Blood Pressure: Not As Simple As Lower Is Better

I started medical school over a quarter century ago.  Even then, we joked about the good ol' days, when we believed that (systolic) blood pressure should be "100 + your age", before the advent of the diagnosis of hypertension.  Of course, we didn't have the innumerable anti-hypertensives we do now.  Perhaps that's why in that grand medical tradition, we didn't address any issues for which we did not have a solution.  These days, you can't avoid all the advertisements exhorting you to lower your blood pressure, that it's for your own good.

Ever since the (1st) Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 1) way back in 1977, we've been struggling to define and thus treat patients with high blood pressure.  Don't get me wrong.  Most, if not all, the major studies demonstrate an improvement in clinical outcome, eg lower mortality, lower heart disease, lower stroke rate, etc, in those randomized to management of their hypertension, regardless of drug choice.

But the subtlety is this: very few studies have included our very old (yes, I know that depends upon how you define very old), which then begs the question, is there a difference between the robust very old (picture Jack LaLanne before he passed away last year at 96yo) and the frail very old (imagine your typical nursing home patient)?  Even then, geriatricians like myself have a difficult time defining frailty.  It's kind of like Judge Potter Stewart's take on pornography: I know it when I see it.  

Well, in a very surprising (for me, anyway) study published early online yesterday in Archives of Internal Medicine, the authors concluded that 1) walking speed (>0.8m/s) can be used to separate robust from frail elderly; 2) the hypertensive robust very old (>80yo) benefit from antihypertensive therapy while frail very old do not!  Of course, it's more complicated than that.  In fact, in those who could not complete the walk test at all, hypertension was associated w/lower mortality!

Wow!  Talk about an eye opener!  Read this study (and it's accompanying commentary) for yourself (I'm trying to find all the references).  You can add it to WHI (Women's Health Initiative) & ACCORD (Action to Control Cardiovascular Risk in Diabetes): we really need to individualize our therapies rather than offer a "one size fits all" approach.  And let's be clear.  I'm NOT telling you to throw your blood pressure medications down the toilet.  But I am asking my colleagues to look over this new study in the context of the references and consider tailoring therapy to the individual, especially our frail very old..

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