The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Yves Lacourcière, MD, FRCP, Hypertension Research Unit, CHUL du CHUQ, Laval University, QC.

There are many reasons why gaining control over high blood pressure (BP) in older patients is desirable. When choosing an antihypertensive agent for older patients, physicians should seek a drug that sustains BP control, especially in the last six hours of the dosing interval or if a dose is missed. Agents with a long duration of action that inhibit the renin-angiotensin system (RAS) are likely to be more useful in controlling the early-morning surges in norepinephrine that have been linked to target organ damage and stroke, particularly in older patients.

Key words: hypertension, renin-angiotensin, angiotensin-receptor blockers, norepinephrine, peroxisome proliferator-activated receptor (PPAR).

Wilbert S. Aronow, MD, CMD, Clinical Professor of Medicine, Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care Medicine; Chief, Cardiology Clinic; Senior Associate Program Director and Research Mentor, Fellowship Programs, Department of Medicine, New York Medical College, Valhalla, NY; Adjunct Professor of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York City, NY, USA.

Older patients are more likely to have hypertension and isolated systolic hypertension, to have target organ damage and clinical cardiovascular disease, and to develop myocardial infarction, angina pectoris, stroke, congestive heart failure, and peripheral arterial disease. Yet, considering the increased risk of cardiovascular death, older patients are less likely to have hypertension controlled. Antihypertensive drug therapy reduces coronary events, stroke, heart failure, and cardiovascular death in older patients. The goal of treatment of hypertension in older patients is to reduce the blood pressure to less than 140/90mmHg and to ≤130/80mmHg in older patients with diabetes mellitus or chronic renal insufficiency. Diuretics should be used as initial drug therapy in older patients with hypertension and no associated medical conditions. The selection of antihypertensive drug therapy in older patients depends on the associated medical conditions.

Key words: hypertension, diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers.

Raymond Fung, MD, BSc, Fellow, Division of Endocrinology, University of Toronto, Toronto, ON.

Lorraine L. Lipscombe, MD, FRCPC, Clinical Associate, Research Fellow, Division of Endocrinology, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

The prevalence of diabetes has been increasing significantly in the last several years, especially in the older population. Cardiovascular disease (CVD) represents the most important complication of diabetes in this age group, as up to 80% of persons with diabetes die from CVD. The treatment of dyslipidemia and hypertension are both key in ameliorating CVD risk. Recent randomized controlled trials have included older persons with diabetes and have demonstrated that both statin therapy for dyslipidemia and antihypertensive agents are highly effective and safe in preventing CVD in this population. This review will examine the evidence for treatment in both areas, outlining the special considerations in the aged.

Key words: diabetes mellitus, cardiovascular disease, statins, hypertension, cholesterol.

J. David Spence, MD, FRCPC, Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, London, ON.

Effective treatment of hypertension is even more beneficial in the elderly than in younger patients because the elderly have a higher absolute risk of vascular events. Treating hypertension not only prevents stroke, but also reduces risk of dementia. Effective blood pressure control is based on identifying and treating its physiological cause. Renal hypertension, primary hyperaldosteronism and renal tubular abnormalities such as Liddle's syndrome can be identified by measuring the plasma renin and aldosterone. Most elderly patients require diuretic therapy for control, but most will require additional drugs to achieve the lower targets now supported by evidence.
Key words: hypertension, elderly, adrenocortical, renovascular.

David H. Fitchett MD, FRCP(C), St Michael's Hospital, University of Toronto, Toronto, ON.

For the diabetic patient, hypertension more than doubles the risk of myocardial infarction, stroke and cardiovascular death, and is central in the development of diabetic nephropathy. Control of hypertension is an important vascular protective measure. However, the thresholds and goals of antihypertensive treatment have fallen as trials have shown improved outcomes with blood pressures reduced to 120/80mmHg or less. Although reducing blood pressure to the lower target levels must be the primary goal of treatment, the use of diuretics and angiotensin-converting enzyme inhibitors should be considered as first-line therapy in the diabetic patient. Both agents have been demonstrated to improve a wide range of cardiovascular outcomes compared to other antihypertensive medications.
Key words: diabetes, hypertension, nephropathy, blood pressure control.

Xiumei Feng, MD, MSc and Norm R.C. Campbell, MD, Division of General Internal Medicine, University of Calgary, Calgary, AB.

Normal blood pressure is less common than "hypertension" in the elderly, and most hypertension is primary, or essential. Nevertheless, secondary hypertension in the elderly should be considered in patients with suggestive features, as the prevalence of secondary hypertension increases with age. The most common causes of secondary hypertension in the elderly are renal parenchyma diseases, primary aldosteronism, renal vascular stenosis and drug induced. Timely recognition and treatment of secondary hypertension will reduce the morbidity and mortality associated with uncontrolled hypertension.
Key words: hypertension, high blood pressure, elderly, secondary causes.

Sheldon Tobe, MD, FRCP(C), Assistant Professor of Medicine, Nephrology, University of Toronto; Division Director Nephrology, Sunnybrook & Women's College Health Sciences Centre, Toronto, ON.
Sudha Cherukuri, MD, DNB(Nephrology), Clinical Fellow, University of Toronto, Toronto, ON.

Isolated systolic hypertension (ISH) is a common disorder in the elderly. Several studies have shown a constant positive and graded association between the level of systolic blood pressure and subsequent mortality from cardiovascular disease and stroke. ISH is defined as an elevated systolic pressure above 160mmHg and a diastolic pressure below 90mmHg. Arterial stiffening is the main cause of increasing systolic pressure in the elderly. The finding of high systolic blood pressure with diastolic below 90mmHg is a marker of higher cardiovascular risk and an indication to follow this patient more closely. The placebo-controlled SHEP and Syst-Eur trials have demonstrated that the treatment of ISH with diuretics or long-acting calcium channel blockers results in a marked reduction in cardiovascular events and stroke.
Key words: hypertension, isolated systolic hypertension, clinical trials, drug therapy, elderly.

