension.
Lancet, 1997, 350, 757-764.
Liu, L.; Wang, J.G.; Gong, L.; Liu, G.; Staessen, J.A. Comparison of
active treatment and placebo in older Chinese patients with isolated
systolic hypertension. Systolic Hypertension in China (Syst-China)
Collaborative Group. J. Hypertens., 1998, 16, 1823-1829.
Kostis, J.B.; Cabrera, J.; Cheng, J.Q.; Cosgrove, N.M.; Deng, Y.;
Pressel, S.L.; Davis, B.R. Association between chlorthalidone
treatment of systolic hypertension and long-term survival. JAMA,
2011, 306, 2588-2593.
Forette, F.; Seux, M.L.; Staessen, J.A.; Thijs, L.; Birkenhger,
W.H.; Babarskiene, M.R.; Babeanu, S.; Bossini, A.; Gil-Extremera,
B.; Girerd, X.; Laks, T.; Lilov, E.; Moisseyev, V.; Tuomilehto, J.;
Vanhanen, H.; Webster, J.; Yodfat, Y.; Fagard, R. Prevention of
dementia in randomised double-blind placebo-controlled Systolic
Hypertension in Europe (Syst-Eur) trial. Lancet. 1998, 352, 1347-1351.
Beckett, N.S.; Peters, R.; Fletcher, A.E.; Staessen, J.A.; Liu, L.;
Dumitrascu, D.; HYVET Study Group. Treatment of hypertension
in patients 80 years of age or older. N. Engl. J. Med., 2008, 358,
1887-1898.
Bejan-Angoulvant, T.; Saadatian-Elahi, M.; Wright, J.M.; Schron,
E.B.; Lindholm, L.H.; Fagard, R.; Staessen, J.A.; Gueyffier, F.
Treatment of hypertension in patients 80 years and older, the lower
the better? A meta-analysis of randomized controlled trials. J.
Hypertens., 2010, 28, 1366-72.
Rubio-Guerra, A.F.; Rodriguez-Lopez, L.; Vargas-Ayala, G.;
Huerta-Ramirez, S.; Serna, D.C.; Lozano-Nuevo, J.J. Depression
increases the risk for uncontrolled hypertension. Exp. Clin.
Cardiol., 2013, 18, 10-12.
Dolder, C.; Nelson, M.; Stump, A. Pharmacological and clinical
profile of newer antidepressants, implications for the treatment of
elderly patients. Drugs Aging, 2010, 27, 625-640.

Received: July 23, 2014

[25]

[26]

[27]

[28]

[29]

[30]

[31]

[32]

[33]

[34]

[35]
[36]

151

Wilson, S.L.; Poulter, N.R. The effect of non-steroidal antiinflammatory drugs and other commonly used non-narcotic
analgesics on blood pressure level in adults. J. Hypertens., 2006;
24, 1457-1469.
Cant-Brito, C.; Chiquete, E.; Duarte-Vega, M.; Rubio-Guerra, A.;
Herrera-Cornejo, M.; Nettel-Garca, J.; Estudio multicntrico
INDAGA. ndice tobillo-brazo anormal en poblacin mexicana con
riesgo vascular. Rev. Med. IMSS., 2011, 45, 239-246.
Rubio-Guerra, A.F. Clinical forum, hypertension in patients
with peripheral arterial disease. Rev. Invest. Clin., 2013, 65, 263268.
Norgren, L.; Hiatt, W.R.; Dormandy, J.A.; Nehler, M.R.; Harris,
K.A.; Fowkes FGR on behalf of the TASC II Working Group.
Inter-Society Consensus for the Management of Peripheral Arterial
Disease (TASC II). Eur. J. Vasc. Endovasc. Surg., 2007, 33, S1S75.
Calhoun, D.A.; Jones, D.; Textor, S.; Goff, D.C.; Murphy, T.P.;
Toto, R.D.; White, A.; Cushman, W.C.; White, W.; Sica, D.;
Ferdinand, K.; Giles, T.D.; Falkner, B.; Carey, R.M.; American
Heart Association Professional Education Committee. Resistant
hypertension: diagnosis, evaluation, and treatment. A scientific
statement from the American Heart Association Professional
Education Committee of the Council for High Blood Pressure
Research. Hypertension, 2008, 51, 1403-1419.
Chrysant, S.G. Effectiveness and safety of phosphodiesterase 5
inhibitors in patients with cardiovascular disease and hypertension.
Curr. Hypertens. Rep., 2013, 15, 475-483.
Krause, T.; Lovibond, K.; Caulfield, M.; McCormack, T.;
Williams, B.; Guideline Development Group. Management
of hypertension, summary of NICE guidance. BMJ, 2011, 343,
d4891.
Schfer, H.H.; De Villiers, J.N.; Sudano, I.; Dischinger, S.; Theus,
G.R.; Zilla, P.; Dieterle, T. Recommendations for the treatment of
hypertension in the elderly and very elderly--a scotoma within
international guidelines. Swiss Med. Wkly., 2012, 142, w13574.
Rubio-Guerra, A.F.; Castro-Serna, D.; Elizalde-Barrera, C.I.;
Ramos-Brizuela, L.M. Current concepts in combination therapy
for the treatment of hypertension, combined calcium channel
blockers and RAAS inhibitors. Integr. Blood Press. Control., 2009,
2, 55-62.
Jamerson, K.; Weber, M.A.; Bakris, G.L, Dahlof, B.; Pitt, B.; Shi,
V.; Hester, A.; Gupte, J.; Gatlin, M.; Velazquez, E.J. Benazepril
plus Amlodipine or Hydrochlorothiazide for Hypertension in HighRisk Patients. N. Engl. J. Med., 2008, 359, 2417-2428.
Stokes, G.S. Management of hypertension in the elderly patient.
Clin. Interv. Aging, 2009, 4, 379-389.
Stokes, G.S.; Bune, A.J.; Huon, N.; Barin, E.S. Long-term
effectiveness of extended-release nitrate for the treatment of
systolic hypertension. Hypertension, 2005, 45, 380-384.

Revised: September 25, 2014

Accepted: December 11, 2014