Letters To The Editor

To the Editor: I read with interest the exchange of letters between Drs. Norenberg and Graves in the December 2007 issue,^1,2 which followed Dr. Graves’ article in the October 2007 issue.³ Dr. Norenberg suggests that it is not always prudent to try to push systolic pressures below 140 mm Hg in the elderly, and Dr. Graves takes the position that physicians like Dr. Norenberg have been “too slow to adapt to evidence-based guidelines for quality of care.” I would like to focus on Dr. Graves’ reference to evidence-based guidelines for the treatment of systolic hypertension in the elderly.

Although there have been multiple published studies of the treatment of this disorder, none has achieved an average systolic blood pressure lower than 140. The Systolic Hypertension in the Elderly Program (SHEP)⁴ came closest with a final systolic blood pressure of 144. No study has ever documented the efficacy and safety of achieving systolic blood pressures less than 140 in a cohort of elderly patients, and there is substantial evidence that excessive lowering of diastolic blood pressure can be harmful.^5,6

Many elderly patients can achieve the target referenced by Dr. Graves, and it is reasonable to expect physicians to continue to strive for that goal, but it would be unwise to push all seniors below 140 systolic. Consider the elderly patient with systolic hypertension who is on a robust three-drug regimen including a diuretic, with a blood pressure of 144/60 and with persistent but tolerable drug side effects. I am aware of no clinical trials that demonstrate that further lowering of this patient’s blood pressure would provide incremental benefit to outweigh the potential risks and costs of additional medications.

We need to be careful not to confuse evidence-based medicine with high-placed opinions, which can result in rigid approaches to treatment that are not in the best interest of our patients.

To the Editor: I read with interest the exchange of letters between Drs. Norenberg and Graves in the December 2007 issue,^1,2 which followed Dr. Graves’ article in the October 2007 issue.³ Dr. Norenberg suggests that it is not always prudent to try to push systolic pressures below 140 mm Hg in the elderly, and Dr. Graves takes the position that physicians like Dr. Norenberg have been “too slow to adapt to evidence-based guidelines for quality of care.” I would like to focus on Dr. Graves’ reference to evidence-based guidelines for the treatment of systolic hypertension in the elderly.

Although there have been multiple published studies of the treatment of this disorder, none has achieved an average systolic blood pressure lower than 140. The Systolic Hypertension in the Elderly Program (SHEP)⁴ came closest with a final systolic blood pressure of 144. No study has ever documented the efficacy and safety of achieving systolic blood pressures less than 140 in a cohort of elderly patients, and there is substantial evidence that excessive lowering of diastolic blood pressure can be harmful.^5,6

Many elderly patients can achieve the target referenced by Dr. Graves, and it is reasonable to expect physicians to continue to strive for that goal, but it would be unwise to push all seniors below 140 systolic. Consider the elderly patient with systolic hypertension who is on a robust three-drug regimen including a diuretic, with a blood pressure of 144/60 and with persistent but tolerable drug side effects. I am aware of no clinical trials that demonstrate that further lowering of this patient’s blood pressure would provide incremental benefit to outweigh the potential risks and costs of additional medications.

We need to be careful not to confuse evidence-based medicine with high-placed opinions, which can result in rigid approaches to treatment that are not in the best interest of our patients.

To the Editor: I read with interest the exchange of letters between Drs. Norenberg and Graves in the December 2007 issue,^1,2 which followed Dr. Graves’ article in the October 2007 issue.³ Dr. Norenberg suggests that it is not always prudent to try to push systolic pressures below 140 mm Hg in the elderly, and Dr. Graves takes the position that physicians like Dr. Norenberg have been “too slow to adapt to evidence-based guidelines for quality of care.” I would like to focus on Dr. Graves’ reference to evidence-based guidelines for the treatment of systolic hypertension in the elderly.

