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Epidemiology of Stroke

Importance of Preventive Pharmacological Strategies in Elderly Patients and Associated Costs

  • Epidemiology
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Summary

Stroke is a major cause of death and disability in developed countries. The incidence of stroke increases exponentially with age, yet, traditionally, many medical practitioners have been reluctant to treat hypertension in older patients. Since 1991, the results of 3 major trials — the British Medical Research Council (MRC) trial of treatment in older adults, the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension) and the Systolic Hypertension in the Elderly Program (SHEP) — have conclusively established the benefits of treating older patients (> 60 years) with both diastolic and isolated systolic hypertension. International guidelines for the management of hypertension — including the Fifth Report of the Joint National Committee, the 1993 report of the World Health Organization and the International Society of Hypertension and the second report of the British Hypertension Society Working Party — have all been modified to reflect the emerging evidence concerning the benefits of treating older patients. Cost-effectiveness data are similarly in accord with giving high priority to the treatment of older individuals with hypertension.

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References

  1. Bonita R. Epidemiology of stroke. Lancet 1992; 339: 342–4

    Article  PubMed  CAS  Google Scholar 

  2. Adelman SM. Economic impact: national survey of stroke. Stroke 1981; 12 Suppl. I: I–69–I–78

    Google Scholar 

  3. Hartunian NS, Smart CN, Thompson MS. The incidence and economic costs of cancer, motor vehicle injuries, coronary heart disease and stroke: a comparative analysis. Am J Public Health 1980; 70: 1249–60

    Article  PubMed  CAS  Google Scholar 

  4. Marmot MG, Poulter NR. Primary prevention of stroke. Lancet 1992; 339: 344–7

    Article  PubMed  CAS  Google Scholar 

  5. Rutan GH, Kuller LH, James PH, et al. Mortality associated with diastolic hypertension and isolated systolic hypertension among men screened for the Multiple Risk Factor Intervention Trial. Hypertension 1988; 77: 504–14

    CAS  Google Scholar 

  6. Bonita R, Beaglehole R, North JDK. Event, incidence and case-fatality rates of cerebrovascular disease in Auckland, New Zealand. Am J Epidemiol 1984; 120: 236–43

    PubMed  CAS  Google Scholar 

  7. Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The fifth report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC V). Arch Intern Med 1993; 153: 154–83

    Article  Google Scholar 

  8. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older patients with isolated systolic hypertension. JAMA 1991; 265: 3255–64

    Article  Google Scholar 

  9. Dahlof B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet 1991; 338: 1281–5

    Article  PubMed  CAS  Google Scholar 

  10. MRC Working Party. Medical Research Council trial of treatment of hypertension in older adults: principal results. BMJ 1992; 304: 405–12

    Article  Google Scholar 

  11. Beard K, Bulpitt C, Mascie-Taylor H, et al. Management of elderly patients with sustained hypertension. BMJ 1992; 304: 412–6

    Article  PubMed  CAS  Google Scholar 

  12. O’Malley K, O’Brien E. Where are the guidelines for treating hypertension in elderly patients? BMJ 1992; 305: 845–6

    Article  PubMed  Google Scholar 

  13. Staessen J, Fagard R, van Hoof R, et al. Mortality in various intervention trials in elderly hypertensive patients: a review. Eur Heart J 1988; 9: 215–22

    PubMed  CAS  Google Scholar 

  14. Thijs L, Fagard R, Lijnen P, et al. A meta-analysis of outcome trials in elderly hypertensives. J Hypertens 1992; 10: 1103–9

    Article  PubMed  CAS  Google Scholar 

  15. Kuramoto K, Matsushita S, Kuwajima I, et al. Prospective study on the treatment of mild hypertension in the aged. Jpn Heart J 1981; 22: 75–85

    Article  PubMed  CAS  Google Scholar 

  16. Management Committee. Treatment of mild hypertension in the elderly: a study initiated and administered by the National Heart Foundation of Australia. Med J Aust 1981; 2: 398–402

