Co~l~plic:rtior~s or I ~ y p e r t c ~ l s in i o ~t l~~ ecldcrly Iiluotl ~ ) ~ c s s tisr ~a erisk filetor for cardiovascol:~rtliscase at all ages but particularly in t l ~ ccltlcrly (1.2). tIypcrtension is the lnajor risk factor Tor stroke, cardiac failure, culolirlry a ~ t c r ydiscasc and luyocardial ir~farctio~i io this age group. (:cl~cbrovirsc~~l:~r accidc~~t Sr~okcsilcc~ulltfor I If?6of all deatl~sin the U~litctlStates atid 7.5% of slrvkc deatlls arc i l l tl~oscngctl over 65 years. Ilypcrtensiot~is rllc 11lvs1polct~t ~llostconunou plccursor of ntl~ervlllro~l~botic brain ir~farctior~ (3.4). Asy~uptut~~:~tic casual Ilyl)erte~~siou is associated will1 a risk of a l t ~ e r o ~ ~ r o r ~ braill ~bodc i t ~ l ' : ~ ~ c tfour i o ~ ~to tl~irty tittles greater lliiul that of ~~orrnotensives.The risk of ntl~c~otlironlbotic brain i~ifarctionis as well correlated wit11 systolic blood pressure as \\,it11 tliastolic or lllearl pressures. Tllc in~pactof systolic 11yl)erleosionis tlot dirl~il~isl~ed with i~dvarici~~g age llrus s t ~ p p o r t i ~tlic ~ gview Illat systolic I~ypertel~sion in the elderly is ;~ssuci:~tctl will1 considcrablc ca~diovascularrisk (2) (see bgure 1). For each 10 nu~ltIg rise it] blvod pressure. t l ~ crisk of athcrotl~rotnboticbraill infarction increases about 3OC?6( 1 ) . 111a I O ycar longitudinal study of I Y I elderly fe~nalcsaged up to 100 years (average 80). it uras sl~o\\*n that the incidence of cerebrovascular events was sigtli[icantly correlated to systolic blood prcssure (5). Twenty perccnt of the hypertensive and 1096 of tlic ~iorniotensivcpatients suffered from a cercbru\~ascularevent during the study. Co~tgestivecardiac Ia1'I ure Systolic bloocl prcssure is a tilajor detcnnit~atitof left ventricular work and t l ~ e relationship bctwcen systolic blood pressure and congestive cardiac failure is e x l r c ~ ~ ~strong. e l y 111t l ~ c17ra~ninghan~ Study (6). I~ypcrtensionwas the donlinaot risk factor for all agcs. In tlie elderly group (age 65-74 years) alniost seven tirnes as lilany Ilyl)crtcnsives developed cartiiac failure as did norniotensives. The occurrence of congestive cardiac failure carricd a poor prognosis as only 50'h of those who developed cardi:~cfailu1.e survivcd live ycars. Corollary artery disease lligl~blood prcssure is a risk factor for coronary artcry diseasc in tlic clderly (7). I'rospcclivc studies liavc convincingly det~lotistratcda substantial excess rate of development of coronary Ilcast discasc in proportion to t l ~ cdegree of elevation of artcrial prcssurc. riotably systolic prcssurc. IGsk of corollary l~cartdiscasc is disti~ictly a t ~ ditnlxcssivcly rclntcd to antcccdent blood prcssurc at all agcs, including t l ~ eldcrly. c Myocnrtlial infarctiott 111a I 0 year study, 170rettc ct al. (5) have rcportcd that llic iticidencc of tnyocardial infarction was sigr~ifican~ly and indepcndcntly correlated todiastolic blood prcssure in fct~lalepatierits over 60 years of age. Twenty seven of the Y4 hypertensive patients (28'%,) and 4 of the 5 1 nortiiotensivcs (7.816) liad niyocardial infarction during the follow-up. 