Summary
Background
The rate of uncontrolled hypertensives aged >80 years is not well known. The available literature on this topic has used the threshold <140/90 mmHg, whereas there is now a consensus for a different target: systolic blood pressure (SBP) < 150 mmHg.
Aims
This prospective observational population-based study sought to assess the frequency and management of uncontrolled hypertension in French patients aged ≥80 years.
Methods
Nine hundred and seventy-one treated hypertensive outpatients were evaluable (204 recruited by cardiologists, 767 by general practitioners [GPs]; mean age 84.8 ± 3.8 years; 57.8% women).
Results
The frequency of SBP ≥ 150 mmHg was 36.6% (44.6% in cardiologists’ patients and 34.4% in GPs’ patients). The frequency of satisfaction with SBP ≥ 150 mmHg was 22.0% for cardiologists (32.6% if diastolic blood pressure [DBP] < 90 mmHg and 9.5% if ≥90 mmHg; P = 0.008) and 30.4% for GPs (51.7% if DBP < 90 mmHg and 13.2% if ≥90 mmHg; P < 0.0001). Non-diabetic status (for cardiologists) and DBP < 90 mmHg (for cardiologists and GPs) were independent determinants of SBP being considered acceptable. Accordingly, in patients with an SBP level ≥ 150 mmHg that was considered too high, treatment was reinforced more often if DBP was ≥90 mmHg (82.3%) than <90 mmHg (68.5%).
Conclusion
In France, hypertension is uncontrolled in more than one in three elderly hypertensives. Physicians are aware that SBP should be lowered to < 150 mmHg in patients aged > 80 years, but when the target is not reached they are less likely to increase treatment if DBP is < 90 mmHg.
Résumé
Contexte
La prévalence de l’hypertension artérielle (HTA) non contrôlée chez les sujets de 80 ans ou plus est mal connue. La littérature disponible sur ce thème a utilisé le seuil PA < 140/90 mmHg, alors qu’il y a maintenant un consensus pour une cible différente: PAS < 150 mmHg.
Objectifs
Cette étude observationnelle a pour objectif d’évaluer la prévalence et la prise en charge de l’HTA non contrôlée des sujets d’âge ≥ 80 ans.
Méthodes
Neuf cent soixante et onze patients suivis en consultation pour une HTA traitée ont été évalués (204 par des cardiologues, 767 par des médecins généralistes (MG) ; âge moyen 84,8 ± 3,8 ans ; 57,8 % de femmes).
Résultats
La prévalence d’une PAS ≥ 150 mmHg était de 44,6 % chez les cardiologues et 34,4 % en médecine générale. Le taux de satisfaction avec une PAS ≥ 150 mmHg était de 30,4 % pour les MG et 22,0 % pour les cardiologues. L’absence de diabète (pour les cardiologues) et une PAD ≤ 90 mmHg (pour cardiologues et MG) étaient les déterminants indépendants d’une PAS considérée comme acceptable. En conséquence, face à une PAS ≥ 150 mmHg et considérée comme trop élevée, le traitement était plus souvent renforcé quand la PAD était ≥ 90 mmHg (82,3 %) que lorsqu’elle était < 90 mmHg (68,5 %).
Conclusions
En France, plus d’un hypertendu âgé sur 3 n’est pas contrôlé. Les médecins savent que la PAS doit être abaissée en-dessous de 150 mmHg chez les plus de 80 ans, mais quand la cible n’est pas atteinte, ils sont malheureusement moins enclins à renforcer le traitement si la PAD est inférieure à 90 mmHg.
Background
There is a large body of epidemiological data concerning the prevalence of hypertension and its rate of control in populations aged < 75 years , but little is known about these aspects in patients aged > 80 years. One recent survey estimated the prevalence of hypertension among French subjects aged ≥ 80 years at 70% (69.7% in women, 70.4% in men) . The HYVET study showed that a drug-induced decrease in blood pressure (BP) by 17/6 mmHg with respect to placebo was associated with a significant decrease in cardiovascular morbidity and mortality .
However, the overall efficacy of antihypertensive therapy depends on the extent to which blood pressure is lowered and the frequency with which hypertension is controlled. In subjects aged between 18 and 75 years, a recent French survey (ENNS 2006–2007) reported the rate of blood pressure control to be 50.9%, with a clear difference between women (58.5%) and men (41.8%), and as a function of age (64% in women and 46.8% in men aged between 45 and 54 years versus 49.6% in women and 33.9% in men aged between 65 and 74 years) .
In hypertensives aged > 80 years, the 2005 and 2013 French recommendations, as well as 2013 European guidelines, recommended that systolic blood pressure (SBP) be reduced to < 150 mmHg , while the 2007 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines aimed at an SBP level < 140 mmHg . Despite its considerable socioeconomic importance, the specific issue of blood pressure control in patients aged ≥ 80 years has rarely been addressed. We therefore decided to carry out this observational study, to investigate both the frequency of patients aged > 80 years with uncontrolled blood pressure and the management of these patients in current clinical practice.
