Michael Kelleher, MD

To the Editor: I read with interest the exchange of letters between Drs. Norenberg and Graves in the December 2007 issue,^1,2 which followed Dr. Graves’ article in the October 2007 issue.³ Dr. Norenberg suggests that it is not always prudent to try to push systolic pressures below 140 mm Hg in the elderly, and Dr. Graves takes the position that physicians like Dr. Norenberg have been “too slow to adapt to evidence-based guidelines for quality of care.” I would like to focus on Dr. Graves’ reference to evidence-based guidelines for the treatment of systolic hypertension in the elderly.

Although there have been multiple published studies of the treatment of this disorder, none has achieved an average systolic blood pressure lower than 140. The Systolic Hypertension in the Elderly Program (SHEP)⁴ came closest with a final systolic blood pressure of 144. No study has ever documented the efficacy and safety of achieving systolic blood pressures less than 140 in a cohort of elderly patients, and there is substantial evidence that excessive lowering of diastolic blood pressure can be harmful.^5,6

Many elderly patients can achieve the target referenced by Dr. Graves, and it is reasonable to expect physicians to continue to strive for that goal, but it would be unwise to push all seniors below 140 systolic. Consider the elderly patient with systolic hypertension who is on a robust three-drug regimen including a diuretic, with a blood pressure of 144/60 and with persistent but tolerable drug side effects. I am aware of no clinical trials that demonstrate that further lowering of this patient’s blood pressure would provide incremental benefit to outweigh the potential risks and costs of additional medications.

We need to be careful not to confuse evidence-based medicine with high-placed opinions, which can result in rigid approaches to treatment that are not in the best interest of our patients.

To the Editor: I read with interest the exchange of letters between Drs. Norenberg and Graves in the December 2007 issue,^1,2 which followed Dr. Graves’ article in the October 2007 issue.³ Dr. Norenberg suggests that it is not always prudent to try to push systolic pressures below 140 mm Hg in the elderly, and Dr. Graves takes the position that physicians like Dr. Norenberg have been “too slow to adapt to evidence-based guidelines for quality of care.” I would like to focus on Dr. Graves’ reference to evidence-based guidelines for the treatment of systolic hypertension in the elderly.

Although there have been multiple published studies of the treatment of this disorder, none has achieved an average systolic blood pressure lower than 140. The Systolic Hypertension in the Elderly Program (SHEP)⁴ came closest with a final systolic blood pressure of 144. No study has ever documented the efficacy and safety of achieving systolic blood pressures less than 140 in a cohort of elderly patients, and there is substantial evidence that excessive lowering of diastolic blood pressure can be harmful.^5,6

Many elderly patients can achieve the target referenced by Dr. Graves, and it is reasonable to expect physicians to continue to strive for that goal, but it would be unwise to push all seniors below 140 systolic. Consider the elderly patient with systolic hypertension who is on a robust three-drug regimen including a diuretic, with a blood pressure of 144/60 and with persistent but tolerable drug side effects. I am aware of no clinical trials that demonstrate that further lowering of this patient’s blood pressure would provide incremental benefit to outweigh the potential risks and costs of additional medications.

We need to be careful not to confuse evidence-based medicine with high-placed opinions, which can result in rigid approaches to treatment that are not in the best interest of our patients.

To the Editor: I read with interest the exchange of letters between Drs. Norenberg and Graves in the December 2007 issue,^1,2 which followed Dr. Graves’ article in the October 2007 issue.³ Dr. Norenberg suggests that it is not always prudent to try to push systolic pressures below 140 mm Hg in the elderly, and Dr. Graves takes the position that physicians like Dr. Norenberg have been “too slow to adapt to evidence-based guidelines for quality of care.” I would like to focus on Dr. Graves’ reference to evidence-based guidelines for the treatment of systolic hypertension in the elderly.

Although there have been multiple published studies of the treatment of this disorder, none has achieved an average systolic blood pressure lower than 140. The Systolic Hypertension in the Elderly Program (SHEP)⁴ came closest with a final systolic blood pressure of 144. No study has ever documented the efficacy and safety of achieving systolic blood pressures less than 140 in a cohort of elderly patients, and there is substantial evidence that excessive lowering of diastolic blood pressure can be harmful.^5,6

Many elderly patients can achieve the target referenced by Dr. Graves, and it is reasonable to expect physicians to continue to strive for that goal, but it would be unwise to push all seniors below 140 systolic. Consider the elderly patient with systolic hypertension who is on a robust three-drug regimen including a diuretic, with a blood pressure of 144/60 and with persistent but tolerable drug side effects. I am aware of no clinical trials that demonstrate that further lowering of this patient’s blood pressure would provide incremental benefit to outweigh the potential risks and costs of additional medications.

We need to be careful not to confuse evidence-based medicine with high-placed opinions, which can result in rigid approaches to treatment that are not in the best interest of our patients.