Wilbert S. Aronow, MD, FACC, FAHA, AGSF, Department of Medicine, Cardiology Division, New York Medical College, Valhalla, NY, USA.

Numerous double-blind, randomized, placebo-controlled studies have documented that antihypertensive drug therapy reduces cardiovascular events in older adults. In the Hypertension in the Very Elderly Trial, individuals 80 years of age and older treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30% reduction in fatal or nonfatal stroke, a 39% reduction in fatal stroke, a 21% reduction in all-cause mortality (p=0.02), a 23% reduction in death from cardiovascular causes, and a 64% reduction in heart failure. The goal of treatment of hypertension in older adults is to reduce the blood pressure to <140/90 mmHg and to <130/80 mmHg in older persons with diabetes or chronic renal insufficiency. Older adults with diastolic hypertension should have their diastolic blood pressure reduced to 80-85 mmHg. Diuretics should be used as initial therapy in persons with no associated medical conditions. The selection of antihypertensive drug therapy in persons with associated medical conditions depends on their medical conditions. If the blood pressure is >20/10 mmHg above the goal blood pressure, drug therapy should be initiated with two antihypertensive drugs, one of which should be a thiazide-type diuretic. Other coronary risk factors must be treated.
Key words: hypertension, older adults, antihypertensive drug therapy, angiotensin-converting enzyme inhibitors, beta-blockers.

Christian Werner, MD, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.
Michael Böhm, MD, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.

Cardiovascular disease represents a continuum that starts with risk factors such as hypertension and progresses to atherosclerosis, target organ damage, and ultimately to heart failure or stroke. Renin-angiotensin system (RAS) blockade with angiotensin converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers (ARBs) has turned out to be beneficial at all stages of this continuum. Several mechanisms govern the progression of myocardial damage to end-stage chronic heart failure (CHF). Chronic neuroendocrine activation, comprising the RAS, sympathetic nervous system and the release of cytokines, leads to remodelling processes and via forward / backward failure to clinical symptoms of CHF. Therefore, combined RAS inhibition is especially effective to improve neuroendocrine blockade in CHF patients with repetitive cardiac decompensations.
Key words: angiotensin converting enzyme inhibitors, angiotensin receptor blockers, renin-angiotensin system, chronic heart failure, clinical trials.

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.

Wilbert S. Aronow, MD, Department of Medicine, Divisions of Cardiology and Geriatrics, Westchester Medical Center/New York Medical College, Valhalla, NY; Clinical Professor of Medicine and Chief, Cardiology Clinic, Westchester Medical Center/New York Medical College, and Adjunct Professor of Geriatrics and Adult Development, Mount Sinai School of Medicine.

In older women, ischemic heart disease (IHD) is diagnosed if there is coronary angiographic evidence of significant IHD, a documented myocardial infarction, a typical history of angina with myocardial ischemia diagnosed by stress testing, or sudden cardiac death. Clinical manifestations of acute myocardial infarction in older women include dyspnea (the most common presenting symptom), chest pain, neurological symptoms and gastrointestinal symptoms. The prognosis of Q-wave myocardial infarction is not significantly different if the myocardial infarction is clinically recognized or unrecognized. IHD should be treated with intensive risk factor modification, antiplatelet therapy, beta-blockers and angiotensin-converting enzyme inhibitors.

Key words: ischemic heart disease, myocardial infarction, antiplatelet drugs, beta-blockers, angiotensin-converting enzyme inhibitors.

The most common cause of death in older women is ischemic heart disease (IHD). The prevalence of IHD is similar in older women compared to older men.¹ In one study of 2,464 women with an average age of 81 years, the prevalence of IHD was 41%.

Wilbert S. Aronow, MD, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla, NY, USA.

The American College of Cardiology/American Heart Association guidelines recommend that patients with asymptomatic left ventricular systolic dysfunction or with congestive heart failure (CHF) be treated with angiotensin-converting enzyme (ACE) inhibitors plus beta-blockers unless there are contraindications to the use of these drugs. Beta-blockers have been demonstrated to significantly reduce all-cause mortality associated with abnormal or normal left ventricular ejection fraction in older and younger patients with CHF. An angiotensin receptor blocker should not be administered to patients with CHF who are being treated with a beta-blocker plus ACE inhibitor, but should be given to patients with CHF treated with beta-blockers who cannot tolerate ACE inhibitors due to cough, angioneurotic edema, rash or altered taste sensation.
Key words: congestive heart failure, left ventricular ejection fraction, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptors blockers.

Ali Ahmed, MD, MPH, FACP, FACC, Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, Department of Epidemiology and International Health, School of Public Health and Geriatric Heart Failure Clinic, University of Alabama at Birmingham; Section of Geriatrics and Geriatric Heart Failure Clinic, VA Medical Center; and Alabama Heart Failure Project, Alabama Quality Assurance Foundation; Birmingham, AB, USA.
Phillip L. Thornton, PhD, CGP, FASCP, Department of Pharmacy Practice, Auburn University James I. Harrison School of Pharmacy and Department of Medicine, Division of Gerontology and Geriatric Medicine and Geriatric Heart Failure Clinic, University of Alabama at Birmingham; Birmingham, AB, USA.

Heart failure is common in older adults and is associated with high mortality and hospitalization rates, and is the only cardiovascular syndrome with increasing incidence and mortality. Angiotensin-converting enzyme (ACE) inhibitors and beta-blockers reduce mortality and hospitalization rates for heart failure patients with left ventricular systolic dysfunction. Unfortunately, these life-saving drugs continue to be underutilized. ACE inhibitors and beta-blockers should be prescribed to all eligible systolic heart failure patients. Generalist physicians, who care for most heart failure patients, are perfectly capable of prescribing these life-saving drugs to older adults with systolic heart failure and should be encouraged to do so.