'rlius, tlic incidence of ~i~yvcardial inlarctioti was more than three tinles l~igl~cr in tlie Ilypcrtc~isivcpatients Illan in dic norn~otcosivc. Mortality ~ssocintedwit11 I t y p e r t e ~ ~ s ill i o ~t11c ~ elderly 'rile I~raminghamStudy (7) has coml)arcd mortality in diKere'n1 age groups according to blood prcssure status and showed that mortality in hypertensive nlalcs wit11systolic blood prcssure above 160 1iiti11.lgis nlucl~greater than in norniotcnsivc nlales. Mortality in elderly 1iy~)ertcnsivcsis twice tl~atof norniotetisives despite a sligl~t decrease in rclative niortality with age. Wliereas the relative mortality betwecn Iiypcrtcnsives and tiorniotcnsivcs is less in the cldcrly than in middle age because of lllc grcatcr nun~bcrof dcallis in die elderly, t l ~ cactual nuti~bcrof hypertcnsioti-relad dcatl~sis incrcascd. For eldcrly rnales, 4.6% of annual dcatlis wcrc associatcd wit11 I~yperlerisior~ cornl~arcdwill] 1.896 ofdcatlls in d ~ 45-54 c ycar agc group (see figurc 2). 'I'llus. in the eldcrly, l ~ i g lblooti ~ prcssure rctnains an important risk factor for cardiovascular discase. Cl~niigcsill the cardiovascular systctl~with raised blood pressure and ageittg 'I'lre agcing process is associaled with anatotnical, pl~ysiologicaland biocllenlical cl~anges.So111eof tl~esecl~a~lgcs may be inlportarit in the patllogenesis of hypertension in the elderly. Tllere is increased rigidity of the aorta al~tlits branclles due to loss of elastic fibres in tlie nledia, an increase in cvlagen at~tlcalciurn conteat, and the presence of atl~eroii~a in the irltiu~a.The functional consequence is that these vessels are less compliant (8). The stilTeiled large vessels behave lrlore like rigid lubes tllan diste~lsiblevessels. Normally, :lortic distensibility reduces the workload of the left ventricle as it reduces impedance. I n less coinpliant vessels tlle systolic pressure generated in tlre left ve~~tricle is transmitted witli very little buffering to the arterial tree. -Illis results in a rise in systolic pressure, Ilence tlle terldency to disproportionate systolic llypertension in old age (9, 10). .l'l~erenin-angiotensi11-aldosteroi~esystenl also undergoes cl~angeswit11age. Low-renin essential l~yperterlsion is a more coilullo~lfeature in the elderly. I'lasma retiin concentration, plasnla reriin activity and aldosterone concentration are all lower ia the elderly. Sotne l~oldthat tlle decrease in plasn~areilin in the elderly is ~ilerelya feedback il~l~ibition induced by tlleir higher arterial pressure. Why treat tlle elderly l~yyertciisive I t has been de~r~otlstrated that I~ypertensioilio the elderly is associated will1 excess risk o~cardiovascularmorbidity and tnortality. But before one can advocate the treatment of Ilyl.~el.tensionin all elderly I~ypertensivcs. pressure reduction must be seen to be ;~ssocinlcdwit11 a reduction ill ~i~orbiiiity antl n~ortality.tviany studies have been ulldertakcn lo assess the benetit ol'anlihypertensive therapy it1 adults but they have not included sutlicicllt elderly Ilypertcl~sivesto draw delinilive corlclusions ( 1 I). 'I'renttnenl and co~nplicatioas l ' l ~ cVeterans Adniinistration Study ( 1 2 ) unfortunately had tlle litnitations orincluding or~lymales ar~dInany llad the co~nplicationsof I~ypcrtensionand otl~erill~~esses prior to raodv~nisationinto contr.ol slid trcatn~entgroups. 