Evidence That Treatment of Systolic/Diastolic High Blood Pressure Is Beneficial

There is ample evidence from large multicenter controlled trials that the treatment of systolic/diastolic high blood pressure in individuals between the ages of 50 and 69 years of age is beneficial.33,49,72 The results of these trials are summarized in Table 3-1. For persons over the age of 50, the Veterans Administration (VA) study reported a reduction (nonsignificant) in aggregate cardiovascular morbidity, the Hypertensive Detection and Follow-up Program (HDFP) reported a reduction in total mortality, and the Australian Trial on Mild Hypertension reported a trend toward reduced stroke and aggregate is chemic heart disease. The only subgroup data available on the effects of treatment analyzed by race and sex come from the HDFP and do not indicate that race and sex significantly affect the benefits of treatment.

Because most major high blood pressure trials had studied only selected groups of ''young old" persons, the European Working Party on Hypertension in the Elderly was designed to study whether medication treatment of diastolic high blood pressure in older subjects reduced morbidity or mortality. This trial enrolled persons over the age of 60 (mean age, 72 years) into treatment or placebo groups.3 After an eight-year follow-up, analysis revealed no effects of medication on mortality from all causes but did show a significant (27 percent) reduction in the cardiovascular mortality rate. There was also a statistically significant (38 percent) reduction in cardiac mortality and a nonsignificant (P = .12) but impressive 32 percent reduction in cerebrovascular mortality. Treatment appeared to be effective for persons with entry systolic blood pressure from 160 to 239 mmHg, but the treatment did not appear to have an impact on participants with entry diastolic blood pressure in the range 90 to 95 mmHg.4 The reduction in endpoints seen in the intervention group disappeared in persons over the age of 80, suggesting that treatment might not be effective in persons of advanced age. However, the number of participants aged 80 and older was small, and these subgroup data thus are not definitive. Persons over the age of 80 with diastolic high blood pressure who are relatively biologically "young" could be treated; the rationale for treating biologically frail persons aged 80 or older (particularly those with substantial noncardiovascular comorbid problems) may be less compelling.

In general, as shown in Table 3-2, treated patients over 60 years of age have relative reductions in cardiovascular morbidity or mortality similar to the reductions that occur in patients under 50 years of

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