Angiotensin Receptor Blockers in Elderly Patients
ARBs are highly appropriate first-line or combination antihypertensive agents for elderly patients with hypertension, heart failure, diabetes, or left ventricular hypertrophy, offering equivalent efficacy to ACE inhibitors with superior tolerability and fewer adverse effects. 1
Role in Hypertension Management
First-Line Therapy Considerations
ARBs are recommended as one of the preferred initial drug classes for hypertension in elderly patients, alongside thiazide diuretics, calcium channel blockers, and ACE inhibitors, based on robust cardiovascular outcome data from randomized controlled trials. 1
Thiazide diuretics or calcium channel blockers are preferred over ARBs in Black elderly patients due to superior efficacy demonstrated in clinical trials. 1
The target blood pressure for elderly patients on ARBs should be <130/80 mmHg for community-dwelling, noninstitutionalized adults ≥65 years, based on evidence from SPRINT and other major trials. 1
For patients ≥80 years, a target of <140/90 mmHg is appropriate if the lower target cannot be safely achieved, though treatment should not be discontinued simply due to age. 1
Dosing and Titration Strategy
Start ARBs at low initial doses in elderly patients (e.g., losartan 25 mg daily, valsartan 40-80 mg daily, candesartan 4 mg daily) and titrate gradually over weeks to months. 1, 2, 3
No routine dose adjustment is required based solely on age, though exposure (AUC) to ARBs like valsartan is approximately 70% higher in elderly versus young patients. 4
Reduce starting dose by 50% in patients with hepatic impairment (e.g., losartan 25 mg in mild-to-moderate hepatic dysfunction). 5
No dose adjustment is necessary for mild-to-moderate renal impairment (GFR 30-90 mL/min/1.73 m²), but ARBs should be used cautiously in severe renal impairment (GFR <30 mL/min/1.73 m²). 4, 5
Role in Heart Failure Management
Heart Failure with Reduced Ejection Fraction (HFrEF)
ARBs are appropriate alternatives to ACE inhibitors in elderly patients who cannot tolerate ACE inhibitors (typically due to cough or angioedema), though evidence for mortality reduction is less robust than with ACE inhibitors. 1, 2
Combination therapy with ARBs plus ACE inhibitors may reduce heart failure hospitalizations but does not improve overall mortality and may increase adverse events, particularly when combined with beta-blockers. 1
ARBs should be initiated at low doses after stabilization of volume status and discontinued intravenous diuretics, with gradual uptitration as tolerated. 2, 3
Heart Failure with Preserved Ejection Fraction (HFpEF)
Candesartan specifically may reduce hospitalizations in elderly patients with HFpEF, based on the CHARM-Preserved trial, though mortality benefit is uncertain. 3
ARBs can improve diastolic function by reducing afterload and promoting ventricular relaxation in elderly patients with diastolic dysfunction. 3
Special Populations and Comorbidities
Diabetes and Nephropathy
ARBs provide cardiovascular and renal protection in elderly diabetic patients and are recommended as preferred agents alongside ACE inhibitors for those with hypertension and diabetes. 1
ARBs demonstrate pronounced antiproteinuric effects and should be considered in elderly diabetic patients with microalbuminuria or overt nephropathy. 1
Left Ventricular Hypertrophy
- Losartan specifically demonstrated superior stroke reduction compared to atenolol in elderly hypertensive patients with left ventricular hypertrophy in the LIFE trial, though this benefit was not observed in Black patients. 1, 5
Tolerability and Safety Profile
Advantages Over Other Antihypertensives
ARBs have an adverse effect profile comparable to placebo, with significantly fewer side effects than ACE inhibitors, particularly regarding cough (absent with ARBs). 1, 6
ARBs cause minimal first-dose hypotension compared to ACE inhibitors, making them particularly suitable for elderly patients at risk for falls. 6, 7
ARBs have fewer drug interactions than many other antihypertensives, as most are not extensively metabolized—an important advantage in elderly patients on multiple medications. 6
Critical Monitoring Requirements
Monitor renal function and serum potassium 1-2 weeks after initiation, with each dose increase, and at least yearly in all elderly patients on ARBs. 1
Monitor for hyperkalemia especially when ARBs are combined with aldosterone antagonists, as this combination significantly increases risk. 2, 3
Measure blood pressure in both sitting and standing positions to detect orthostatic hypotension, though ARBs do not increase orthostatic hypotension or fall risk compared to standard treatment. 1
Assess for volume depletion before initiating ARBs, as hypovolemic elderly patients require lower starting doses to prevent hypotension. 5
Combination Therapy Strategies
ARBs potentiate blood pressure reduction when combined with low-dose thiazide diuretics, making this an effective two-drug regimen for elderly patients requiring combination therapy. 6
Most elderly patients require two or more antihypertensive drugs to achieve blood pressure targets, and ARBs integrate well into combination regimens. 1
Avoid combining ARBs with ACE inhibitors in routine practice unless specifically managing heart failure, as dual RAS blockade increases adverse events without clear mortality benefit. 1
Common Pitfalls and Contraindications
Do not discontinue ARBs when patients turn 80 years old if therapy is successful and well-tolerated; age alone is not a reason to stop effective treatment. 1
ARBs are absolutely contraindicated in pregnancy (can cause fetal renal failure, skull hypoplasia, and death) and should be discontinued immediately when pregnancy is detected. 4, 5
Avoid ARBs in patients with bilateral renal artery stenosis or severe volume depletion without dose adjustment and close monitoring. 5
Do not assume all ARBs are interchangeable for organ protection; specific benefits (e.g., losartan for LVH, candesartan for HFpEF) were demonstrated with particular agents at specific doses. 6