Document 6424595

Co~l~plic:rtior~s
or I ~ y p e r t c ~ l s in
i o ~t l~~ ecldcrly
Iiluotl ~ ) ~ c s s tisr ~a erisk filetor for cardiovascol:~rtliscase at all ages but particularly in
t l ~ ccltlcrly (1.2). tIypcrtension is the lnajor risk factor Tor stroke, cardiac failure,
culolirlry a ~ t c r ydiscasc and luyocardial ir~farctio~i
io this age group.
(:cl~cbrovirsc~~l:~r
accidc~~t
Sr~okcsilcc~ulltfor I If?6of all deatl~sin the U~litctlStates atid 7.5% of slrvkc deatlls arc
i l l tl~oscngctl over 65 years. Ilypcrtensiot~is rllc 11lvs1polct~t
~llostconunou
plccursor of ntl~ervlllro~l~botic
brain ir~farctior~
(3.4).
Asy~uptut~~:~tic
casual Ilyl)erte~~siou
is associated will1 a risk of a l t ~ e r o ~ ~ r o r ~ braill
~bodc
i t ~ l ' : ~ ~ c tfour
i o ~ ~to tl~irty tittles greater lliiul that of ~~orrnotensives.The risk of
ntl~c~otlironlbotic
brain i~ifarctionis as well correlated wit11 systolic blood pressure as
\\,it11 tliastolic or lllearl pressures. Tllc in~pactof systolic 11yl)erleosionis tlot dirl~il~isl~ed
with i~dvarici~~g
age llrus s t ~ p p o r t i ~tlic
~ gview Illat systolic I~ypertel~sion
in the elderly is
;~ssuci:~tctl
will1 considcrablc ca~diovascularrisk (2) (see bgure 1). For each 10 nu~ltIg
rise it] blvod pressure. t l ~ crisk of athcrotl~rotnboticbraill infarction increases about
3OC?6( 1 ) .
111a I O ycar longitudinal study of I Y I elderly fe~nalcsaged up to 100 years (average 80).
it uras sl~o\\*n
that the incidence of cerebrovascular events was sigtli[icantly correlated
to systolic blood prcssure (5). Twenty perccnt of the hypertensive and 1096 of tlic
~iorniotensivcpatients suffered from a cercbru\~ascularevent during the study.
Co~tgestivecardiac Ia1'I ure
Systolic bloocl prcssure is a tilajor detcnnit~atitof left ventricular work and t l ~ e
relationship bctwcen systolic blood pressure and congestive cardiac failure is
e x l r c ~ ~ ~strong.
e l y 111t l ~ c17ra~ninghan~
Study (6). I~ypcrtensionwas the donlinaot risk
factor for all agcs. In tlie elderly group (age 65-74 years) alniost seven tirnes as lilany
Ilyl)crtcnsives developed cartiiac failure as did norniotensives. The occurrence of
congestive cardiac failure carricd a poor prognosis as only 50'h of those who developed
cardi:~cfailu1.e survivcd live ycars.
Corollary artery disease
lligl~blood prcssure is a risk factor for coronary artcry diseasc in tlic clderly (7).
I'rospcclivc studies liavc convincingly det~lotistratcda substantial excess rate of
development of coronary Ilcast discasc in proportion to t l ~ cdegree of elevation of
artcrial prcssurc. riotably systolic prcssurc. IGsk of corollary l~cartdiscasc is disti~ictly
a t ~ ditnlxcssivcly rclntcd to antcccdent blood prcssurc at all agcs, including t l ~ eldcrly.
c
Myocnrtlial infarctiott
111a I 0 year study, 170rettc ct al. (5) have rcportcd that llic iticidencc of tnyocardial
infarction was sigr~ifican~ly
and indepcndcntly correlated todiastolic blood prcssure in
fct~lalepatierits over 60 years of age.