111 tllose witli diastolic pressure between 90 and 1 1 4 mml-lg tlicre were 8 1 patients over GO years and tliey comprised one fifth of tlle entire study group. The i~lcidericeof rnajor complications of trypertension increased witli age. and this one fifth accourlted for alniost lialf of to~zlevents. In the uolreated group 15.2% of patients under 5 0 years of agc developed rnorbid events co~npared\\.it11 62.9% or tliose over 59 years. In tile trcated group the incidence of norb bid evcr~tswas 6.9%) and 28.99& respectively (see ligurc 3). -. -. - . .. ..-..- I I!?l-wl,.nr c. (!I ~ ~ I ( ~ I I ?FYPIII*. III ,, 7 .l'reat~nenta t ~ dreduction of r~~ortalitp 'l'lie five-year lindings of the klyperte~lsion Detectioo and I;ollow-up I'rogram Cwoperative Study ( 13) arc p;lrticulary perti~~ent. In tllis conlrnunity-based randomised controlled trial i~ivvlvingovcr 10,000 hypertensives, rriortality ligurcs are comparccl bctwccli tl~oseallocated to n systctiiatic antillypcrtcnsivc trcaltncnt progranlme (stepped care) and tlrosc rcTcr~.edto community riicdical care (referred care). Tlie stepped care group was offered antihypcrtensive Iherapy in special centres, free of cl~argewill1 a ~naxirnun~ elTort to encourage patient compliance'with therapy which was increased stepwise to acl~icvcand rnaintai~lreduction or blood pressure to or bclow set goals. Tlie referred care group were rererred Tor treatment lo Iheir usual sources ofcare. A 17% reduction in 5 year total rnorlality was reported in dle specially treated group. 'I'licrc were 2,367 patients. agcd 60-69. includcd in thc study. In tl~isiIgc group therc nfas a 16.4% reduction in nlortality in !he stepped care group altliougl~tile din'crcnce in diastolic blood pressure bctwcco l l ~ etwo groups conlpared at t l ~ cend of 5 years was a Inere 5.1 ~nniHg. althougll tlic difirel~cein diastolic blood prcssure between the two goup's compared at tlie elid of 5 years was a riiere 5.1 rlirlll lg. It is 1101clear if diis reduction in niortality was causcd by rcductiori of diastolic blood ~~rcssurc by 5 i~iitillg or if better gc~icral~iicdicalcare contribuled to llte successful result it1 the stcl)l~cdcare. cspecinlly as also noti-cardiovascular deaths were reduced by 14r?0.I t is clear that rliaiiy sturlies airrlcd at assessit~gtlie beiicfiis of ailtiliypertelisive Illeri~pyI~iivcbceit directed at tlie adult population in general with sorlle i~ifonnatioii011 tlie clclcrly c~ilcrgi~ig as a side issue. Tlic ~iiulticcotrestudy by tlic European Working I'nrty o ~ Iiligli Dlovcl Pressure in tlie Elderly ( 14, 15, 16, 17) is curre~itlyassessiilg the rolc of at~tihyocrterisivctliernpy specifically in elderly liypcrlensivcs. Tlie antiliypertctlsivc tlicr;~l~y has beer1 sliowii to be cflicncious and relatively well tolerated in tlie loi~gtcin~.Ilowcver, the rcsults of l l ~ ecll'ects of tlic treatti~etiton iilortality and tiu)tbidity ; I I C iivt yet available. In sutlitllary. beitelit has bccii sliowll fur die lieattliclit of l~ypertcnsioilat all ages, but llie bcuefit io tlic elderly is not as clear-cut as in yourigcr individuals. \YII:I~ is I~ypertet~sioa i e l l ~ eelderly? lllood pressure is a coiiti~~uous variable atid as tlie level rises, so do llie associaled risks ( I). As in yourig people there is no clearly identifiable critical or safe level, so cut--off pc~it~ts iiiust be arbitrary. 