BACKGROUND: In oldest-old patients (>80), few trials showed efficacy of treating hypertension and they included mostly the healthiest elderly. The resulting lack of knowledge has led to inconsistent guidelines, mainly based on systolic blood pressure (SBP), cardiovascular disease (CVD) but not on frailty despite the high prevalence in oldest-old. This may lead to variation how General Practitioners (GPs) treat hypertension. Our aim was to investigate treatment variation of GPs in oldest-olds across countries and to identify the role of frailty in that decision. METHODS: Using a survey, we compared treatment decisions in cases of oldest-old varying in SBP, CVD, and frailty. GPs were asked if they would start antihypertensive treatment in each case. In 2016, we invited GPs in Europe, Brazil, Israel, and New Zealand. We compared the percentage of cases that would be treated per countries. A logistic mixed-effects model was used to derive odds ratio (OR) for frailty with 95% confidence intervals (CI), adjusted for SBP, CVD, and GP characteristics (sex, location and prevalence of oldest-old per GP office, and years of experience). The mixed-effects model was used to account for the multiple assessments per GP. RESULTS: The 29 countries yielded 2543 participating GPs: 52% were female, 51% located in a city, 71% reported a high prevalence of oldest-old in their offices, 38% and had >20 years of experience. Across countries, considerable variation was found in the decision to start antihypertensive treatment in the oldest-old ranging from 34 to 88%. In 24/29 (83%) countries, frailty was associated with GPs' decision not to start treatment even after adjustment for SBP, CVD, and GP characteristics (OR 0.53, 95%CI 0.48-0.59; ORs per country 0.11-1.78). CONCLUSIONS: Across countries, we found considerable variation in starting antihypertensive medication in oldest-old. The frail oldest-old had an odds ratio of 0.53 of receiving antihypertensive treatment. Future hypertension trials should also include frail patients to acquire evidence on the efficacy of antihypertensive treatment in oldest-old patients with frailty, with the aim to get evidence-based data for clinical decision-making.

Centre for Primary Health Care Basel Switzerland

Danish College of General Practitioners Copenhagen Denmark

Department for Family Medicine Medical faculty University of Ljubljana Ljubljana Slovenia

Department of Clinical Sciences in Malmö Centre for Primary Health Care Research Lund University Malmö Sweden

Department of Family Medicine Institute of Family Medicine at Shupyk National Medical Academy of Postgraduate Education Kiev Ukraine

Department of Family Medicine Semmelweis University Budapest Hungary

Department of General Internal Medicine Inselspital Bern University Hospital University of Bern Bern Switzerland

Department of General Practice and Family Medicine Center for Public Health Medical University of Vienna Vienna Austria

Department of General Practice University of Tampere Tampere Finland

Department of Nephrology and Department of Family Medicine University Clinical Centre University St Cyril and Metodius Skopje Macedonia

Department of Public Health and Primary Care Leiden University Medical Center Hippocratespad 21 2333 ZD Leiden The Netherlands

Faculty of Medicine Department of Family Medicine Riga Stradiņs University Riga Latvia

Family Doctor Invited Assistant of the Department of Family Medicine NOVA Medical School Lisbon Portugal

Family Medicine Department Health Center Tuzla Medical School University of Tuzla Tuzla Bosnia and Herzegovina

Family Medicine Department of Clinical Sciences Lund University Malmö and senior researcher Region Kronoberg Växjö Sweden

Family Medicine Department Wroclaw Medical University Wrocław Poland

Family Medicine Specialist Kemaliye Town Hospital Erzincan University Erzincan Turkey

Hospital Israelita Albert Einstein São Paulo Brazil

Institute for Health and Behaviour Research Unit INSIDE University of Luxembourg Luxembourg Luxembourg

Institute of Family Medicine Lausanne Lausanne Switzerland

Institute of General Practice Goethe University Frankfurt Main Germany

Institute of Primary and Community Care Lucerne Lucerne Switzerland

Institute of Primary Care University Hospital Zurich University of Zurich Zurich Switzerland

Institute of Primary Health Care University of Bern Bern Switzerland

Irish College of General Practitioners Dublin Ireland

Leeds Centre for Respiratory Medicine St James's University Hospital Beckett Street Leeds LS9 7TF UK

LIMICS INSERM U1142 F 75006 Paris Université Paris 13 Sorbonne Paris Cité UMR_S 1142 F93000 Bobigny Sorbonne Universités UPMC Université Paris 06 UMR_S 1142 F75006 Paris Paris France

Ordinace Řepy s r o Prague Prague Czech Republic

Primary Care and Health Sciences Keele University Keele Staffordshire ST5 5BG UK

Primary Care Unit Faculty of Medicine University of Geneva Geneva Switzerland

Research Unit for General Medicine and Primary Health Care Faculty of Medicine School of Health Sciences University of Ioannina Ioannina Greece

Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel

School of Population Health University of Auckland Auckland New Zealand

SNAMID Prata Sannita Italy

SSLMG Societé Scientifique Luxembourgois en Medicine generale Luxembourg Luxembourg