Twenty seven of the Y4 hypertensive patients (28'%,) and 4 of the 5 1 nortiiotensivcs
(7.816) liad niyocardial infarction during the follow-up. 'rlius, tlic incidence of
~i~yvcardial
inlarctioti was more than three tinles l~igl~cr
in tlie Ilypcrtc~isivcpatients
Illan in dic norn~otcosivc.
Mortality ~ssocintedwit11 I t y p e r t e ~ ~ s ill
i o ~t11c
~ elderly
'rile I~raminghamStudy (7) has coml)arcd mortality in diKere'n1 age groups according
to blood prcssure status and showed that mortality in hypertensive nlalcs wit11systolic
blood prcssure above 160 1iiti11.lgis nlucl~greater than in norniotcnsivc nlales.
Mortality in elderly 1iy~)ertcnsivcsis twice tl~atof norniotetisives despite a sligl~t
decrease in rclative niortality with age. Wliereas the relative mortality betwecn
Iiypcrtcnsives and tiorniotcnsivcs is less in the cldcrly than in middle age because of lllc
grcatcr nun~bcrof dcallis in die elderly, t l ~ cactual nuti~bcrof hypertcnsioti-relad
dcatl~sis incrcascd. For eldcrly rnales, 4.6% of annual dcatlis wcrc associatcd wit11
I~yperlerisior~
cornl~arcdwill] 1.896 ofdcatlls in d ~ 45-54
c
ycar agc group (see figurc 2).
'I'llus. in the eldcrly, l ~ i g lblooti
~
prcssure rctnains an important risk factor for
cardiovascular discase.
Cl~niigcsill the cardiovascular systctl~with raised blood pressure and ageittg
'I'lre agcing process is associaled with anatotnical, pl~ysiologicaland biocllenlical
cl~anges.So111eof tl~esecl~a~lgcs
may be inlportarit in the patllogenesis of hypertension
in the elderly.
Tllere is increased rigidity of the aorta al~tlits branclles due to loss of elastic fibres in tlie
nledia, an increase in cvlagen at~tlcalciurn conteat, and the presence of atl~eroii~a
in the
irltiu~a.The functional consequence is that these vessels are less compliant (8). The
stilTeiled large vessels behave lrlore like rigid lubes tllan diste~lsiblevessels. Normally,
:lortic distensibility reduces the workload of the left ventricle as it reduces impedance.
I n less coinpliant vessels tlle systolic pressure generated in tlre left ve~~tricle
is
transmitted witli very little buffering to the arterial tree. -Illis results in a rise in systolic
pressure, Ilence tlle terldency to disproportionate systolic llypertension in old age (9,
10).
.l'l~erenin-angiotensi11-aldosteroi~esystenl also undergoes cl~angeswit11age. Low-renin
essential l~yperterlsion is a more coilullo~lfeature in the elderly. I'lasma retiin
concentration, plasnla reriin activity and aldosterone concentration are all lower ia the
elderly. Sotne l~oldthat tlle decrease in plasn~areilin in the elderly is ~ilerelya feedback
il~l~ibition
induced by tlleir higher arterial pressure.
Why treat tlle elderly l~yyertciisive
I t has been de~r~otlstrated
that I~ypertensioilio the elderly is associated will1 excess risk
o~cardiovascularmorbidity and tnortality. But before one can advocate the treatment of
Ilyl.~el.tensionin all elderly I~ypertensivcs. pressure reduction must be seen to be
;~ssocinlcdwit11 a reduction ill ~i~orbiiiity
antl n~ortality.tviany studies have been
ulldertakcn lo assess the benetit ol'anlihypertensive therapy it1 adults but they have not
included sutlicicllt elderly Ilypertcl~sivesto draw delinilive corlclusions ( 1 I).
'I'renttnenl and co~nplicatioas
l ' l ~ cVeterans Adniinistration Study ( 1 2 ) unfortunately had tlle litnitations orincluding
or~lymales ar~dInany llad the co~nplicationsof I~ypcrtensionand otl~erill~~esses
prior to
raodv~nisationinto contr.ol slid trcatn~entgroups.