7'1ic lirl~itsset are based on increase in morbidity a i d iiiortnlity. 111tlic preserit cotltcxt we take lGO/YO1iutil-Ig(5dipliase) as the upper lilrlitof nornial pressure. I t is iivw recognised that we tllust take systolic pressure into account as well as die tliastolic. I)isl)roportionate systolic liypertension exists wllen the rise in systolic pressure is exaggcrated conipared wit11 ale diastolic pressure. It is defi~iedas syslolic pressure = (tliastolic pressure - 15) x 2. Isolated systolic hypertension is variously delirietl as a systolic pressure greater than 150 mnlI.Ig( 18) or ii systolic pressure in excess of 159 rnrrlHg(l9), wliile the diastolic pressure reniairis below 90 nimHg. A tllird definition, and perhaps tlie most appropriate, is a systolic pressure of 160 or greeter wid1 n diastolic pressure of 95 nitiiI-Ig(20). Disproportioiiate systolic hypertension and isolated systolic hypertension are yreseiilly utitler ilivestigatioli and a plan of managenlent is not known. Ilotv C O I ~ I ~ I I O IisI llypertet~sio~~ in the elderly? The prevalerice of Iiypertension in dte elderly depends on the blood pressure levels wliich are chosen and on ttie number :lod circurnstarices in wliich readings are taken. In the United Stales t l ~ cNativrial I lealtll Survcy ( 2 1 ). usittg 160/Y5 iiiinklg as tile lower litiiit of Iiyperteii~io~i. foulid a prevale~lceof about 4036 in tlie elderly age group. Estit~intesofdisproportionate systolic Iiypertension vary and a figure as high as 40% of tliose attetidirig a Iiigh blootl pressure cliiiic has been suggested ( I I). Using 159190 as tlte systolic and diastolic liniits. isolated systolic liypertension is relatively rare: 2.7% of tlic populatioll if readings are repeated oo a separate occasiori (19). Clearly, if 95 tiiiiil lg is used as Ihc cut-olT level for diastolic pressure, a liiglier prevalerice will 1)crtaiit. W l ~ o t rto ~ treat? Wlteii selecting patients for a~ltiltypcrtensivetl~erapyotie is teiiipercd by the hiowledge Ilia1 cldcrlv patients itlily react dill'erctilly to drugs than younger subjects (22). Agcing induces pi~ysiolvgicnl and pathological clianges wliich nlay influence the ~~lii~rii~acvkinctics ;\tit1 ~ C S ~ O I I Sto C drugs (23. 24). lVlicrcarc varyitig ol)iiiiolis colicertlitig tlie level ol' blood pressure at wliicl~to start 165 rr cnrriicr~tin the elderly patients. I t is generally agrccd tliat. regardless of' age paticots \ v i l l ~a sustained diastolic blood pressure of 115 ~ n m l l gor more sl~ouldreceive t~eatn~cnt. 111fact. nlosi dvctors trcat tliose wit11diastolic pressureover 1 I 0 1111nlIg.We sl~ouldcarefully consider therapy in elderly patients whose blood pressure is l~iglicr than 1601100 mmHg on two occasions. In patients with diastolic blood pressure in dle range 100- 1 I 0 11iin1-1gtlie presence ofcoriiplications or a sitnultaneous systolic blood pressure of greater lliar~180 ~nrnllgwould sway tile b a l a ~ ~ cine favour of tlicrapy. At Iwesent rl~ostEurvpcan pliysiciaris do not treat isolated systolic Iiypertension (25). 