Although there have been multiple published studies of the treatment of this disorder, none has achieved an average systolic blood pressure lower than 140. The Systolic Hypertension in the Elderly Program (SHEP)⁴ came closest with a final systolic blood pressure of 144. No study has ever documented the efficacy and safety of achieving systolic blood pressures less than 140 in a cohort of elderly patients, and there is substantial evidence that excessive lowering of diastolic blood pressure can be harmful.^5,6

Many elderly patients can achieve the target referenced by Dr. Graves, and it is reasonable to expect physicians to continue to strive for that goal, but it would be unwise to push all seniors below 140 systolic. Consider the elderly patient with systolic hypertension who is on a robust three-drug regimen including a diuretic, with a blood pressure of 144/60 and with persistent but tolerable drug side effects. I am aware of no clinical trials that demonstrate that further lowering of this patient’s blood pressure would provide incremental benefit to outweigh the potential risks and costs of additional medications.

We need to be careful not to confuse evidence-based medicine with high-placed opinions, which can result in rigid approaches to treatment that are not in the best interest of our patients.

In Reply: First, I am gratified by the tremendous interest in the care of the hypertensive patient that my article has generated. Dr. Norenberg and Dr. Kelleher are insightful clinicians, as evidenced by the issues that their letters raise. Secondly, as I am now 54 years old, SHEP’s definition of “elderly” as 60 years old and older appears less accurate to me! However, I think we might all agree that to date there has not been a trial with people 65 years old and younger that has not shown benefit to treatment of the blood pressure to less than 140/90 mm Hg.

I believe that Dr. Kelleher’s quest for more “evidence-based” data refers to treatment data in patients above that age. Hopefully, this quest will be answered by the results of the Hypertension in the Very Elderly Trial (HYVET).¹ In this trial, 3,845 patients older than 80 years were treated to less than 140/90 mm Hg. On July 12, 2007, the trial was stopped by the data safety and monitoring board, with the expectation of published results at the European Society of Hypertension and International Society of Hypertension joint meeting in Berlin in 2008.

Third, I must remind the reader that in practicing evidence-based medicine, we clinicians always must interpret the results of double-blind placebo-controlled trials, which tell us the mean effect of a treatment, but apply this information to the individual patient seated in front of us. A recent study² of individual blood pressure response to four forms of monotherapy showed that, in some patients, the blood pressure rose with hydrochlorothiazide instead of falling!

Fourth, Dr. Kelleher implies, correctly, that not all patients can reach the target of less than 140/90. In this regard I think the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)³ is very instructive. ALLHAT is the first trial ever to show improvement in the percent of people reaching goal blood pressure, rising from 52% to 63% during the 5-year study. ALLHAT shows us how good we can be and that we should not accept the failure to reach goal blood pressure in at least two-thirds of our patients.

The final and most important point is that the time for arguing the guideline recommendations^4–6 based on our own opinion is past. Third-party payers and patients are demanding we meet those guidelines until new information suggests that they need to be altered. HYVET may force such an alteration, but until then Dr. Norenberg, Dr. Kelleher, and I must attempt to reach the target of less than 140/90 in the majority of our patients.

The final and most important point is that the time for arguing the guideline recommendations^4–6 based on our own opinion is past. Third-party payers and patients are demanding we meet those guidelines until new information suggests that they need to be altered. HYVET may force such an alteration, but until then Dr. Norenberg, Dr. Kelleher, and I must attempt to reach the target of less than 140/90 in the majority of our patients.

In Reply: First, I am gratified by the tremendous interest in the care of the hypertensive patient that my article has generated. Dr. Norenberg and Dr. Kelleher are insightful clinicians, as evidenced by the issues that their letters raise. Secondly, as I am now 54 years old, SHEP’s definition of “elderly” as 60 years old and older appears less accurate to me! However, I think we might all agree that to date there has not been a trial with people 65 years old and younger that has not shown benefit to treatment of the blood pressure to less than 140/90 mm Hg.

I believe that Dr. Kelleher’s quest for more “evidence-based” data refers to treatment data in patients above that age. Hopefully, this quest will be answered by the results of the Hypertension in the Very Elderly Trial (HYVET).¹ In this trial, 3,845 patients older than 80 years were treated to less than 140/90 mm Hg. On July 12, 2007, the trial was stopped by the data safety and monitoring board, with the expectation of published results at the European Society of Hypertension and International Society of Hypertension joint meeting in Berlin in 2008.