111 tllose witli diastolic pressure between 90 and 1 1 4 mml-lg tlicre were 8 1 patients over
GO years and tliey comprised one fifth of tlle entire study group. The i~lcidericeof rnajor
complications of trypertension increased witli age. and this one fifth accourlted for
alniost lialf of to~zlevents. In the uolreated group 15.2% of patients under 5 0 years of
agc developed rnorbid events co~npared\\.it11 62.9% or tliose over 59 years. In tile
trcated group the incidence of norb bid evcr~tswas 6.9%) and 28.99& respectively (see
ligurc 3).
-. -. - . ..
..-..-
I
I!?l-wl,.nr c. (!I ~ ~ I ( ~ I I ?FYPIII*.
III
,,
7
.l'reat~nenta t ~ dreduction of r~~ortalitp
'l'lie five-year lindings of the klyperte~lsion Detectioo and I;ollow-up I'rogram
Cwoperative Study ( 13) arc p;lrticulary perti~~ent.
In tllis conlrnunity-based randomised controlled trial i~ivvlvingovcr 10,000 hypertensives, rriortality ligurcs are comparccl bctwccli tl~oseallocated to n systctiiatic antillypcrtcnsivc trcaltncnt progranlme
(stepped care) and tlrosc rcTcr~.edto community riicdical care (referred care). Tlie
stepped care group was offered antihypcrtensive Iherapy in special centres, free of
cl~argewill1 a ~naxirnun~
elTort to encourage patient compliance'with therapy which was
increased stepwise to acl~icvcand rnaintai~lreduction or blood pressure to or bclow set
goals. Tlie referred care group were rererred Tor treatment lo Iheir usual sources ofcare.
A 17% reduction in 5 year total rnorlality was reported in dle specially treated group.
'I'licrc were 2,367 patients. agcd 60-69. includcd in thc study. In tl~isiIgc group therc
nfas a 16.4% reduction in nlortality in !he stepped care group altliougl~tile din'crcnce in
diastolic blood pressure bctwcco l l ~ etwo groups conlpared at t l ~ cend of 5 years was a
Inere 5.1 ~nniHg.
althougll tlic difirel~cein diastolic blood prcssure between the two goup's compared at
tlie elid of 5 years was a riiere 5.1 rlirlll lg.
It is 1101clear if diis reduction in niortality was causcd by rcductiori of diastolic blood
~~rcssurc
by 5 i~iitillg or if better gc~icral~iicdicalcare contribuled to llte successful
result it1 the stcl)l~cdcare. cspecinlly as also noti-cardiovascular deaths were reduced by
14r?0.I t is clear that rliaiiy sturlies airrlcd at assessit~gtlie beiicfiis of ailtiliypertelisive
Illeri~pyI~iivcbceit directed at tlie adult population in general with sorlle i~ifonnatioii011
tlie clclcrly c~ilcrgi~ig
as a side issue. Tlic ~iiulticcotrestudy by tlic European Working
I'nrty o ~ Iiligli Dlovcl Pressure in tlie Elderly ( 14, 15, 16, 17) is curre~itlyassessiilg the
rolc of at~tihyocrterisivctliernpy specifically in elderly liypcrlensivcs. Tlie antiliypertctlsivc tlicr;~l~y
has beer1 sliowii to be cflicncious and relatively well tolerated in tlie
loi~gtcin~.Ilowcver, the rcsults of l l ~ ecll'ects of tlic treatti~etiton iilortality and
tiu)tbidity ; I I C iivt yet available.
In sutlitllary. beitelit has bccii sliowll fur die lieattliclit of l~ypertcnsioilat all ages, but
llie bcuefit io tlic elderly is not as clear-cut as in yourigcr individuals.
