Why is antihypertensive drug therapy needed in elderly patients with systolodiastolic hypertension?

OBJECTIVE: This paper presents a meta-analysis of eight outcome trials of antihypertensive drug treatment in elderly hypertensive patients, and uses the results of these trials to discuss day-to-day issues in the treatment of elderly hypertensive patients. META-ANALYSIS: In an intention-to-treat analysis, cardiovascular mortality was decreased on average by 22% (95% confidence interval -32% to -10%). This decrease was a result of reductions in both coronary and cerebrovascular mortality, by 26% (-40% to -9%) and 33% (-50% to -9%), respectively. So far, the effectiveness of antihypertensive therapy in reducing cardiovascular mortality has not been established with confidence in trials where the diastolic blood pressure at random allocation to treatment groups was below 95 mmHg or in patients above 75 years of age. IMPLICATIONS FOR DAY-TO-DAY PRACTICE: No blood pressure treatment goal has been definitively established but a reduction in systolic blood pressure to about 150 mmHg may be optimal. Extrapolation of trial results to the elderly population with systolodiastolic hypertension at large seems acceptable for a Western population, but may be premature for elderly Asians and Africans. beta-Blockers and especially diuretics are recommended as first-line drugs in elderly patients with symptomless, uncomplicated hypertension, since the effectiveness of other drugs in reducing morbidity and mortality has not yet been established. Recommendations for the treatment of symptomless patients with isolated systolic hypertension may be premature. Ongoing trials on systolic hypertension in Europe (Syst-Eur) and China (Syst-China) may provide further information.