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Modifications of Blood Pressure Profiles in the Very Old: Role of Frailty and Comorbidities

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Blood Pressure and Arterial Wall Mechanics in Cardiovascular Diseases

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Abstract

The 2013 ESC-ESH Guidelines for the management of arterial hypertension stated that in elderly (>80 years) individuals, lowering SBP to < 150mmHg is strongly evidence-based. These guidelines are mainly based on the results of the Hypertension in the Very Elderly (HYVET) study which showed the beneficial effect of decreasing SBP with antihypertensive treatment in patients older than 80 years. This trial was conducted in a highly selected population of robust elderly patients with very low comorbidities. Thus, despite the interest of these results, we believe that the question of the benefits of antihypertensive treatment in the very old is not unequivocally settled and may depend on the magnitude of co-morbidities, frailty and functional decline.

The PARTAGE (Predictive values of blood pressure and arterial stiffness in institutionalized very aged population) multicenter study performed in very old, frail subjects living in nursing homes reported a 30% increase in all-cause mortality in patients ranked in the lowest tertile of SBP (<130mmHg) compared to the two upper tertiles. These results remained identical after adjusting for several confounders such as age, gender, history of previous CV disease, index of co-morbidity, cognitive function and autonomy status. These paradoxical results can be explained by the fact that in these very old frail subjects, a low SBP may not simply be a sign of so-called good arterial health, but often of malnutrition and of co-morbidities such as heart failure, neurological disorders etc., as well as other concomitant conditions associated with poor prognosis. Irrespective of the underlying explanation, the present results indicate that the BP levels in very old “frail” individuals are evidently not reliable. These findings raise the question as to relevance of BP levels as an indicator of the cardiovascular risk in these subjects. This is of major interest since iatrogenic-induced problems are also a major issue in geriatric subjects. In fact, at the present time, no study has provided evidence that higher morbidity-mortality rates in those with very low BP is due to low BP in itself or is just a sign of general bad health.

Interventional clinical trials will provide critical information to guide physicians in order to fixe specific goals for treating hypertension and decreasing the risk of cardiovascular complications in these very old and frail individuals.

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Authors and Affiliations

  1. Department of Geriatrics, University Hospital of Nancy, Universite De Lorraine, 1, allée du Morvan, Vandoeuvre Les Nancy, 54500, France

    Athanase Benetos MD, PhD & Sylvie Gautier MD

  2. INSERM U1116,Université de Lorraine, Nancy, France

    Athanase Benetos MD, PhD

  3. Department of Medicine, Paris Descartes University, Assistance Publique des Hôpitaux de Paris – Hôtel-Dieu Hospital, Diagnosis and Therapeutics Center, 1 Place du Parvis Notre-Dame, Paris, 75004, France

    Michel E. Safar MD

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Correspondence to Athanase Benetos MD, PhD .

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Editors and Affiliations

  1. Hôtel-Dieu Hospital Diagnosis and Therapeutics Center, Paris Descartes University, Paris, Paris, France

    Michel E. Safar

  2. St Vincent Clinic and Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Darlinghurst, Sydney, New South Wales, Australia

    Michael F. O'Rourke

  3. Department of Cardiology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA

    Edward D. Frohlich

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Benetos, A., Gautier, S., Safar, M.E. (2014). Modifications of Blood Pressure Profiles in the Very Old: Role of Frailty and Comorbidities. In: Safar, M., O'Rourke, M., Frohlich, E. (eds) Blood Pressure and Arterial Wall Mechanics in Cardiovascular Diseases. Springer, London. https://doi.org/10.1007/978-1-4471-5198-2_30

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