\YII:I~ is I~ypertet~sioa
i e l l ~ eelderly?
lllood pressure is a coiiti~~uous
variable atid as tlie level rises, so do llie associaled risks
( I). As in yourig people there is no clearly identifiable critical or safe level, so cut--off
pc~it~ts
iiiust be arbitrary. 7'1ic lirl~itsset are based on increase in morbidity a i d
iiiortnlity. 111tlic preserit cotltcxt we take lGO/YO1iutil-Ig(5dipliase) as the upper lilrlitof
nornial pressure.
I t is iivw recognised that we tllust take systolic pressure into account as well as die
tliastolic. I)isl)roportionate systolic liypertension exists wllen the rise in systolic
pressure is exaggcrated conipared wit11 ale diastolic pressure. It is defi~iedas syslolic
pressure = (tliastolic pressure - 15) x 2.
Isolated systolic hypertension is variously delirietl as a systolic pressure greater than
150 mnlI.Ig( 18) or ii systolic pressure in excess of 159 rnrrlHg(l9), wliile the diastolic
pressure reniairis below 90 nimHg. A tllird definition, and perhaps tlie most
appropriate, is a systolic pressure of 160 or greeter wid1 n diastolic pressure of 95
nitiiI-Ig(20). Disproportioiiate systolic hypertension and isolated systolic hypertension
are yreseiilly utitler ilivestigatioli and a plan of managenlent is not known.
Ilotv C O I ~ I ~ I I O IisI llypertet~sio~~
in the elderly?
The prevalerice of Iiypertension in dte elderly depends on the blood pressure levels
wliich are chosen and on ttie number :lod circurnstarices in wliich readings are taken. In
the United Stales t l ~ cNativrial I lealtll Survcy ( 2 1 ). usittg 160/Y5 iiiinklg as tile lower
litiiit of Iiyperteii~io~i.
foulid a prevale~lceof about 4036 in tlie elderly age group.
Estit~intesofdisproportionate systolic Iiypertension vary and a figure as high as 40% of
tliose attetidirig a Iiigh blootl pressure cliiiic has been suggested ( I I). Using 159190 as
tlte systolic and diastolic liniits. isolated systolic liypertension is relatively rare: 2.7%
of tlic populatioll if readings are repeated oo a separate occasiori (19). Clearly, if
95 tiiiiil lg is used as Ihc cut-olT level for diastolic pressure, a liiglier prevalerice will
1)crtaiit.
W l ~ o t rto
~ treat?
Wlteii selecting patients for a~ltiltypcrtensivetl~erapyotie is teiiipercd by the hiowledge
Ilia1 cldcrlv patients itlily react dill'erctilly to drugs than younger subjects (22).
Agcing induces pi~ysiolvgicnl and pathological clianges wliich nlay influence the
~~lii~rii~acvkinctics
;\tit1 ~ C S ~ O I I Sto
C drugs (23. 24).
lVlicrcarc varyitig ol)iiiiolis colicertlitig tlie level ol' blood pressure at wliicl~to start
165
rr cnrriicr~tin the elderly patients. I t is generally agrccd tliat. regardless of' age paticots
\ v i l l ~a
sustained diastolic blood pressure of 115 ~ n m l l gor more sl~ouldreceive
t~eatn~cnt.
111fact. nlosi dvctors trcat tliose wit11diastolic pressureover 1 I 0 1111nlIg.We
sl~ouldcarefully consider therapy in elderly patients whose blood pressure is l~iglicr
than 1601100 mmHg on two occasions. In patients with diastolic blood pressure in dle
range 100- 1 I 0 11iin1-1gtlie presence ofcoriiplications or a sitnultaneous systolic blood
pressure of greater lliar~180 ~nrnllgwould sway tile b a l a ~ ~ cine favour of tlicrapy. At
Iwesent rl~ostEurvpcan pliysiciaris do not treat isolated systolic Iiypertension (25).
