Should we start or maintain treatment for hypertension in elderly people with diabetes?

Bernard BAUDUCEAU*, Lyse BORDIER*, Béatrice DULY-BOUHANICK**, *Endocrinology department of the Bégin Army Training Hospital, Saint-Mandé, **Arterial hypertension and therapeutic department, Rangueil University Hospital, Toulouse

Definition of hypertension Whether people are diabetic or not, the definition of hypertension is identical, but differs depending on the measurement methods. However, due to the age-related increase in arterial stiffness, hypertension is predominantly systolic in these individuals. The white coat effect increases with age and must be detected to avoid overtreatment, a source of falls, especially since elderly diabetic patients are particularly exposed to orthostatic hypotension. With clinical measurement of blood pressure (BP), hypertension is defined in the medical office by a systolic blood pressure (SBP) ≥ 140 mmHg and/or a diastolic blood pressure (DBP) ≥ 90 mmHg. These measurements taken in a seated position must be observed several times unless the BP exceeds 180/110 mmHg or when the cardiovascular risk is high, which requires rapid treatment (figure 1). Figure 1. 2021 European Society of Hypertension recommendations for in-office and out-of-office blood pressure measurement – Guidelines_measurement_PA_translated_Vedf 23 11 2021 (sfhta.eu). To rule out white coat hypertension that is not amenable to any drug treatment and to monitor the effectiveness of the treatment, an ambulatory BP assessment is recommended. It is practiced in two ways, self-measurement of blood pressure (AMT) which is preferred by the French authorities and ambulatory measurement of blood pressure (MAPA). AMT with a validated device using a humeral cuff is recommended. It must be the subject of therapeutic education, both to explain the rhythm of the measurements 3 times in the morning at 1 minute intervals and 3 times in the evening 3 days in a row, as well as to explain how to calculate the average of its 18 measures. These optimal recommendations need to be adapted to the condition of the person or those around them. Validated measuring devices are listed on the European STRIDE-BP website. The SBP and DBP thresholds defining hypertension are then greater than 135/85 mmHg. ABPM makes it possible to assess the variability of BP over 24 hours, but also to measure nocturnal BP. It cannot be repeated too often due to the inconvenience it sometimes causes and the lack of availability of devices. The BP threshold values ​​which define hypertension are > 135/85 mmHg during the day and > 120/70 at night and > 130/80 over 24 hours. The combination of these different measurement methods makes it possible to differentiate 4 situations depending on the consistency or otherwise of the results of these techniques (figure 2). Figure 2. The 4 blood pressure statuses defined by the different measurement techniques. Frequency of hypertension In mainland France, hypertension is the most common chronic disease affecting 17 million people aged over 18. Its prevalence increases very significantly with age, rising, according to health insurance, from around 3% in the 30-39 age group to 70% over the age of 80 with a slight male predisposition. These figures are even higher in the DROM (overseas department and region), particularly among women(2). During diabetes, which affects 1 in 5 men and 1 in 6 women at age 75, the frequency of hypertension is particularly high, reaching nearly 90% in the GERODIAB study, whose patients at inclusion were on average elderly. of 77.1 years(3). Hypertension is sometimes ignored in the absence of symptoms, which has given it the label of silent killer, so much so that in France, a third of patients are unaware of their hypertension. The recommendations stipulate to organize screening not systematically, because this is not possible, but opportunistically. Therefore, BP must be measured at each consultation, whatever the reason, particularly in elderly people with diabetes. A major cardiovascular risk factor Among modifiable cardiovascular risk factors such as diabetes, dyslipidemia, smoking and a sedentary lifestyle, hypertension certainly plays a leading role as all epidemiological studies attest. It is also an essential cause of heart or kidney failure and contributes to the onset of dementia. The combination of diabetes and hypertension significantly increases the occurrence of cardiovascular complications, as all studies have demonstrated(4). An updated cardiovascular risk score called SCORE2 and that adapted to diabetic people SCORE2-Diabetes have been proposed taking into account SBP. These scales estimate the 10-year risk of fatal and non-fatal events (myocardial infarction, stroke) in apparently healthy people aged 40 to 69 years, with untreated risk factors or stable for a long time(5). As this assessment cannot be applied to very elderly people, the SCORE2-Older Persons (SCORE2-OP) algorithm is proposed in this context by the European Society of Cardiology (ESC). If hypertension intervenes preferentially on the risk of stroke, its deleterious role is also exerted with hypercholesterolemia at the coronary level and on the lower limbs with tobacco. Diabetes, for its part, occurs at all levels of the vascular tree in the context of macroangiopathy. Thus, in a Swedish study of 187,106 type 2 diabetic patients aged 140/90 mmHg according to the 2023 Recommendations of the European Society of Arterial Hypertension (ESH) and the European Society of Nephrology (7). The thresholds for initiation of treatment, but also the therapeutic objectives are a little different in the elderly, in particular because of the risk of orthostatic hypotension and arterial stiffness which leads to a preferential rise in SBP. In very elderly people over 80 years old, the decision is individualized and this threshold is generally set at 160/90 mmHg. In this context, health and diet measures must be adapted to the person, particularly with regard to sodium intake, in order to avoid the risk of malnutrition. Blood pressure objectives The blood pressure objectives proposed by the different learned societies are generally consistent, whether people are diabetic or not. However, certain recommendations stand out marginally on a few figures (table). For the ESH, the BP objectives are as follows: – for the general population aged 18 to 64: 150 mmHg translates into a reduction in myocardial infarction by 26% and cardiovascular mortality by 25%; – treat for a baseline SBP of 140-150 mm Hg, is associated with a reduction in myocardial infarction of 16%; – conversely, initiate treatment if the PAS is