1Ion~cvcr.wllen a groupof North A~neric;~n pliysicians were 'pollcd' at a recent ~ilecting of Chest Pliysicians. it was clear tliat the vast ~najorityoftllose present treated isolated systolic hypertension. 'This reflects dicir inore aggressive approach to treahnent of hypertension in general. but also indicates that tile Americans are prepared to e of studies oftllc cficacy of blood pressure reduction on mortality anticipate d ~ results and ~norbidityin tlie elderly. lrrvestigatio~is lrivcstipations are inairily ainlcd at assessing the effects ratllcr dlan tile cause of I~yl)crtcnsionand sl~ouldbc kept to a mininiun~:elctrocardiogram, dipstick urinalysis, scrurn crcatininc. serurn electrolytes and urate. Clinically significant lel\ ventricular Ilyl)ertropliy is detectable on tlie convc~itional electrocardiogram. 7'1ic dipstick urinalysis is usually sensitive e~iouglito dctect abnor~nalitiesand only if the findings are positive is it worlhwhile progressing to a inidstream urirlalysis with culture and sensilivity testing. Serum creatininc is not a sensitive nleasure of renal function and will be raised only if approximately 70% of kidney tissue is riot functioning. Tllcrfore. if an accurate assessment is deemed, neccssary crealinine clearance sl~uuldbe ~ncasured.Changes i n scrurn elcctroly~esand serum uratc are unlikely prior to drug trcatnicnt and tlie n~ainreason for doing tlic~nis to asscss thc ~>ossiblc deleterious cll'cct of diuretic treatment. Eve11 if secondary llypertension is suspected extensive i~ivestigationsniust be carried out unless surgical i~~lerverition is feasible and desirable. Cl~oiceor drug In clioosing a particular drug tlie physician ulust attempt to con~bincellicacy will1 a ~ i ~ i n i ~ nof u munwanted clTects. 111general. it is best to avoid antihypertensive agents such as metllyldopa, reserpine, and clor~idir~c dlat cause depression of dlc central nervous sysleln. l'l~ougligood data are lacking, it is generally l~eldthat die elrlcrly are rnore prone lo tlie unwanted ccnlralnervous-systeln elfects of these drugs. 'l'his generalisation must be tc~al>crcdby an iritcriln report of an ongoing study by the European Working I'arty on lligll Blood I'ressure in tlie Elderly (EWI'I-IE) ( 15). in whicl~conlplicalions with n~ctl~yldopa do not appear lo be a prublcnl. In lliis stucly, Iiowcvcr, melliyldopa is uscd in low doscs. 'I'lle elderly and particularly tliosc with ccrel~rovasculardiscasc arc suscel~tibleto postural Iiypotcnsion bccausc tllcy have less rcsponsivc barorcflcxes (26,27). For tllis reason. adrencrgic-ncuron blocking drugs (guanctl~idi~ic, bcthanidinc and dcbrisoquine) tllat causc postural hypertension sliould not bc uscd. V;~sodilatorsl~oldpro~nisc for the future, particularly in systolic l~yl)ertcnsion,but at prcscnt data arc insullicicn~ to ninkc an i~~fornlcd dccisio~i(8). tlic brainsterii vasonlotor centre diereby i~lllibitingsy~~~patlietic outflow and rcducirlg systenlic arterial pressure. Both tliese agents may produce several side-effects like tlro\\~sinessand depression and should therefore be used restrictively. Adrenergicrleurun blocking drugs (guanctl~idine.bctlianidine arid debrisoquine) cause postural Iippo[eosion and sliould not bc used in tllc present context. I_)i~~retics l'l~iazidediuretics are elrective in reducitip blood