Hypertension: Complex Answers to Our Fundamental Questions

I am embarrassed to admit that somewhere in the mid-1990s I temporarily lost interest in the issue of hypertension in the elderly because I thought most of the clinical questions I had were fully answered. I was in the same league as the microbiologists in the 1960s who proclaimed that infectious diseases had been conquered!

In fact, we are just beginning to understand hypertension and all its ramifications. Although I am not qualified to even begin to assemble all the remaining issues, let me list a few:

How do we make the diagnosis in all those people who have hypertension?
How do we choose the drug(s) that are appropriate?
What is the ideal target blood pressure in the elderly?
How do we get our patients to adhere to treatment (including non-pharmacological therapy)?
What is the nature of the relationship between hypertension and dementia?

One of the first times I realized that even the most authoritative sources often pay lip service only to the concept of "evidence based medicine" was when I read about treatment of hypertension in Edition 13 of Harrison's Principles of Internal Medicine (1994). The algorithm it presented at that time indicated that the initial treatment of hypertension should be an ACE inhibitor, calcium channel blocker or beta-blocker. If the blood pressure remained out of control, only then was a diuretic suggested. The only evidence used to support this algorithm was a statement in the text regarding thiazide diuretics: "increasing resistance to their routine use has occurred primarily because of their adverse metabolic effects" (page 1124). I am proud to say that at the same time, Canadian authorities still felt that thiazides were the appropriate drug with which to commence therapy.

This issue of Geriatrics & Aging focuses on hypertension, and Dr. Kelly Zarnke's review of recent trials, including the ALLHAT study, will convince most readers that the Canadian Hypertension Society was perhaps more astute (or perhaps more prescient) than the contributors to Harrison's. Dr. J. David Spence discusses selection of the appropriate antihypertensive agent in the elderly. I have my own prejudices (which I have never spared the reader), and with respect to this topic I am convinced that simple algorithms will never replace individualized therapy. Although I believe thiazides are the drug of choice in the elderly, many other medical conditions so often occur in our patients that another drug might be preferred in certain cases. What if the drugs your patient is taking do not match the exact recommendations of the most recent study? I still believe that excellent blood pressure control is more important than the specific drug used, and if that patient's blood pressure is 120/80mmHg, I would not change anything. Of course, for new patients or for those whose pressures are not optimally controlled, the prudent physician will look carefully at Dr. Zarnke's review.

The other articles pertaining to hypertension include Secondary Causes of Hypertension by Drs. Norm Campbell and Xiumei Feng, Isolated Systolic Hypertension by Drs. Tobe and Cherukuri, and an article on Hypertension and Diabetes by Dr. David Fitchett. Physicians often ignore non-pharmacological treatment of hypertension in the elderly, despite the evidence that it remains effective in this age group. Dr. Robert Petrella tackles this important issue in his review of lifestyle approaches to prevention and treatment of high blood pressure.

Others topics covered in this issue include Hot Flashes in Men with Prostate Cancer by Dr. Neil Baum, Treatment of Osteoporotic Vertebral Compression Fractures by Drs. Adachia, Boulos and Papaioannou and Karen Beattie, and a conference report, Alzheimer and Related Dementias: The Prevention of Disease, Morbidity and Suffering, held at the Baycrest Centre for Geriatric Care's Kunin-Lunenfeld Applied Research Unit.

Enjoy this issue.