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Am Fam Physician. 2000;61(9):2866

The decreases in cardiovascular morbidity and mortality achieved by controlling hypertension in elderly patients have been well documented. Therapy based on beta blockers and diuretics resulted in a reduction of more than 40 percent in major cardiovascular end points such as stroke, myocardial infarction and total mortality. Hansson and colleagues investigated the potential benefits of newer antihypertensive medications such as angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers in elderly patients.

They enrolled more than 6,600 men and women 70 to 84 years of age who had systolic blood pressures of at least 180 mm Hg, diastolic blood pressures of at least 105 mm Hg, or both. Patients were randomly assigned to one of three treatment strategies: (1) “conventional” therapy using beta blockers or diuretics; (2) ACE inhibitors or (3) calcium channel blockers. More than 2,000 patients (11,000 patient-years) were followed in each treatment group. The patients were followed from enrollment (1992 to 1994) until the end of 1998.

More than 60 percent of the patients in the three treatment groups were still taking the randomized therapy at the end of the trial. All three treatments reduced blood pressure effectively and with similar results. The rate of fatal cardiovascular events was 19 to 20 per 1,000 patient-years in all three treatment groups. The three groups did not differ in the frequency of fatal and nonfatal stroke. The groups taking conventional and newer drugs did not differ in their rates of myocardial infarction. However, patients assigned to therapy with ACE inhibitors had better myocardial infarction and congestive cardiac failure rates than patients assigned to therapy with calcium channel blockers.

The authors conclude that conventional and newer antihypertensive drugs are equally effective in lowering blood pressure, and this decrease in blood pressure resulted in substantial savings in cardiovascular morbidity and mortality in elderly patients. Although the study raises some concerns about calcium channel blockers, the authors emphasize that the choice of medication must be individualized, taking into account factors such as coexisting conditions, cost and side effects.

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