Third, I must remind the reader that in practicing evidence-based medicine, we clinicians always must interpret the results of double-blind placebo-controlled trials, which tell us the mean effect of a treatment, but apply this information to the individual patient seated in front of us. A recent study² of individual blood pressure response to four forms of monotherapy showed that, in some patients, the blood pressure rose with hydrochlorothiazide instead of falling!

Fourth, Dr. Kelleher implies, correctly, that not all patients can reach the target of less than 140/90. In this regard I think the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)³ is very instructive. ALLHAT is the first trial ever to show improvement in the percent of people reaching goal blood pressure, rising from 52% to 63% during the 5-year study. ALLHAT shows us how good we can be and that we should not accept the failure to reach goal blood pressure in at least two-thirds of our patients.

The final and most important point is that the time for arguing the guideline recommendations^4–6 based on our own opinion is past. Third-party payers and patients are demanding we meet those guidelines until new information suggests that they need to be altered. HYVET may force such an alteration, but until then Dr. Norenberg, Dr. Kelleher, and I must attempt to reach the target of less than 140/90 in the majority of our patients.

The final and most important point is that the time for arguing the guideline recommendations^4–6 based on our own opinion is past. Third-party payers and patients are demanding we meet those guidelines until new information suggests that they need to be altered. HYVET may force such an alteration, but until then Dr. Norenberg, Dr. Kelleher, and I must attempt to reach the target of less than 140/90 in the majority of our patients.

In Reply: First, I am gratified by the tremendous interest in the care of the hypertensive patient that my article has generated. Dr. Norenberg and Dr. Kelleher are insightful clinicians, as evidenced by the issues that their letters raise. Secondly, as I am now 54 years old, SHEP’s definition of “elderly” as 60 years old and older appears less accurate to me! However, I think we might all agree that to date there has not been a trial with people 65 years old and younger that has not shown benefit to treatment of the blood pressure to less than 140/90 mm Hg.

I believe that Dr. Kelleher’s quest for more “evidence-based” data refers to treatment data in patients above that age. Hopefully, this quest will be answered by the results of the Hypertension in the Very Elderly Trial (HYVET).¹ In this trial, 3,845 patients older than 80 years were treated to less than 140/90 mm Hg. On July 12, 2007, the trial was stopped by the data safety and monitoring board, with the expectation of published results at the European Society of Hypertension and International Society of Hypertension joint meeting in Berlin in 2008.

Third, I must remind the reader that in practicing evidence-based medicine, we clinicians always must interpret the results of double-blind placebo-controlled trials, which tell us the mean effect of a treatment, but apply this information to the individual patient seated in front of us. A recent study² of individual blood pressure response to four forms of monotherapy showed that, in some patients, the blood pressure rose with hydrochlorothiazide instead of falling!

Fourth, Dr. Kelleher implies, correctly, that not all patients can reach the target of less than 140/90. In this regard I think the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)³ is very instructive. ALLHAT is the first trial ever to show improvement in the percent of people reaching goal blood pressure, rising from 52% to 63% during the 5-year study. ALLHAT shows us how good we can be and that we should not accept the failure to reach goal blood pressure in at least two-thirds of our patients.

The final and most important point is that the time for arguing the guideline recommendations^4–6 based on our own opinion is past. Third-party payers and patients are demanding we meet those guidelines until new information suggests that they need to be altered. HYVET may force such an alteration, but until then Dr. Norenberg, Dr. Kelleher, and I must attempt to reach the target of less than 140/90 in the majority of our patients.

The final and most important point is that the time for arguing the guideline recommendations^4–6 based on our own opinion is past. Third-party payers and patients are demanding we meet those guidelines until new information suggests that they need to be altered. HYVET may force such an alteration, but until then Dr. Norenberg, Dr. Kelleher, and I must attempt to reach the target of less than 140/90 in the majority of our patients.