Timis Society of Family Medicine Sano Med West Private Clinic Timisoara Romania

Vennesla Primary Health Care Centre Bergen Norway

Zobrazit více v PubMed

Wilson PW. Established risk factors and coronary artery disease: the Framingham study. Am J Hypertens. 1994;7(7 Pt 2):7S–12S. doi: 10.1093/ajh/7.7.7S. PubMed DOI

Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhager WH, Bulpitt CJ, de Leeuw PW, Dollery CT, Fletcher AE, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The systolic hypertension in Europe (Syst-Eur) trial investigators. Lancet. 1997;350(9080):757–764. doi: 10.1016/S0140-6736(97)05381-6. PubMed DOI

Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, Stoyanovsky V, Antikainen RL, Nikitin Y, Anderson C, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887–1898. doi: 10.1056/NEJMoa0801369. PubMed DOI

Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA. 1991, 265(24):3255–3264. PubMed

The United Nations: World Population Prospects: The 2012 Revision. Available at http://esa.un.org/unpd/wpp. Accessed 31 Mar 2017.

Messerli FH, Sulicka J, Gryglewska B. Treatment of hypertension in the elderly. N Engl J Med. 2008;359(9):972–973. PubMed

Hypertension EETFftMoA: 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. Journal of hypertension 2013, 31(10):1925–1938. PubMed

Kennedy PJ, Leathley CM, Hughes CF. Clinical practice variation. Med J Aust. 2010;193(8 Suppl):S97–S99. PubMed

den Elzen WP, Lefebre-van de Fliert AA, Virgini V, Mooijaart SP, Frey P, Kearney PM, Kerse N, Mallen CD, McCarthy VJ, Muth C, et al. International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey. Br J Gen Pract. 2015;65(631):e121–e132. doi: 10.3399/bjgp15X683569. PubMed DOI PMC

http://www.woncaeurope.org/, Accessed 31 Mar 2017.

http://www.egprn.org/, Accessed 31 Mar 2017.

http://vdgm.woncaeurope.org/, Accessed 31 Mar 2017.

World Medical A World medical association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191–2194. doi: 10.1001/jama.2013.281053. PubMed DOI

Sternberg SA, Wershof Schwartz A, Karunananthan S, Bergman H, Mark Clarfield A. The identification of frailty: a systematic literature review. J Am Geriatr Soc. 2011;59(11):2129–2138. doi: 10.1111/j.1532-5415.2011.03597.x. PubMed DOI

Pfeffer MA, McMurray JJ. Lessons in uncertainty and humility - clinical trials involving hypertension. N Engl J Med. 2016;375(18):1756–1766. doi: 10.1056/NEJMra1510067. PubMed DOI

Williamson JD, Supiano MA, Applegate WB, Berlowitz DR, Campbell RC, Chertow GM, Fine LJ, Haley WE, Hawfield AT, Ix JH, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged >/=75 years: a randomized clinical trial. JAMA. 2016;315(24):2673–2682. doi: 10.1001/jama.2016.7050. PubMed DOI PMC

Zhang XE, Cheng B, Wang Q. Relationship between high blood pressure and cardiovascular outcomes in elderly frail patients: a systematic review and meta-analysis. Geriatr Nurs. 2016; PubMed

Materson BJ, Garcia-Estrada M, Preston RA. Hypertension in the frail elderly. J Am Soc Hypertens. 2016;10(6):536–541. doi: 10.1016/j.jash.2016.03.187. PubMed DOI

van Peet PG, Drewes YM, Gussekloo J, de Ruijter W. GPs' perspectives on secondary cardiovascular prevention in older age: a focus group study in the Netherlands. Br J Gen Pract. 2015;65(640):e739–e747. doi: 10.3399/bjgp15X687373. PubMed DOI PMC

Mermans E, Degryse J, Vaes B. Treatment intentions of general practitioners regarding hypertension in the oldest old: a vignette study. BMC Fam Pract. 2016;17(1):122. doi: 10.1186/s12875-016-0523-y. PubMed DOI PMC

McAvoy BR, Kaner EF. General practice postal surveys: a questionnaire too far? BMJ. 1996;313(7059):732–733. doi: 10.1136/bmj.313.7059.732. PubMed DOI PMC

Hyman DJ, Pavlik VN. Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine. Arch Intern Med. 2000;160(15):2281–2286. doi: 10.1001/archinte.160.15.2281. PubMed DOI

Kellerman SE, Herold J. Physician response to surveys. A review of the literature. Am J Prev Med. 2001;20(1):61–67. doi: 10.1016/S0749-3797(00)00258-0. PubMed DOI

Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50(10):1129–1136. doi: 10.1016/S0895-4356(97)00126-1. PubMed DOI

Prescriptions of Essentially Placebo Treatments Among General Practitioners in 21 Countries

General practitioners' deprescribing decisions in older adults with polypharmacy: a case vignette study in 31 countries

Patient Characteristics and General Practitioners' Advice to Stop Statins in Oldest-Old Patients: a Survey Study Across 30 Countries

Burden of cardiovascular disease across 29 countries and GPs' decision to treat hypertension in oldest-old