    Google Scholar 

  17. Amery A, Birkenhager W, Brixko P, et al. Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet 1985; 1: 1349–54

    Article  PubMed  CAS  Google Scholar 

  18. Coope J, Warrender TS. Randomised trial of treatment of hypertension in elderly patients in primary care. BMJ 1986; 293: 1145–51

    Article  PubMed  CAS  Google Scholar 

  19. Guidelines Sub-Committee. 1993 guidelines for the management of mild hypertension: memorandum from a World Health Organization/International Society of Hypertension meeting. J Hypertens 1993; 11: 905–18

    Article  Google Scholar 

  20. Sever P, Beevers G, Bulpitt C, et al. Management guidelines in essential hypertension: report of the second working party of the British Hypertension Society. BMJ 1993; 306: 983–7

    Article  PubMed  CAS  Google Scholar 

  21. Jackson R, Barham P, Bills J, et al. Management of raised blood pressure in New Zealand: a discussion document. BMJ 1993; 307: 107–10

    Article  PubMed  CAS  Google Scholar 

  22. Bulpitt CJ, Fletcher AE, Amery A, et al. The hypertension in the very elderly trial (HYVET): rationale, methodology and comparison with previous trials. Drugs Aging 1994; 5: 171–83

    Article  PubMed  CAS  Google Scholar 

  23. Kannel WB. Role of blood pressure in cardiovascular morbidity and mortality. Prog Cardiovasc Dis 1974; 17: 5–24

    Article  PubMed  CAS  Google Scholar 

  24. Kannel WB, Dawber TR, Sorlie P, et al. Components of blood pressure and risk of atherothrombotic brain infarction: the Framingham Study. Stroke 1976; 7: 327–31

    Article  PubMed  CAS  Google Scholar 

  25. Shekelle RB, Ostfeld AM, Klawans HL. Hypertension and risks of stroke in an elderly population. Stroke 1974; 5: 71–5

    Article  PubMed  CAS  Google Scholar 

  26. Miall WE. Systolic or diastolic hypertension — which matters most. Clin Exper Hypertens 1982; A4: 1121–31

    Article  Google Scholar 

  27. Staessen J, Amery A, Fagard R. Isolated systolic hypertension in the elderly. J Hypertens 1990; 8: 393–405

    Article  PubMed  CAS  Google Scholar 

  28. Silagy CA, McNeil JJ. Epidemiologic aspects of isolated systolic hypertension and implications for future research. Am J Cardiol 1992; 69: 213–8

    Article  PubMed  CAS  Google Scholar 

  29. Mann SJ. Systolic hypertension in the elderly: pathophysiology and management. Arch Intern Med 1992; 152: 1977–84

    Article  PubMed  CAS  Google Scholar 

  30. Kawachi I, Purdie G. The benefits and risks of treating mild to moderate hypertension. NZ Med J 1989; 102: 377–9

    CAS  Google Scholar 

  31. MacMahon SW, Cutler JA, Furberg CD, et al. The effects of drug treatment for hypertension on morbidity and mortality from cardiovascular diseases: a review of randomized controlled trials. Prog Cardiovasc Dis 1986; 29 (11 Suppl.): 99–118

    Article  PubMed  CAS  Google Scholar 

  32. Amery A, Birkenhager W, Bulpitt C, et al. Syst-Eur: a multicentre trial on the treatment of isolated systolic hypertension in the elderly — objectives, protocol and organisation. Aging 1992; 3: 287–302

    Google Scholar 

  33. Systolic Hypertension in the Elderly’s Collaborative Group Coordinating Center. Systolic hypertension in the elderly: Chinese trial (Syst-China) — interim report. Chinese Journal of Cardiology 1992; 20: 270–5

