Department of Clinical Pharmacology, Hospices Civils de Lyon, Lyon, France.
J Hypertens. 2010 Jul;28(7):1366-72. doi: 10.1097/HJH.0b013e328339f9c5.
Results of randomized controlled trials are consistent in showing reduced rates of stroke, heart failure and cardiovascular events in very old patients treated with antihypertensive drugs. However, inconsistencies exist with regard to the effect of these drugs on total mortality.
We performed a meta-analysis of available data on hypertensive patients 80 years and older by selecting total mortality as the main outcome. Secondary outcomes were coronary events, stroke, cardiovascular events, heart failure and cause-specific mortality. The common relative risk (RR) of active treatment versus placebo or no treatment was assessed using a random-effect model. Linear meta-regression was performed to explore the relationship between intensity of antihypertensive therapy and blood pressure (BP) reduction and the log-transformed value of total mortality odds ratios (ORs).
The overall RR for total mortality was 1.06 (95% confidence interval 0.89-1.25), with significant heterogeneity between hypertension in the very elderly trial (HYVET) and the other trials. This heterogeneity was not explained by differences in the follow-up duration between trials. The meta-regression suggested that a reduction in mortality was achieved in trials with the least BP reductions and the lowest intensity of therapy. Antihypertensive therapy significantly reduced (P < 0.001) the risk of stroke (35%), cardiovascular events (27%) and heart failure (50%). Cause-specific mortality was not different between treated and untreated patients.
Treating hypertension in very old patients reduces stroke and heart failure with no effect on total mortality. The most reasonable strategy is the one associated with significant mortality reduction; thiazides as first-line drugs with a maximum of two drugs.
随机对照试验的结果一致表明，在接受抗高血压药物治疗的非常高龄患者中，中风、心力衰竭和心血管事件的发生率降低。然而，这些药物对总死亡率的影响存在不一致性。
我们通过选择总死亡率作为主要结局，对 80 岁及以上的高血压患者的现有数据进行了荟萃分析。次要结局为冠心病事件、中风、心血管事件、心力衰竭和特定原因死亡率。使用随机效应模型评估活性治疗与安慰剂或无治疗的常见相对风险（RR）。进行线性荟萃回归以探索抗高血压治疗强度和血压（BP）降低与总死亡率比值比（OR）的对数变换值之间的关系。
总死亡率的总体 RR 为 1.06（95%置信区间 0.89-1.25），HYVET 试验和其他试验之间存在显著的异质性。这种异质性不能用试验之间的随访时间差异来解释。荟萃回归表明，在 BP 降低最少和治疗强度最低的试验中，死亡率降低。抗高血压治疗显著降低了（P < 0.001）中风（35%）、心血管事件（27%）和心力衰竭（50%）的风险。治疗组和未治疗组的特定原因死亡率无差异。
治疗非常高龄患者的高血压可降低中风和心力衰竭的风险，对总死亡率无影响。最合理的策略是与显著降低死亡率相关的策略；噻嗪类药物作为一线药物，最多使用两种药物。