1Ion~cvcr.wllen a groupof North A~neric;~n
pliysicians were 'pollcd' at a recent ~ilecting
of Chest Pliysicians. it was clear tliat the vast ~najorityoftllose present treated isolated
systolic hypertension. 'This reflects dicir inore aggressive approach to treahnent of
hypertension in general. but also indicates that tile Americans are prepared to
e
of studies oftllc cficacy of blood pressure reduction on mortality
anticipate d ~ results
and ~norbidityin tlie elderly.
lrrvestigatio~is
lrivcstipations are inairily ainlcd at assessing the effects ratllcr dlan tile cause of
I~yl)crtcnsionand sl~ouldbc kept to a mininiun~:elctrocardiogram, dipstick urinalysis,
scrurn crcatininc. serurn electrolytes and urate.
Clinically significant lel\ ventricular Ilyl)ertropliy is detectable on tlie convc~itional
electrocardiogram. 7'1ic dipstick urinalysis is usually sensitive e~iouglito dctect
abnor~nalitiesand only if the findings are positive is it worlhwhile progressing to a inidstream urirlalysis with culture and sensilivity testing. Serum creatininc is not a sensitive
nleasure of renal function and will be raised only if approximately 70% of kidney tissue
is riot functioning. Tllcrfore. if an accurate assessment is deemed, neccssary crealinine
clearance sl~uuldbe ~ncasured.Changes i n scrurn elcctroly~esand serum uratc are
unlikely prior to drug trcatnicnt and tlie n~ainreason for doing tlic~nis to asscss thc
~>ossiblc
deleterious cll'cct of diuretic treatment.
Eve11 if secondary llypertension is suspected extensive i~ivestigationsniust be carried
out unless surgical i~~lerverition
is feasible and desirable.
Cl~oiceor drug
In clioosing a particular drug tlie physician ulust attempt to con~bincellicacy will1 a
~ i ~ i n i ~ nof
u munwanted clTects.
111general. it is best to avoid antihypertensive agents such as metllyldopa, reserpine,
and clor~idir~c
dlat cause depression of dlc central nervous sysleln. l'l~ougligood data
are lacking, it is generally l~eldthat die elrlcrly are rnore prone lo tlie unwanted ccnlralnervous-systeln elfects of these drugs. 'l'his generalisation must be tc~al>crcdby an
iritcriln report of an ongoing study by the European Working I'arty on lligll Blood
I'ressure in tlie Elderly (EWI'I-IE) ( 15). in whicl~conlplicalions with n~ctl~yldopa
do
not appear lo be a prublcnl. In lliis stucly, Iiowcvcr, melliyldopa is uscd in low doscs.
'I'lle elderly and particularly tliosc with ccrel~rovasculardiscasc arc suscel~tibleto
postural Iiypotcnsion bccausc tllcy have less rcsponsivc barorcflcxes (26,27). For tllis
reason. adrencrgic-ncuron blocking drugs (guanctl~idi~ic,
bcthanidinc and dcbrisoquine) tllat causc postural hypertension sliould not bc uscd. V;~sodilatorsl~oldpro~nisc
for the future, particularly in systolic l~yl)ertcnsion,but at prcscnt data arc insullicicn~
to ninkc an i~~fornlcd
dccisio~i(8).
tlic brainsterii vasonlotor centre diereby i~lllibitingsy~~~patlietic
outflow and rcducirlg
systenlic arterial pressure. Both tliese agents may produce several side-effects like
tlro\\~sinessand depression and should therefore be used restrictively. Adrenergicrleurun blocking drugs (guanctl~idine.bctlianidine arid debrisoquine) cause postural
Iippo[eosion and sliould not bc used in tllc present context.
I_)i~~retics
l'l~iazidediuretics are elrective in reducitip blood pressure in elderly Iiypertensives and
do not cause nlajvr cli~licalor biocliernical disturba~icesbut to mininiise biochemical
disturbances it is bcst to use a lo\v dose of for exa~ilpleI~ydrocllloroClliazide(25 nig
daily). l'llc clderlp are said to be 1ilore prone to tl~epotassiuni-losing crrects oftliiazide
diuretics. I3ppokalacniia niny induce ventricular ectopic activity (33) and the risk of
nrrllylll~niasis inore niarketl wlicn a Iiyi)okalac~~lic
patient perfornls exercise (34).
