Risks and Benefits of Antihypertensive Medications in Older Adults

To the Editor The recent observational study by Tinetti et al 1 reported that treatment with antihypertensive medications is associated with an increased risk of serious fall injuries among community-living older adults with a mean age of 80 years. One reason for this study was to examine a population that may be less healthy than those enrolled in clinical trials and who may have had a higher risk of serious injuries from falls. Approximately 9% of the cohort experienced a serious injury over the follow-up period, most of which were fractures. Although the mean follow-up time is not stated, the annual rate of fractures appears to have been approximately 1.5% to 2.0%. In the Hypertension in the Very Elderly Trial (HYVET), among 3845 participants (mean age, 83 years) followed up for 2.1 years, the annual fracture rate was roughly similar at approximately 1.3%. 2 In HYVET, the risk of fractures was not higher in the group randomized to receive antihypertensive treatment (42 fractures) compared with the group randomized to receive placebo (60 fractures [hazard ratio, 0.69; 95% CI, 0.46-1.05; P = .086). In contrast to the null findings for fractures, the trial was stopped early because of a significant reduction in stroke, total mortality, and other serious cardiovascular events in the actively treated group. 3 The number of cardiovascular events (n = 331) was more than triple the number of fractures (n = 102). Likewise, the Systolic Hypertension in the Elderly Trial, which compared the thiazide-like diuretic chlorthalidone vs placebo, found a reduction in the risk of stroke and other serious cardiovascular events in the actively treated group, but no difference in falls and fractures. 4,5