    Google Scholar 

  34. Joffres MR, Hamet P, Rabkin SW, et al. On behalf of the Canadian Heart Health Services Task Group: prevalence, control and awareness of high blood pressure among Canadian adults. Can Med Assoc J 1992; 146: 1997–2005

    CAS  Google Scholar 

  35. Kannel WB, Dawber TR, McGee DL. Perspectives on systolic hypertension: the Framingham study. Circulation 1986; 61: 1179–82

    Article  Google Scholar 

  36. Van Loo JM, Peer PG, Thien TA. Twenty-five minutes between blood pressure readings: the influence on prevalence rates of isolated systolic hypertension. J Hypertens 1986; 4: 631–5

    Article  PubMed  Google Scholar 

  37. Colandrea MA, Friedman GD, Nichaman MZ, et al. Systolic hypertension in the elderly: an epidemiologic assessment. Circulation 1970; 41: 239–45

    Article  PubMed  CAS  Google Scholar 

  38. Ruddy MC, Bialy GB, Malka ES, et al. The relationship of plasma renin activity to clinic and ambulatory blood pressure in elderly people with isolated systolic hypertension. J Hypertens 1988; 6 (4 Suppl.): S412–S415

    CAS  Google Scholar 

  39. Applegate WB, Davis BR, Black RH, et al. Prevalence of postural hypotension at baseline in the Systolic Hypertension in the Elderly Program (SHEP) Cohort. J Am Geriatr Soc 1991; 39: 1057–64

    PubMed  CAS  Google Scholar 

  40. Kaplan NM. The promises and perils of treating the elderly hypertensive. Am J Med Sei 1993; 305: 183–97

    Article  CAS  Google Scholar 

  41. Beers MH, Ouslander JG. Risk factors in geriatric drug prescribing: a practical guide to avoiding problems. Drugs 1989; 37: 105–12

    Article  PubMed  CAS  Google Scholar 

  42. Strandgaard S. Cerebral blood flow and antihypertensive drugs in the elderly. Acta Med Scand 1983; 676 (Suppl.): 103–9

    CAS  Google Scholar 

  43. Oster JR, Materson BJ. Pseudohypertension: an update. Cardiovasc Risk Factors 1992; 2: 112–20

    Google Scholar 

  44. Col N, Fanale JE, Kronholm P. The role of medication non-compliance and adverse drug reactions in hospitalizations of the elderly. Arch Intern Med 1990; 150: 841–5

    Article  PubMed  CAS  Google Scholar 

  45. Goldstein G, Materson B, Cushman WC, et al. Treatment of hypertension in the elderly, II: cognitive and behavioral function — results of a Department of Veterans Affairs Cooperative Study. Hypertension 1990; 15: 361–9

    Article  PubMed  CAS  Google Scholar 

  46. Gurwitz JH, Avorn J. The ambiguous relation between aging and adverse drug reactions. Ann Intern Med 1991; 114: 956–66

    PubMed  CAS  Google Scholar 

  47. Curb JD, Borhani NO, Blaszkowski TP, et al. Long-term surveillance for adverse effects of antihypertensive drugs. JAMA 1985; 253: 3263–8

    Article  PubMed  CAS  Google Scholar 

  48. Schocken DD, Roth GS. Reduced ß-adrenergic receptor concentrations in aging man. Nature 1977; 267: 856–8

    Article  PubMed  CAS  Google Scholar 

  49. Applegate WB. Hypertension in elderly patients. Ann Intern Med 1989; 291: 901–15

    Google Scholar 

  50. Applegate WB, Phillips HL, Schnaper H, et al. A randomized, controlled trial of the effects of three antihypertensive agents on blood pressure control and quality of life in elderly females. Arch Intern Med 1991; 151: 1817–23