Methods
This nationwide survey was carried out between December 2007 and May 2008. The investigators were selected at random from a list of about 15000 general practitioners (GPs) and 1500 cardiologists throughout France.
Each investigator was asked to include four consecutive hypertensive patients aged ≥80 years and taking antihypertensive medication at the time of consultation. All the patients included had to have been known to their GP or cardiologist for several months. There were no specific exclusion criteria, but the doctors had to include outpatients who were able to come to surgery and to answer their questions correctly. Each physician was asked to complete a questionnaire that included the following information (obtained from the patient’s medical file, direct examination and medical interview): demographic characteristics; family history of cardiovascular diseases; smoking status; hypercholesterolaemia; diabetes mellitus; target organ damage (left ventricular hypertrophy and/or microalbuminuria); established cardiovascular disease; renal disease (creatinine clearance <60 mL/min according to Cockcroft’s formula or proteinuria > 500 mg/day); duration of hypertension; current clinical blood pressure; and current antihypertensive drug use. Blood pressure was measured at a single visit, in the sitting position, by the physician, with his/her usual sphygmomanometer. Measurements had to be done according to the World Health Organization recommendations (i.e. three consecutive readings after a 5-minute rest time).
At the end of the questionnaire, physicians gave their opinion about the patient’s blood pressure control by ticking a box to select one of the following two propositions: ‘blood pressure too high and should be lowered’ or ‘blood pressure acceptable’. Physicians were then asked to report their decisions at the end of the consultation: prescription of self blood pressure measurement (SBPM) or ambulatory blood pressure monitoring (ABPM); intensification of lifestyle changes; requesting the advice of another specialist; change to current antihypertensive treatment; or no change in treatment. In cases of treatment modification, the doctor was asked to indicate whether they had added a drug to the existing regimen, replaced one or more drugs by other drugs and/or increased the dose of one or several drugs.
Patients were informed orally, signed an informed consent form and their identities were kept secret, in accordance with French law. An ‘institutional board’ supervised the study.
Data analysis
As differences in blood pressure and cardiovascular risk were expected between GPs’ and cardiologists’ patients, all analyses were stratified according to the physician status. The prevalence of uncontrolled hypertension was calculated according to the available guidelines: percentage of patients with SBP ≥ 150 mmHg . Assuming a prevalence of uncontrolled hypertension of about 50% and a precision of the 95% confidence interval (CI) of 3%, a sample size of about 1000 patients was required for this study. For descriptive analyses, means ± standard deviations are reported for continuous variables and absolute numbers and percentages are reported for categorical variables. The factors associated with high blood pressure and with the physician’s interpretation of blood pressure results were identified by univariate analysis (Student’s t test for quantitative variables and chi-square test for qualitative variables) and by multivariable analysis with a logistic regression analysis performed using a manual backward procedure. All the variables associated with the dependent variable in univariate analysis, with a P value < 0.20, were considered in the maximal model of the multivariable analysis. Best-fit models obtained after applying backward procedure contain only the variables showing an adjusted P value < 0.05. Analyses were carried out with SAS version 9.2 software (SAS Institute, Cary, NC, USA).
Results
In total, 248 physicians participated in this study; they enrolled 1119 patients, 971 of whom could be evaluated (204 recruited by cardiologists and 767 recruited by GPs). The main characteristics of the patients are presented, as a function of physician status, in Table 1 . The most frequently reported risk factor associated with hypertension was dyslipidaemia, followed by diabetes mellitus and obesity. Active tobacco consumption was quite low. The cardiology patients (C group) had a much higher prevalence of target organ damage than the patients consulting GPs (GP group).