1':rtients with abnormal potassium levels nlay also liave a poorer progrlosis in case of
nl!locardinl irrfarclion wit11 liigl~crrisk of arrllpthmias (35). Tliercrore, potassium
sul~l~lellie~itatioll
should he givcn or the tl~i:izidcsliould be combined witli a potassiumsparing diuretic such as triarntere~~c.
As many elderly patients find individual
potassiuln preparations unpalatable one rnay conlbine the tlliazide will1 potassiunl in
one tablet. I'otassiutn supplc~nentationis particularly appropriate if the patielit is also
on digitalis therapy. Glucose intolerance is one of the major risk factors ror coronary
artery disease. In tlie EWPI-iE study tlie group treated with tlliazide diuretics showed a
significant deterioration in glucose tolerance (17, 36). Cli~~ical
diabetes mellilus is
likely to be induced only in tl~osewho already have borderline diabetes. We expect tllat
tlle reduction of blood pressure would more tllan oli'sct tlle tl~corcticalrisk associated
witli a small drug-i~lduccdrise in blood sugar level.
Serunl uric acid levels also rise in patients on tlliazidc diuretic therapy. In the EWI'HE
stutly the group treated with diuretics sl~owcda 25% increase in scrurn uric acid but
cliiiical gout was extretncly rare. Tlic sanlc indica[ions and contraindicatiot~s;rl)l)ly as
in younger patients.
Sun~e~ai-y
I Iigli blood pressure in the elderly is associated wid1 a high incidence of cardiovascular
disease but tllcre are no definite data wliicli prove that treatnient of mild to noder rate
Iiypertension in this age group inlproves prognosis. I-iowever, a review of available
literature suggests that treatrlient is beneficial. We adopta policy as outlined above. We
suggest a tlliazide diuretic or a beta-adrenoceptor blocking drug as first-line tl~erapy.
'I'llese drugs niay be combined if an inadequate response is seen and other drugs nlay be
used if dre blood pressure is not controlled.
asscsslneljt or tlic rolc or blood
I . Knlincl WU. W o l f I'A. Vcrtcr J. McNaliiara PM: I~liidc~iiiological
prcssurc in stroke: t l ~ cI : r e ~ ~ i i t i ~ l i nSttltly.
~n
J A M A I Y 70: 2 14: 3 0 1 - 10.
i c l Gordon'l': I ~ v n l ~ ~ n loftlie
i o t i cnrdiovnscular ~ i s kill tliccldcrly: tlic I 7 r i i ~ i i i ~ i g l iStudy.
n ~ ~ i Bull
2. K n ~ ~ ~WII.
N Y Acatl. Mcd. 1978: 54: 573-91.
3. Slickcllc It[!, Ostl'cltl A M . Klnwnt~sIll, Jr: I I y l ~ c ~ t c l i s i nlid
o ~ i risk o f stroke ill llic cldcrly ~ ~ o l > u l i ~ I i o ~ i .
Strokc 1974; 5: 7 1-5.
c ~hlocitl
~ t s prcssulc i ~ t i t risk
l
of n111cr~IIiro11i4. Kn~iliclW I ) . 1)rwlxr 'l'lt. Sorlic I'.Woll' I'A: C r ~ ~ i i l ~ o r iof
h ~ t i cbraill ilil'arctioci: llic I:r;i~iii~igl~n~n
St~idy.Strokc IY76; 7: 327-31.
5.
I'otcttc I:. L)c In I:ucrite J. Golrrlnrd JL. l l c t i r y J17. I l e r v y h.11': Elderly liypertension as a risk factor
c ~ ~ r Corrccl)ts
r.
Ilypcrtetis Cnrtl. Disortl. (Sytlticy) 1980: 1 (4): l I.