Robert J. Petrella, MD, PhD, President, Canadian Coalition for High Blood Pressure Prevention and Control; Associate Professor and Medical Director, Canadian Centre for Activity and Aging, University of Western Ontario, London, ON.

Hypertension is the leading reason for office visits to primary care physicians and is also the leading chronic disease of aging. Given the aging demographic in Canada, its burden on the health care system will grow, making prevention and treatment of hypertension a priority. Solid evidence regarding effective pharmacological therapies in hypertension is available, yet diagnosis and treatment rates remain poor. Likewise, solid evidence regarding the effect of non-pharmacological or lifestyle interventions also is available for clinicians. Furthermore, lifestyle interventions may potentiate the effects of pharmacological therapies due to their inherent modification of positive chronic disease behaviour, resulting in improved maintenance of treatment interventions. With pressure to see many patients in the busy primary care practice, clinicians should resist the "quick-fix" approach to treating hypertension solely by pharmacological means. Consideration of lifestyle modification is worth the time in terms of obtaining sustained control of a growing population at risk.
Key words: hypertension, lifestyle interventions, behaviour change.

Kelly B. Zarnke, MD, MSc, Departments of Medicine, Epidemiology & Biostatistics, University of Western Ontario, London, ON, and on behalf of the Canadian Hypertension Education Program (CHEP).

Poor blood pressure control, particularly among the older Canadian population, remains an important cause of preventable cardiovascular morbidity and mortality. It behooves Canadian health care workers to identify, treat and control hypertension. Recent trials, including ALLHAT and LIFE, add to the information clinicians need to achieve these targets. ALLHAT establishes the central role of thiazide-like diuretics for many hypertensive patients. ALLHAT demonstrates that good blood pressure control can be achieved in the majority of hypertensive patients if a systematic effort is maintained. LIFE adds important information regarding angiotensin receptor blockers as an effective alternative to the other commonly used classes of antihypertensive drugs, particularly among patients with diabetes or isolated systolic hypertension. Finally, the Canadian Hypertension Education Program will continue to produce and disseminate annually updated systematic reviews and recommendations related to the assessment and management of hypertension.
Key words: hypertension, recent clinical trials, clinical practice guidelines.

I am embarrassed to admit that somewhere in the mid-1990s I temporarily lost interest in the issue of hypertension in the elderly because I thought most of the clinical questions I had were fully answered. I was in the same league as the microbiologists in the 1960s who proclaimed that infectious diseases had been conquered!

In fact, we are just beginning to understand hypertension and all its ramifications. Although I am not qualified to even begin to assemble all the remaining issues, let me list a few:

How do we make the diagnosis in all those people who have hypertension?
How do we choose the drug(s) that are appropriate?
What is the ideal target blood pressure in the elderly?
How do we get our patients to adhere to treatment (including non-pharmacological therapy)?
What is the nature of the relationship between hypertension and dementia?

One of the first times I realized that even the most authoritative sources often pay lip service only to the concept of "evidence based medicine" was when I read about treatment of hypertension in Edition 13 of Harrison's Principles of Internal Medicine (1994). The algorithm it presented at that time indicated that the initial treatment of hypertension should be an ACE inhibitor, calcium channel blocker or beta-blocker. If the blood pressure remained out of control, only then was a diuretic suggested. The only evidence used to support this algorithm was a statement in the text regarding thiazide diuretics: "increasing resistance to their routine use has occurred primarily because of their adverse metabolic effects" (page 1124). I am proud to say that at the same time, Canadian authorities still felt that thiazides were the appropriate drug with which to commence therapy.

This issue of Geriatrics & Aging focuses on hypertension, and Dr. Kelly Zarnke's review of recent trials, including the ALLHAT study, will convince most readers that the Canadian Hypertension Society was perhaps more astute (or perhaps more prescient) than the contributors to Harrison's. Dr. J. David Spence discusses selection of the appropriate antihypertensive agent in the elderly. I have my own prejudices (which I have never spared the reader), and with respect to this topic I am convinced that simple algorithms will never replace individualized therapy. Although I believe thiazides are the drug of choice in the elderly, many other medical conditions so often occur in our patients that another drug might be preferred in certain cases. What if the drugs your patient is taking do not match the exact recommendations of the most recent study? I still believe that excellent blood pressure control is more important than the specific drug used, and if that patient's blood pressure is 120/80mmHg, I would not change anything. Of course, for new patients or for those whose pressures are not optimally controlled, the prudent physician will look carefully at Dr. Zarnke's review.

The other articles pertaining to hypertension include Secondary Causes of Hypertension by Drs. Norm Campbell and Xiumei Feng, Isolated Systolic Hypertension by Drs. Tobe and Cherukuri, and an article on Hypertension and Diabetes by Dr. David Fitchett. Physicians often ignore non-pharmacological treatment of hypertension in the elderly, despite the evidence that it remains effective in this age group. Dr. Robert Petrella tackles this important issue in his review of lifestyle approaches to prevention and treatment of high blood pressure.

Others topics covered in this issue include Hot Flashes in Men with Prostate Cancer by Dr. Neil Baum, Treatment of Osteoporotic Vertebral Compression Fractures by Drs. Adachia, Boulos and Papaioannou and Karen Beattie, and a conference report, Alzheimer and Related Dementias: The Prevention of Disease, Morbidity and Suffering, held at the Baycrest Centre for Geriatric Care's Kunin-Lunenfeld Applied Research Unit.

Enjoy this issue.