| Patient characteristics | C group | GP group | Total |
|---|---|---|---|
| ( n = 204) | ( n = 767) | ( n = 971) | |
| Age (years) | 84.0 ± 3.2 | 85.0 ± 3.9 a | 84.8 ± 3.8 |
| Age group | |||
| <85 years | 134 (66) | 400 (42) | 534 (55) |
| 85–89 years | 57 (28) | 275 (36) | 332 (34) |
| ≥90 years | 13 (6) | 91 (12) | 104 (11) |
| Female sex | 117 (57.6) | 437 (57.8) | 554 (57.8) |
| Hypertension duration > 1 year | 199 (97.5) | 737 (97.1) | 936 (97.2) |
| BMI (kg/m 2 ) | 26.89 ± 3.92 | 26.35 ± 4.47 | 26.47 ± 4.36 |
| Obesity (BMI ≥30 kg/m 2 ) | 42 (20.9) | 135 (18.0) | 177 (18.7) |
| Current smoker | 13 (6.4) | 53 (6.9) | 66 (6.8) |
| Family history of premature CVD (men at age <55 years; women at age <65 years) | 26 (12.7) | 96 (12.5) | 122 (12.6) |
| Dyslipidaemia (LDL-C ≥ 1.60 g/L and/or HDL-C ≤ 0.40 g/L or treatment) | 97 (47.5) | 404 (52.7) | 501 (51.6) |
| Diabetes mellitus | 57 (27.9) | 175 (22.8) | 232 (23.9) |
| Target organ damage (LVH or abnormal albuminuria) | 84 (41.2) | 154 (20.1) b | 238 (24.5) |
| Established CVD (angina, myocardial infarction, stroke, peripheral artery disease) | 91 (44.6) | 311 (40.5) | 402 (41.4) |
| Renal disease (creatinine clearance < 60 mL/min or proteinuria > 500 mg/day) | 37 (18.1) | 109 (14.2) | 146 (15.0) |
Current antihypertensive treatment
Patients were taking a mean of two classes of antihypertensive drugs ( Table 2 ). The mean number of classes of drug used was higher in the C group than in GP group: 2.43 ± 0.97 and 1.98 ± 0.92, respectively. Moreover, 44.4% of the patients in the C group were given drugs from three or more classes, versus only 26.7% in the GP group. Diuretics were the most frequently prescribed antihypertensive agents (66% in the C group, 54% in the GP group) followed by angiotensin-converting enzyme inhibitors (47% and 37%, respectively). Calcium channel blockers were the third most frequently prescribed class of drugs in the C group (42%) and the fourth most frequently prescribed class of drugs in the GP group (29%). Diuretics were absent from the drugs prescribed to 10.9% of the patients (32/294) taking drugs from three or more different classes (10/90 in the C group and 22/204 in the GP group).
| C group | GP group | Total | |
|---|---|---|---|
| ( n = 203 a ) | ( n = 766 a ) | ( n = 969) | |
| Number of treatments | |||
| Single agent | 33 (16.3) | 270 (35.2) | 303 (31.3) |
| Two-drug combination | 80 (39.4) | 292 (38.1) | 372 (38.4) |
| Three-drug combination | 65 (32.0) | 156 (20.4) | 221 (22.8) |
| Combination of four or more drugs | 25 (12.4) | 48 (6.3) | 73 (7.5) |
| Antihypertensive drug classes | |||
| Diuretics | 134 (66.0) | 414 (54.0) | 548 (56.5) |
| ACE inhibitors | 96 (47.3) | 285 (37.2) | 381 (39.3) |
| ARBs | 65 (32.0) | 275 (35.9) | 340 (35.1) |
| CCBs | 85 (41.9) | 222 (29.0) | 307 (31.7) |
| Beta-blockers | 82 (40.4) | 217 (28.3) | 299 (30.9) |
| Alpha-blockers | 10 (4.9) | 48 (6.3) | 58 (6.0) |
| Other antihypertensive drug classes | 22 (10.8) | 58 (7.6) | 80 (8.3) |
| Description of single agents ( n = 303) | |||
| ACE inhibitors | 6 (18.2) | 67 (24.8) | 73 (24.1) |
| ARBs | 3 (9.1) | 71 (26.3) | 74 (24.4) |
| Diuretics | 12 (36.4) | 52 (19.3) | 64 (21.1) |
| CCBs | 6 (18.2) | 41 (15.2) | 47 (15.5) |
| Beta-blockers | 3 (9.1) | 26 (9.6) | 29 (9.6) |
| Others | 3 (9.1) | 13 (4.8) | 16 (5.3) |
| Description of two-drug combinations ( n = 372) | |||
| ACE inhibitors + diuretics | 22 (27.5) | 70 (24.0) | 92 (24.7) |
| ARBs + diuretics | 10 (12.5) | 62 (21.2) | 72 (19.3) |
| ACE inhibitors + beta-blockers | 6 (7.5) | 21 (7.2) | 27 (7.3) |
| Beta-blockers + diuretics | 7 (8.7) | 17 (5.8) | 24 (6.5) |
| ACE inhibitors + CCBs | 11 (13.7) | 21 (7.2) | 32 (8.6) |
| ARBs + CCBs | 5 (6.2) | 19 (6.5) | 24 (6.5) |
| CCBs + diuretics | 2 (2.5) | 22 (7.5) | 24 (6.5) |
| Others | 63 (12.2) | 60 (20.5) | 123 (33.1) |
| Description of three-drug combinations ( n = 221) | |||
| Beta-blockers + ACE inhibitors + diuretics | 18 (27.7) | 32 (20.5) | 50 (22.6) |
| ARBs + diuretics + CCBs | 10 (15.4) | 27 (17.3) | 37 (16.7) |
| ARBs + diuretics + beta-blockers | 7 (10.8) | 21 (13.5) | 28 (12.7) |
| ACE inhibitors + diuretics + CCBs | 9 (13.8) | 18 (11.5) | 27 (12.2) |
| Others | 21 (32.3) | 58 (37.2) | 79 (35.7) |
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