Claassen Jurgen A H R, Richard Edo, Mooijaart Simon P, Moll van Charante Eric P
Radboudumc, afd. Klinische Geriatrie, Nijmegen.
Contact: Jurgen A.H.R. Claassen (
Ned Tijdschr Geneeskd. 2023 Mar 15;167:D7334.
Recent guidelines, including the ESC, have moved towards lower targets (<140 mmHg, 130 if tolerated systolic, < 80 mmHg diastolic) for antihypertensive treatment in older adults. The evidence for clinically relevant benefit against limited risk of side effects applies to relatively fit older adults, representing less than 30 % of older patients in clinical practice. We discuss that formal evidence of treatment benefit for frail older adults is absent, although there is limited evidence that this benefit is similar for frail and non-frail participants in clinical trials (e.g. SPRINT). On the other hand, we discuss that the evidence for harm associated with antihypertensive treatment in frail older adults is weak when critically appraised. This applies to the risk of cerebral hypoperfusion, orthostatic hypotension, coronary hypoperfusion, and renal hypoperfusion. The frequently cited J-curve reflects patient characteristics, but is not evidence of harm induced by treatment-induced blood pressure lowering. In this context of absent solid evidence for both benefit and harm, we provide practical treatment advice for hypertension in frail older adults.
包括欧洲心脏病学会（ESC）在内的近期指南已将老年人降压治疗目标下调（收缩压<140 mmHg，若能耐受则为130 mmHg，舒张压<80 mmHg）。针对副作用风险有限的临床相关获益证据适用于相对健康的老年人，在临床实践中这类老年人占老年患者的比例不到30%。我们讨论了尽管在临床试验（如强化降压治疗预防心血管事件试验[SPRINT]）中，有限的证据表明虚弱和非虚弱参与者的获益相似，但目前尚无针对虚弱老年人治疗获益的正式证据。另一方面，我们讨论了在严格评估时，虚弱老年人降压治疗相关危害的证据不足。这适用于脑灌注不足、体位性低血压、冠状动脉灌注不足和肾灌注不足的风险。经常被引用的J曲线反映了患者特征，但并非治疗性降低血压所致危害的证据。在缺乏获益和危害的确凿证据的情况下，我们为虚弱老年人的高血压提供了实际的治疗建议。