pressure in elderly Iiypertensives and do not cause nlajvr cli~licalor biocliernical disturba~icesbut to mininiise biochemical disturbances it is bcst to use a lo\v dose of for exa~ilpleI~ydrocllloroClliazide(25 nig daily). l'llc clderlp are said to be 1ilore prone to tl~epotassiuni-losing crrects oftliiazide diuretics. I3ppokalacniia niny induce ventricular ectopic activity (33) and the risk of nrrllylll~niasis inore niarketl wlicn a Iiyi)okalac~~lic patient perfornls exercise (34). 1':rtients with abnormal potassium levels nlay also liave a poorer progrlosis in case of nl!locardinl irrfarclion wit11 liigl~crrisk of arrllpthmias (35). Tliercrore, potassium sul~l~lellie~itatioll should he givcn or the tl~i:izidcsliould be combined witli a potassiumsparing diuretic such as triarntere~~c. As many elderly patients find individual potassiuln preparations unpalatable one rnay conlbine the tlliazide will1 potassiunl in one tablet. I'otassiutn supplc~nentationis particularly appropriate if the patielit is also on digitalis therapy. Glucose intolerance is one of the major risk factors ror coronary artery disease. In tlie EWPI-iE study tlie group treated with tlliazide diuretics showed a significant deterioration in glucose tolerance (17, 36). Cli~~ical diabetes mellilus is likely to be induced only in tl~osewho already have borderline diabetes. We expect tllat tlle reduction of blood pressure would more tllan oli'sct tlle tl~corcticalrisk associated witli a small drug-i~lduccdrise in blood sugar level. Serunl uric acid levels also rise in patients on tlliazidc diuretic therapy. In the EWI'HE stutly the group treated with diuretics sl~owcda 25% increase in scrurn uric acid but cliiiical gout was extretncly rare. Tlic sanlc indica[ions and contraindicatiot~s;rl)l)ly as in younger patients. Sun~e~ai-y I Iigli blood pressure in the elderly is associated wid1 a high incidence of cardiovascular disease but tllcre are no definite data wliicli prove that treatnient of mild to noder rate Iiypertension in this age group inlproves prognosis. I-iowever, a review of available literature suggests that treatrlient is beneficial. We adopta policy as outlined above. We suggest a tlliazide diuretic or a beta-adrenoceptor blocking drug as first-line tl~erapy. 'I'llese drugs niay be combined if an inadequate response is seen and other drugs nlay be used if dre blood pressure is not controlled. asscsslneljt or tlic rolc or blood I . Knlincl WU. W o l f I'A. Vcrtcr J. McNaliiara PM: I~liidc~iiiological prcssurc in stroke: t l ~ cI : r e ~ ~ i i t i ~ l i nSttltly. ~n J A M A I Y 70: 2 14: 3 0 1 - 10. i c l Gordon'l': I ~ v n l ~ ~ n loftlie i o t i cnrdiovnscular ~ i s kill tliccldcrly: tlic I 7 r i i ~ i i i ~ i g l iStudy. n ~ ~ i Bull 2. K n ~ ~ ~WII. N Y Acatl. Mcd. 1978: 54: 573-91. 3. Slickcllc It[!, Ostl'cltl A M . Klnwnt~sIll, Jr: I I y l ~ c ~ t c l i s i nlid o ~ i risk o f stroke ill llic cldcrly ~ ~ o l > u l i ~ I i o ~ i . Strokc 1974; 5: 7 1-5. c ~hlocitl ~ t s prcssulc i ~ t i t risk l of n111cr~IIiro11i4. Kn~iliclW I ) . 1)rwlxr 'l'lt. Sorlic I'.Woll' I'A: C r ~ ~ i i l ~ o r iof h ~ t i cbraill ilil'arctioci: llic I:r;i~iii~igl~n~n St~idy.Strokc IY76; 7: 327-31. 