    Article  PubMed  CAS  Google Scholar 

  51. Black HR. Age-related issues in the treatment of hypertension. Am J Cardiol 1993; 72: 10H–13H

    Article  PubMed  CAS  Google Scholar 

  52. Johnston GD. Selecting appropriate antihypertensive drug dosages. Drugs 1994; 47: 567–75

    Article  PubMed  CAS  Google Scholar 

  53. Bums JF, Weir MR, Oparil S, et al. An assessment of diltiazem and hydrochlorothiazide in hypertension. JAMA 1990; 263: 1507–12

    Article  Google Scholar 

  54. Materson BJ, Oster JR, Michael UF, et al. Dose response to chlorthalidone in patients with mild hypertension: efficacy of a lower dose. Clin Pharmacol Ther 1978; 24: 192–8

    PubMed  CAS  Google Scholar 

  55. Vardan S, Mehrotra KG, Moorkherjee S, et al. Efficacy and reduced metabolic side effects of a 15-mg chlorthalidone formulation in the treatment of mild hypertension: a multicenter study. JAMA 1987; 258: 484–8

    Article  PubMed  CAS  Google Scholar 

  56. Medical Research Council Working Party. Medical Research Council trial of treatment of mild hypertension: principal results. BMJ 1985; 291: 97–104

    Article  Google Scholar 

  57. Carlsen JE, Kober L, Torp-Pendersen C, et al. Relationship between dose of bendrofluazide, antihypertensive effect, and adverse biochemical effects. BMJ 1990; 300: 975–8

    Article  PubMed  CAS  Google Scholar 

  58. Maling TJB, Kawachi I. Minimum effective dosage in the drug treatment of hypertension: a cost effective strategy for prescribers. NZ Med J 1990; 103: 231–3

    CAS  Google Scholar 

  59. Aldiger JC, Plouin PF, Alexandre JM, et al. Dose dependency of Captopril effects in severely hypertensive patients. J Cardiovasc Pharmacol 1981; 3: 1229–35

    Article  Google Scholar 

  60. Veterans Administration Cooperative Study Group. Captopril: evaluation of low doses, twice daily doses and the addition of diuretic for the treatment of mild to moderate hypertension. Clin Sei 1982; 63: 443s–445s

    Google Scholar 

  61. Cushman WC, Khatri I, Materson BJ, et al. Treatment of hypertension in the elderly, III: response of isolated systolic hypertension to various doses of hydrochlorothiazide — results of a Department of Veterans Affairs Cooperative Study. Arch Intern Med 1991; 151: 1954–60

    Article  PubMed  CAS  Google Scholar 

  62. McVeigh GE, Galloway DB, Johnston GD. The case for low dose diuretics in hypertension: comparison of low and conventional doses of cyclopenthiazide. BMJ 1988; 297: 95–8

    Article  PubMed  CAS  Google Scholar 

  63. Passmore AP, Whitehead EM, Crawford V, et al. The antihypertensive and metabolic effects of low and conventional dose cyclopenthiazide in type II diabetics with hypertension. QJ Med 1991; 295: 919–28

    Google Scholar 

  64. Fotherby MD, Harper GD, Potter JF. General practitioners’ management of hypertension in elderly patients. BMJ 1992; 305: 750–2

    Article  PubMed  CAS  Google Scholar 

  65. Weinstein MC, Stason WB. Hypertension: a policy perspective. Cambridge, MA: Harvard University Press, 1976

    Google Scholar 

  66. Littenberg B, Garber AM, Sox HC. Screening for hypertension. Ann Intern Med 1990; 112: 191–202

    Google Scholar 

  67. Kawachi I, Malcolm LA. The cost-effectiveness of treating mild-to-moderate hypertension: a reappraisal. J Hypertens 1991; 9: 199–208

    Article  PubMed  CAS  Google Scholar 

  68. Edelson JT, Weinstein MC, Tosteson AN, et al. Long-term cost-effectiveness of various initial monotherapies for mild to moderate hypertension. JAMA 1990; 263: 407–13

    Article  PubMed  CAS  Google Scholar 

  69. Johannesson M, Jönsson B. Cost-effectiveness analysis of hypertension treatment: a review of methodological issues. Health Policy 1991; 19: 55–78

