Prognostic significance of blood pressure in the very old. Implications for the treatment decision.

A positive relationship between blood pressure and mortality at the age of 60 to 69 years becomes a negative relationship in men over the age of 75 years and in women over the age of 85 years, with hypertensive individuals living longer. This negative relationship in very old people probably reflects cardiac, respiratory and neoplastic disease in those with low blood pressure, and good myocardial function in those with high blood pressure. Therefore, in very elderly hypertensive people we cannot conclude that a reduction in blood pressure will not be beneficial, e.g. in reducing stroke events. However, the results of clinical trials of antihypertensive treatment in the elderly provide inadequate evidence to assess the benefit of treating hypertensive individuals over the age of 80 years. Randomly allocated controlled trials are required in this age group. The antihypertensive treatments that may be most suitable for the very elderly are diuretics with a beta-adrenergic blocking drug added if necessary. Angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers have not, as yet, a proven role in the treatment of hypertension in the very old.