Strict control [ systolic BP ( SBP ) < 140 mmHg ] was not consistently better than mild control ( SBP < 150 mmHg ) for adults aged ≥65 years .
Mild SBP control benefitted subjects in all age ranges over 65 years .
Conclusions In this review , older adults with hypertension had decreased cardiovascular morbidity and mortality  with antihypertensives compared with no treatment .
Strict control was not consistently better than mild control in older adults .
The current evidence is insufficient to determine the safest , most beneficial hypertension regimen in older adults
Background Hypertension increases with increasing age .
Optimal treatment of hypertension is important to reduce cardiovascular disease .
Recent guidelines for hypertension have made recommendations for older adults but are supported by evidence that includes younger individuals .
This systematic review evaluates the benefits and harms of antihypertensive agents in adults aged ≥65 years .
Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).
CONTEXT Antihypertensive therapy is well established to reduce hypertension-related morbidity and mortality , but the optimal first-step therapy is unknown . OBJECTIVE To determine whether treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor lowers the incidence of coronary heart disease ( CHD ) or other cardiovascular disease ( CVD ) events vs treatment with a diuretic . DESIGN The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial ( ALLHAT ) , a r and omized , double-blind , active-controlled clinical trial conducted from February 1994 through March 2002 . SETTING AND PARTICIPANTS A total of 33 357 participants aged 55 years or older with hypertension and at least 1 other CHD risk factor from 623 North American centers . INTERVENTIONS Participants were r and omly assigned to receive chlorthalidone , 12.5 to 25 mg/d ( n = 15 255 ) ; amlodipine , 2.5 to 10 mg/d ( n = 9048 ) ; or lisinopril , 10 to 40 mg/d ( n = 9054 ) for planned follow-up of approximately 4 to 8 years . MAIN OUTCOME MEASURES The primary outcome was combined fatal CHD or nonfatal myocardial infa rct ion , analyzed by intent-to-treat . Secondary outcomes were all-cause mortality , stroke , combined CHD ( primary outcome , coronary revascularization , or angina with hospitalization ) , and combined CVD ( combined CHD , stroke , treated angina without hospitalization , heart failure [ HF ] , and peripheral arterial disease ) . RESULTS Mean follow-up was 4.9 years . The primary outcome occurred in 2956 participants , with no difference between treatments . Compared with chlorthalidone ( 6-year rate , 11.5 % ) , the relative risks ( RRs ) were 0.98 ( 95 % CI , 0.90 - 1.07 ) for amlodipine ( 6-year rate , 11.3 % ) and 0.99 ( 95 % CI , 0.91 - 1.08 ) for lisinopril ( 6-year rate , 11.4 % ) . Likewise , all-cause mortality did not differ between groups . Five-year systolic blood pressures were significantly higher in the amlodipine ( 0.8 mm Hg , P = .03 ) and lisinopril ( 2 mm Hg , P<.001 ) groups compared with chlorthalidone , and 5-year diastolic blood pressure was significantly lower with amlodipine ( 0.8 mm Hg , P<.001 ) . For amlodipine vs chlorthalidone , secondary outcomes were similar except for a higher 6-year rate of HF with amlodipine ( 10.2 % vs 7.7 % ; RR , 1.38 ; 95 % CI , 1.25 - 1.52 ) . For lisinopril vs chlorthalidone , lisinopril had higher 6-year rates of combined CVD ( 33.3 % vs 30.9 % ; RR , 1.10 ; 95 % CI , 1.05 - 1.16 ) ; stroke ( 6.3 % vs 5.6 % ; RR , 1.15 ; 95 % CI , 1.02 - 1.30 ) ; and HF ( 8.7 % vs 7.7 % ; RR , 1.19 ; 95 % CI , 1.07 - 1.31 ) . CONCLUSION Thiazide-type diuretics are superior in preventing 1 or more major forms of CVD and are less expensive . They should be preferred for first-step antihypertensive therapy
Strict control [ systolic BP ( SBP ) < 140 mmHg ] was not consistently better than mild control ( SBP < 150 mmHg ) for adults aged ≥65 years .
Mild SBP control benefitted subjects in all age ranges over 65 years .
Conclusions In this review , older adults with hypertension had decreased cardiovascular morbidity and mortality  with antihypertensives compared with no treatment .
Strict control was not consistently better than mild control in older adults .
The current evidence is insufficient to determine the safest , most beneficial hypertension regimen in older adults
Background Hypertension increases with increasing age .
Optimal treatment of hypertension is important to reduce cardiovascular disease .
Recent guidelines for hypertension have made recommendations for older adults but are supported by evidence that includes younger individuals .
This systematic review evaluates the benefits and harms of antihypertensive agents in adults aged ≥65 years .