5. I'otcttc I:. L)c In I:ucrite J. Golrrlnrd JL. l l c t i r y J17. I l e r v y h.11': Elderly liypertension as a risk factor c ~ ~ r Corrccl)ts r. Ilypcrtetis Cnrtl. Disortl. (Sytlticy) 1980: 1 (4): l I. 0. K : l ~ r t ~ eWU. l Cnstelli WP. blcNntrrnra Pbl. b l c K c c PA. Fcirlleib h l : llole o f blood pressure i n the tlcvcloliriicrit ol'cotigcstive Iicnrt I;.iilure. l ' l l c Frarlririgllntr~Study. N. Engl. J. Mcd. 1972: 287: 78 1-7. 7. K n t i t ~ cWU. l Gortloti'T. Scli\vartz M J : Systolic vcrsl~sdinstolic blood pressure and r i s k o f coro~iaryheart tliscnse: tlie !:ra~iiiliplinn~Study. AII. J. Cnrdiul. 1971: 27: 335-46. 8. Sitlion A C . Safnr h l A . Levotison JA. Khcdcr A b l . L c v y UI: Systolic hypcrtcnsiori: I i a e n ~ o d y n m i c ri~ccl~atiisrir nntl clioice tif antillypcrtcnsive trcatlllctit. AIII. J. Cnrdiol. 1979: 44: 505-1 1. 9. l'nrnzi ICC: Should you lrcat systolic l i y p e r t c t ~ s i oiri i ~ eldcrly patients? Geriatrics 1978: 33(1): 25-9. 10. Korll-Wcscr J: Trcntt~ier~tofliypcrte~~siori it1 t l ~ c elderly. 111: C r w k s J, st evens or^ 11-1,eds. Drugsandthe Eltlctly. Lotidoll: blacblillan 1979: 247-62. I I. Kocll-Wese J: Artearinl hypertensioti it1 o l d age. I l e r z 1978: 3: 235-44. 12. Vrtcrnrts Adrtiiriistratiot~Cool)crntive Stutly G r o u p VI Aritil~ypertensiveAgents. Effects o f treatrllent otl ~ ~ i o r l i i t l iirt t y Irypcrtcnsion. Ill.lnflctence o r age. diastolic pressure and prior cardiovascular disease. frlttllcr ntinlysis cil' side cll'ccts. Circulntion 1972: 45: Y9 1-1004. 13. Ilyliertension Detcctioli and Follow-up P r o g r a r ~ Cooperative ~ Sludy: Five year findings o f llle I~yl)crtetisiorldetcctici~land rollow-up prograrii. I. Reduction i n mortality o f persons wiUi high b l w d prcssure iiiclutlilifi tilild I~yperte~isior~. J A b I A 1979: 242: 2562-7 1. 1.1. A ~ i i c r yA. Ilertll:rux P. Dirkenhaper W e l nl: Ariti1tyl)erlensive l i e r a p y i n elderly pslienls: pilot trial o f t l ~ eErlrcipenn Working Party o ~ t il i p l ~Ulood Pressure i n the Elderly. C;erontology 1977: 23: 426-37. 15. A ~ i r e r vA. Uertlraux P. llirketltilger W et al: Antiliypertetisive tl~erapyi n patients above age 60: third i t ~ t c r i r rreport ~ ol'tlic Europcnt~W o r k i ~ ~Party g o n I l i g l i Ulood Pressure in the Elderly ( E W P t I E ) . Acta C:irtliol. 1978: 33: 1 13-34. 10. Atricry A . D c Scliilcptirijver I\. Should cldcrly Iiyl)crtclisives be treated:' Lntlcel 1975: 1: 272-3. 17. t\rllcry I\. Ilcrtlinux P. Bulpitt C ct al: Glucose ititulcrnrice during diuretic therapy: results o f t r i a l b y the I~~trrloc:iri Working I'nrty oli Ilypertctisior~in llic 1;ldcrly. L:lrrcct 1978: 1 : 68 1-3. 18. Kocli-Wcscr J: Conclntiotl nf'patliopl~ysiolugyand pli;~rniacoU~erapy i n p r i t l ~ a r yhypertension. Am. J. C:~rdiol. 1973: 32: 499-5 10. 19. Colarldren hlh. Fricdrlliin GI). N i c l l a ~ i i i ubl l Z . Lyrid C N : Systolic hypertension i n llie elderly - an eoidcn~icrlogicnlnsscssriiclit. Circul;ttiolt 1970: 4 I: 239-45. 20. K n t ~ t i eWU. l W o l f ['A. h.lcGcc DL. Dawbcr 'I'R. blcNntrinrn P. Castelli WP: Systolic blood pressure. n ~ t c r i nrigidity l ntid risk ol' stroke. J A h l h IYX 1: 245: 1225-9. 21. Ostl'cld t\bl: Eldcrly Iiyl~erterisivepatictlt. Eliiderl~iulogicreview. N Y State J. bled. 1978: 78: I125-9. 