    Article  PubMed  CAS  Google Scholar 

  70. Kawachi I, Wilson NA. The evolution of antihypertensive therapy. Soc Sei Med 1990; 31: 1239–43

    Article  CAS  Google Scholar 

  71. Hjemdahl P, Wiklund IK. Quality of life on antihypertensive therapy: scientific end-point or marketing exercise? J Hypertens 1992; 10: 1437–46

    Article  PubMed  CAS  Google Scholar 

  72. Kitler ME. Elderly hypertensives and quality of life: some methodological considerations. Eur Heart J 1993; 14: 113–21

    Article  PubMed  CAS  Google Scholar 

  73. Levine S, Croog SH. What constitutes quality of life? A conceptualization of the dimensions of life quality in healthy populations and patients with cardiovascular disease. In: Wenger NK, Mattson ME, Furberg CD, editors. Assessment of quality of life in clinical trials of cardiovascular therapies. New York: LeJacq Communications, 1984: 46–58

    Google Scholar 

  74. Croog SH, Levine S, Testa MA, et al. Effects of antihypertensive therapy on quality of life. N Engl J Med 1986; 314: 1657–64

    Article  PubMed  CAS  Google Scholar 

  75. Fletcher AE, Bulpitt CJ, Chase DM, et al. Quality of life with three antihypertensive treatments: Cilazapril, atenolol, nifedipine. Hypertension 1992; 19: 499–507

    Article  PubMed  CAS  Google Scholar 

  76. Palmer AJ, Fletcher AE, Rudge PJ, et al. Quality of life in hypertensives treated with atenolol or Captopril: a doubleblind crossover trial. J Hypertens 1992; 10: 1409–16

    Article  PubMed  CAS  Google Scholar 

  77. Croog SH, Kong BW, Levine S, et al. Hypertensive black men and women: quality of life and effects of antihypertensive medications. Arch Intern Med 1990; 150: 1733–41

    Article  PubMed  CAS  Google Scholar 

  78. Wassertheil-Smoller S, Blaufox MD, TAIM Research Group. Effect of antihypertensives on sexual function and quality of life: the TAIM study. Ann Intern Med 1991; 114: 613–20

    PubMed  CAS  Google Scholar 

  79. Testa MA, Anderson RB, Nackley JA, et al. Quality of life and antihypertensive therapy in men. A comparison of Captopril and enalapril. N Engl J Med 1993; 328: 907–13

    Article  PubMed  CAS  Google Scholar 

  80. deLame PA, Droussin AM, Thomson M, et al. The effects of enalapril on hypertension and quality of life. Acta Cardiol 1989; 44: 289–302

    CAS  Google Scholar 

  81. Steiner SS, Friedhoff AJ, Wilson BL, et al. Antihypertensive therapy and quality of life: a comparison of atenolol, Captopril, enalapril, and propranolol. J Hum Hypertens 1990; 4: 217–25

    PubMed  CAS  Google Scholar 

  82. Task Force on the Availability of Cardiovascular Drugs to the Medically Indigent. Report of the task force on the availability of cardiovascular drugs to the medically indigent. Circulation 1992; 85: 850–60

    Google Scholar 

  83. Stason WB. Cost and quality trade-offs in the treatment of hypertension. Hypertension 1989; 13 (Suppl. I): I–145–I–148

    Google Scholar 

  84. Croog SH, Elias MF, Colton T, et al. Effects of antihypertensive medications on quality of life in elderly hypertensive women. Am J Hypertens 1994; 7: 329–39

    PubMed  CAS  Google Scholar 

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  1. Department of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Avenue, Boston, Massachusetts, 02115, USA

    Ichiro Kawachi

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Kawachi, I. Epidemiology of Stroke. Drugs & Aging 5, 288–299 (1994). https://doi.org/10.2165/00002512-199405040-00005

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