0. K : l ~ r t ~ eWU.
l
Cnstelli WP. blcNntrrnra Pbl. b l c K c c PA. Fcirlleib h l : llole o f blood pressure i n the
tlcvcloliriicrit ol'cotigcstive Iicnrt I;.iilure. l ' l l c Frarlririgllntr~Study. N. Engl. J. Mcd. 1972: 287: 78 1-7.
7. K n t i t ~ cWU.
l
Gortloti'T. Scli\vartz M J : Systolic vcrsl~sdinstolic blood pressure and r i s k o f coro~iaryheart
tliscnse: tlie !:ra~iiiliplinn~Study. AII. J. Cnrdiul. 1971: 27: 335-46.
8. Sitlion A C . Safnr h l A . Levotison JA. Khcdcr A b l . L c v y UI: Systolic hypcrtcnsiori: I i a e n ~ o d y n m i c
ri~ccl~atiisrir
nntl clioice tif antillypcrtcnsive trcatlllctit. AIII. J. Cnrdiol. 1979: 44: 505-1 1.
9. l'nrnzi ICC: Should you lrcat systolic l i y p e r t c t ~ s i oiri
i ~ eldcrly patients? Geriatrics 1978: 33(1): 25-9.
10. Korll-Wcscr J: Trcntt~ier~tofliypcrte~~siori
it1 t l ~ c
elderly. 111: C r w k s J, st evens or^ 11-1,eds. Drugsandthe
Eltlctly. Lotidoll: blacblillan 1979: 247-62.
I I. Kocll-Wese J: Artearinl hypertensioti it1 o l d age. I l e r z 1978: 3: 235-44.
12. Vrtcrnrts Adrtiiriistratiot~Cool)crntive Stutly G r o u p VI Aritil~ypertensiveAgents. Effects o f treatrllent
otl ~ ~ i o r l i i t l iirt
t y Irypcrtcnsion. Ill.lnflctence o r age. diastolic pressure and prior cardiovascular disease.
frlttllcr ntinlysis cil' side cll'ccts. Circulntion 1972: 45: Y9 1-1004.
13. Ilyliertension Detcctioli and Follow-up P r o g r a r ~ Cooperative
~
Sludy: Five year findings o f llle
I~yl)crtetisiorldetcctici~land rollow-up prograrii. I. Reduction i n mortality o f persons wiUi high b l w d
prcssure iiiclutlilifi tilild I~yperte~isior~.
J A b I A 1979: 242: 2562-7 1.
1.1. A ~ i i c r yA. Ilertll:rux P. Dirkenhaper W e l nl: Ariti1tyl)erlensive l i e r a p y i n elderly pslienls: pilot trial o f
t l ~ eErlrcipenn Working Party o ~ t il i p l ~Ulood Pressure i n the Elderly. C;erontology 1977: 23: 426-37.
15. A ~ i r e r vA. Uertlraux P. llirketltilger W et al: Antiliypertetisive tl~erapyi n patients above age 60: third
i t ~ t c r i r rreport
~
ol'tlic Europcnt~W o r k i ~ ~Party
g o n I l i g l i Ulood Pressure in the Elderly ( E W P t I E ) . Acta
C:irtliol. 1978: 33: 1 13-34.
10. Atricry A . D c Scliilcptirijver I\. Should cldcrly Iiyl)crtclisives be treated:' Lntlcel 1975: 1: 272-3.
17. t\rllcry I\. Ilcrtlinux P. Bulpitt C ct al: Glucose ititulcrnrice during diuretic therapy: results o f t r i a l b y the
I~~trrloc:iri
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Discussioo
I;cr.l~oe~.en:
WI1y d o you a v o i d
u s e of a l p l l a - ~ ~ i e t l i p l d v ~ ~ a ?
0 'A la I l ~ l - :
hlait~lybecausc it h a s a CNS d c l > r c s s i o n elTect.