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Under-representation of Frail or Medically Compromised Hypertensive
Older People in the Paper
Gulistan Bahat*, Asli Tufan, Mehmet Akif Karan
Department of Internal Medicine, Division of Geriatrics, Istanbul
Medical School, Istanbul University, Capa, 34390, Istanbul, Turkey
Last name of authors: Bahat, Tufan, Karan
Corresponding author: Gulistan Bahat
Address: Istanbul University, Istanbul Med...
Corresponding author: Gulistan Bahat
Address: Istanbul University, Istanbul Medical School, Department of
Internal Medicine, Capa, 34390, Istanbul, Turkey
Telephone: + 90 212 414 20 00-33204
Fax: + 90 212 532 42 08
E-mail address: email@example.com
We have read the article by Briasoulis et al. on effect of
antihypertensive treatment in patients over 65 years of age with great
interest . They comprehensively reviewed prospective randomized trials
and assessed the effects of antihypertensive treatment on cardiovascular,
all-cause mortality, stroke and heart failure in patients over 65 years of
age.By the way of 18 clinically relevant studies, they concluded that
treatment to blood pressure target of 150/80 mm Hg or to blood pressure
reduction of >25/10 mm Hg effectively decreases all-cause mortality,
cardiovascular mortality, stroke and heart failure in patients over 65
years of age.
However, elderly constitute a rather heterogeneous population and
study recommendations could only be generalized to a given population if
the given study participants are real and good representative of the
population they recommend for. Departures from representativeness are
amplified with increasing age. Progressively older adults who do
participate in studies, may be progressively less representative of the
group they are intended to reflect -as more non-representatively vigorous
and robust. Consequently, the older the age, the greater the disparity
may be between what is recommended based on 'evidence' and what is best
for the patient .
The randomized trials that showed benefit from the treatment of
hypertension in older adults included relatively fit patients .
Accordingly, older adults who are frail may not benefit from
antihypertensive therapy. There are some recent reports pointing out this
problem. In a study of 2340 adults >65 years in 2012, among frail
adults, there was no association between blood pressure and mortality.
Moreover, a higher blood pressure was associated with a lower risk of
death among the most frail (ie, those who could not walk the distance at
all) . Another exampe is that, in a study of 1562 Latino adults aged 60
-101 years, the relationship between systolic blood pressure and mortality
was reported to vary by self-reported walking speed. Higher systolic blood
pressure was associated with an elevated risk of mortality in fast walkers
while not in slow walkers .
We conclude that Briasoulis et al.'s conclusion could not be
generalized to the elderly >65 years of age due to under-representation
of frail or medically compromised patients that are rather prevalent in
this age group . We think that their conclusion should be considered in
view of this important limitation.
1. Cardiac risk factors and prevention: Effects of antihypertensive
treatment in patients over 65 years of age: a meta-analysis of randomised
controlled studies. Briasoulis A, Agarwal V, Tousoulis D, Stefanadis C.
2. Golomb BA, Chan VT, Evans MA, Koperski S, White HL, Criqui MH. The
older the better: are elderly study participants more non-representative?
A cross-sectional analysis of clinical trial and observational study
samples. BMJ Open. 2012;2:pii e000833.
3. Egan BM. Section Editors: Bakris GL, Kaplan NM, Schmader KE. Treatment
of hypertension in the elderly patient, particularly isolated systolic
(accessed on March 6, 2014).
4. Odden MC, Peralta CA, Haan MN, Covinsky KE. Rethinking the association
of high blood pressure with mortality in elderly adults: the impact of
frailty. Arch Intern Med 2012; 172:1162.
5. Odden MC, Covinsky KE, Neuhaus JM, Mayeda ER, Peralta CA, Haan MN. The
association of blood pressure and mortality differs by self-reported
walking speed in older Latinos. J Gerontol A Biol Sci Med Sci. 2012;67:977