22. O'hlallcy K. Judge T. Crooks J: Geriatric clir~icillpliarlriacology and therapeutics. In: Avery G.ed. [)rug trcntrrierit: lirinciplcs nrtd practice o f clitiicnl pltarnlacology and therapeutics. Sydney: A D I S I'rcss. 1YXO: 158-81. 23. Crooks J. O'blallcy K. Stevenson III:I'lrnrri~;lcokirietics i n the clderly. Clin. Pliarmacokinet 1976: I: 240-96. 24. Grcenblntt DJ. Sellers E M . Sllntlcr 1<1: I)rugdisl)ositiot~ illo l d agc. N. Engl. J. bled. 1982: 306: 10818. 25. O'blallcy K . O'l3ricn 13: D r u g tllernl)y: blat~:rpcti~ctit ol'ltypertensioti ill tile elderly. N. Engl. J. bled. 1980: 302: 1397-1 401. 26. Pickcririg I ' G . Gribbitl U. Oliver DO: Unrorcllex sensitivity irt patie~ltso n long-term Iiaenlodialysis. Cliti. Sci. 1972: 43: 645-57. 27. Shi~rl~cy-Schal'cr EP: 1;ll'ccts rll'Valsnva's tll:tt1ocuvrc or1 tlie norrilal ar1d (hilirigcircuIation. Br.,Med. J. 1955: I: hV3-5. 28. C:lstlcdcrt Cbl. Gcorgc C'F: l ' l l c cll'cct ol':igeitr~ ti11 the Irclx~ticclearance ol' propranolol. Ur. J. Cliti. I1li:irrii:lc~~l.1979: 7: 49-54, 30. t i r c c t ~ l i l : ~ tDJ. t Kocli-Wcscr 1: r\dvclsc rc:lc~ions to ~)rolir:~riolol i n Ilospitalized rr~etlicnlpntisnts: a rclnirt l'rotii t l ~ cIlostoti ('oll:tbor:ttivc Ilrrtg Stlrvcill:lr~cc I'rogrnnr. PI\ I-lenrt J. 1973: 86: 478-84. 3 I. Kctid:ill blJ. l3r(i\vti I.). Y:~tes I</\: Pl:~striitt i ~ c t ~ ~ p r ocoticctitr:iti~i~~ lol it1 yiutig. o l d arid l ~ y p c r t c ~ ~ s i v e ~ttl)jccts.l l r , J. c l i t ~ . l'li:~rri~:ietil.lV77: 4: 497-0. 3 2 . lsliiz:~ki 1'. II~~:I~;IIII;I 11. T:l\v:ir:~ K . Ni~k:~y:r11. S~IO hl. S;~tci K: I'l~:ir~ii:ict~kirietics and pharriincodytr:ltrlics i t 1 yocrt~g111irt11:iIi ~ t l cltlcrly d Iiyl,crtctlsive stl0jcets: :Istudy usilig scrtolol as 3 model drug. J. I1li:~r~ri:tctd.ltxl). l ' l ~ c r .IVSO: 2 12: 173-4 I. 33, O'C:~lI:~gl~:rti WG. l.;tlicr blS, hlcCi:~rry K. 0.Ilricti l{.l'. C~'h1:iIlsy K: t \ ~ ~ t i l ~ y ~ ~ e r t cand r ~ srcrl:rI ivc l t : t c t ~ i ~ ~ t l v r ~cll'ccis : ~ t ~ ~ ti c~ l ' : i ~ c ~ i t :i ~I ot i lt lti;~tItiltdi r i clclcrly l ~ y ~ i ~ ! r l c ~ ip:~tic~tls. sivc Ur. J. C l i ~ i l'li:~rr~~:~ct)l. . 1')s:: 14: 135- I Jfll' ( / \ l l ~ t l . 3.1. I Ic~llat~d 011. N i a o ~ J \ ~' . LaVon l i r ~ l l ~ ~1tN: e r t Lliuretic-i~~duced ventricular ectol,ic activity. Am. J. bled. 1981: 70: 762-8. 35. llollilicld JIV. S l a r o ~I'E: ~ Cardiac a r r l ~ y ~ l ~ n iassociated ias \vitl~diuretic induced I~ypokalae~nia and I~!po~i~ngnesnc~nin. In: Itoynl Society of Medicine. International Congress and S g ~ n p s i u n Series i No. 44. London: Academic Press Inc (London) Ltd. and tlie Royal Societ!. o r Medicine. 198 1: 17-24. 30. Nordrcl~augJl:: hlalipinnr arrli!~tllniias in relation ro scruni potassium values in patients with an acute n~yocardialinlarction. Acta hletl. Scand. I YP I : sulipl. 647: 101-7. 37. I.c\\.is PJ. lioll~lcrEhl. I'crric A. L)ollcry C'r: Delcrioration 01' plucose lolerance in I~yl,ertcnsivc pntients on prolonged diuretic rreatlnent. Larlcer 1976: I: 564-6. Discussioo I;cr.l~oe~.en: WI1y d o you a v o i d u s e of a l p l l a - ~ ~ i e t l i p l d v ~ ~ a ? 0 'A la I l ~ l - : hlait~lybecausc it h a s a CNS d c l > r c s s i o n elTect.