老年人高血壓-2022年台灣高血壓治療指引

2025-10-20 11:16M

參考資料-2022台灣高血壓治療指引(只有英文版)

裡面提到 the “J-curve” phenomenon., 在血壓的部分是指. 血壓降到某個程度之下. 冠狀動脈心臟病機率反而增加. 

統合分析. 

收縮壓超標20mmHg的血管性死亡率與舒張壓超標10mgHg相近

血壓降到 115/75 以下. 不會再降低風險(不需特意將血壓降更低)

年齡60-79歲. 收縮壓維持90~144. 舒張壓維持 60-74. 死亡率最低

韓國研究. 60-95歲. 收縮壓維持 100-110. 全因死亡率或心血管疾病死亡率最低. 

血壓最低降到110/60是安全的

HYVET研究. 80歲以上. 基礎血壓 173/90. 使用 indapamide + perinfopril 將血壓降到140/80. 可降低30%非致死性中風. 降低 21% 全因死亡率

 is a placebo-controlled RCT to test the effect of antihypertensive therapy on the risk of stroke and all-cause death in very elderly patients (age  80 years) with a baseline BP of 173.0/90.8 mmHg.619 Use of indapamide, plus perindopril if necessary, decreased fatal or nonfatal stroke by 30% (p = 0.06) and all-cause death by 21% (p = 0.02) with final achieved BP of 140/80 mmHg.

2022台灣高血壓治療指引(只有英文版)
17. ELDERLY PATIENTS 

Recommendations/Keypoints  For patients aged  65 years, the SBP threshold for pharmacological therapy is  130 mmHg (COR I, LOE B).  For patients aged  65 years, the SBP target for pharmacological therapy is < 130 mmHg. (COR I, LOE B). 

In a meta-analysis of individual data from one million adults from 61 prospective studies (Prospective Study Collaboration), BP was associated strongly with the age-specific mortality rates from stroke and CHD.252 In general, a 20 mmHg difference in SBP is approximately equivalent in its hazards to a 10 mmHg difference in DBP. These relationships with vascular mortality continued steeply down as far as a SBP of 115 mmHg and a DBP of 75 mmHg, below which there was little evidence.252 All of these proportional differences in vascular mortality were about half as extreme at ages 80-89 years as at ages 40-49 years, but the annual absolute differences in risk were greater in old age.252 Similar findings were observed in the Asia Pacific Cohort Studies Collaboration,6 and a Chinese cohort study.43 In the sub-analysis of the Felodipine Event Reduction (FEVER) trial, the relative risk reduction of CV events was greater in patients aged > 65 years compared with those aged  65 years.613 Taken together, controlling BP in the elderly is very important. Isolated systolic hypertension (ISH) is more common in the elderly. The major concern in the hypertension management in the elderly is fear of the “J-curve” phenomenon that an aggressive BP lowering might t increase the risk of coronary event given that the DBP is already in the lower ranges in these elderly patients. In a cohort study of 1.25 million subjects, the lowest risk for CV disease in people aged 60-79 years was 90-114 mmHg in SBP and 60-74 mmHg in DBP, without any evidence of J-curve phenomenon above these levels.615 Among 1,235,246 individuals who participated in routine medical examinations in Korea, the lowest risk of all-cause death and ASCVD death in the elderly (age 60-95 years) was observed in the range of 100-110 mmHg in SBP, and there was no J-curve above this BP level. 

In the three most important RCTs in the elderly (age > 60 years) with ISH (SHEP, Syst-Eur, Syst-China), the risk of myocardial infarction was reduced in the treatment group compared to the placebo group.616-618 No J-curve phenomenon was observed. Therefore, it seems to be safe to decrease SBP to a level above 110 mmHg and DBP to above 60 mmHg. The Hypertension in the Very Elderly Trial (HYVET) is a placebo-controlled RCT to test the effect of antihypertensive therapy on the risk of stroke and all-cause death in very elderly patients (age  80 years) with a baseline BP of 173.0/90.8 mmHg.619 Use of indapamide, plus perindopril if necessary, decreased fatal or nonfatal stroke by 30% (p = 0.06) and all-cause death by 21% (p = 0.02) with final achieved BP of 140/80 mmHg. However, the HYVET trial is not a BP target-driven trial, and it cannot answer the question that whether the effects could be even better if lower BP levels are achieved. There were two BP target-driven trials for the elderly hypertensive patients before the SPRINT trial, the JATOS and the VALISH trials.620,621 The JATOS trial tested a SBP < 140 mmHg vs. < 160 mmHg in the Japanese elderly patients,620 while VALISH trial tested a SBP < 140 mmHg vs. < 150 mmHg in the Japanese elderly patients.621 A lower BP target, compared with a higher BP target, did not translate into better CV outcomes in both trials.620,621 However, the number of enrollment was too low to have enough power for analysis.621 In addition, follow-up durations were very short and the event rates were very low (1.1 to 1.2%/ year in JATOS, 0.82 to 0.85%/year in VALISH),620,621 making the conclusions not convincing.621 A larger trial with longer follow-up period was needed. The SPRINT trial is a recent target-driven trial and probably the most important one.622 One of the inclusion criteria was the elderly patients with age  75 years, and about 28% of the total study population of 9,361 patients were the elderly. In the pre-defined sub-analysis of the elderly patients, a BP target of < 120 mmHg (intensive treatment group), compared with a BP target of < 140 mmHg (standard treatment group), reduced the composite endpoints by 34% (95% CI: 0.51-0.85) and all-cause mortality by 33% (95% CI: 0.49-0.91).623 The overall rate of serious adverse events was not different between treatment groups. Interestingly, the incidence of orthostatic hypotension of the two treatment groups (5.0% vs. 5.7%) did not differ.624 The final achieved SBP was 123.4 mmHg vs. 134.8 mmHg, and the DBP was 62.0 mmHg vs. 67.2 mmHg.623 Similar findings were reported in a more recent sub-analysis of very elderly patients (age  80 years) in the same trial.625 The STEP trial,9 comprising exclusively of Chinese patients aged 60 to 80 years, replicates what had been observed in the SPRINT trial, and reassures the safety and effi