Transcript HYPERTENSION IN ELDERLY

HYPERTENSION IN ELDERLY
Dr. Kunal Kothari
Emeritus Professor of Medicine and Clinical Cardiology
Director Primary Health Care and Strategic initiative
HYPERTENSION
S
L O W
I
K
I
L
E
N
T
L E R
200

180
160
140
A sharp thump
120
A blowing or whooshing sound
100
A softer thump
80
A softer blowing sound
K1
K2
K3
K4



60

40
20
0
K5
Sphygmanometersize of the cuffs
Food
Exercise
Caffeine
Smoking
Benefits of Lowering Blood
Pressure
Antihypertensive Therapy has been
associated with reductions in:

Stroke Incidence (35-40 %).

MI (20-25 %).

Heart Failure ( averaging > 50 %).
Guidelines
The Seventh Report of the Joint National Committee on
Detection, Evaluation, and Treatment of High Blood
Pressure (JNC VII) uses the following guidelines to
define HTN in adults:
Category
Systolic
Normal
<120
120-139
140-159
>160
Pre-hypertension
Stage 1 hypertension
Stage 2 hypertension
Diastolic
and
or
or
or
<80
85-89
90-99
>100
Clinic
Pressure
White Coat
Hypertension
Sustained
Hypertension
True
Normotension
Masked
Hypertension
140/90
135/85
Ambulatory Pressure
Pseudo Hypertension


Recording of high B.P. but do not have
Common cause of this is brachial artery
compression
WHITE COAT
HYPERTENSION


BP recording in office or clinic is high
while at home is normotensive
"white coat" hypertension appear to
have no greater risk than people with
normal blood pressure ( Aug. 2, 2005, American
college of cardiology )
MASKED HYPERTENSION
Proposed the term masked hypertension
Pickering et al (Hypertension 2002;102:113944)
Documented by Ohkubo et al (N Engl J Medicine
2003;348:2407-15)
MASKED HYPERTENSION



HYPERTENSION IS NOT DETECTED BY THE ROUTINE
METHODS. "UNDETECTED AMBULATORY
HYPERTENSION"
UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW
CLINIC PRESSURE ON THAT PARTICULAR OCCASION
SHOW MORE EXTENSIVE TARGET ORGAN DAMAGE
THAN TRUE NORMOTENSIVE SUBJECTS
Blood Pressure in 347,978 men aged
35-57 screened for MRFIT
¼
35
½
30
% of
Men
28
23
25
19
20
15
10
¼
13
7
6.5
5
0
<110
110-119 120-129
5
130-139 140-149 150-159 >160
Systolic pressure mmHg
Lifetime Risk of Developing
Hypertension in Middle Aged
(Vasan et al, JAMA 2002; 287: 1010)
Risk for Hypertension in a 55 year old
Time, yr
10
15
20
25
Women
52%
72%
83%
91%
Men
56%
78%
88%
93%
Diagnostic Evaluation of the Hypertensive
Patient- How much is enough?

How high is the blood pressure?

Why is it high?

What is the risk?
Clinical Manifestations I
Physical exam:
Abdomen
Funduscopic
Vascular
Cardiac
Pulmonary
Neurological
Lab tests:
Urinalysis
Blood Chemistry
ECG
Renal ultrasound
Echocardiogram
Vascular studies
Differential Diagnosis
1.
2.
Rule out isolated incident of increased blood
pressure.
Rule out secondary hypertension related to:
Renal disease
Cushing's disease
Pheochromocytoma
Hyperthyroidism
Hyperparathyroidism
Complications
Complications as a result of HTN include:
Stroke
Dementia
Myocardial Infarction
Congestive Heart Failure
Retinal Vasculopathy
Aortic Dissection
Renal Disease or Failure
Management
Medications
Diuretics- Thiazides (HCTZ), Loop (Furosemide), Potassiumsparing (Spironolactone)
Beta-Blockers- Atenolol, Nadolol, Propranolol
ACE Inhibitors- Benezapril, Captopril, Cilizapril
ARBs- Losartan, Valsartan
Ca+ Channel Blockers- Nifedipine, Verapamil
Alpha blockers- Prazosin, Terazosin
Vasodilators- Apresoline
Management
Primary goal is to reduce cardiovascular
and renal morbidity and mortality.
Other keys to management are:
Prevention
Patient education
Life-style modification
Medication
Hospitalization should be
considered if
Very high BP
Severe headache
Chest pain
Neurologic symptoms
Altered mental status
Acutely worsening renal failure
S & S of hypertensive emergency
DOES ELDERLY
HYPERTENSION HAVE
SPECIFIC CHARACTERISTICS?
CHARACTERISTICS OF HYPERTENSION
IN THE ELDERLY
Increased
Systolic blood pressure and pulse pressure
Left ventricular mass and wall thickness
Arterial stiffness
Calculated total peripheral resistance
Decreased
Cardiac output and heart rate
Renal blood flow, plasma renin activity, and angiotensin II levels
Arterial compliance and blood volume
Diastolic blood pressure
Black H. JCH 2003; 5:12
Arterial Wall Compliance and Pulse Pressure Wave
Elastic Vessel
Systole Diastole
Stiff Vessel
Systole Diastole
Stroke Volume
Aorta
Resistance
Arterioles
Pressure (Flow)
Young Artery
Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.
Arteriosclerotic Artery
Do lifestyle measures really
work for elderly hypertension?
Lifestyle Modifications
Modification
Weight Reduction
Adopt DASH eating plan
Approximate SBP
Reduction
(range)
5-10 mmHg/10kg
8-14 mmHg
Dietary sodium reduction
2-8 mmHg
Physical activity
4-9 mmHg
Moderation of alcohol
consumption
2–4 mmHg
Change in Mean Arterial Blood Pressure
4
2
0
-2
-4
-6
-8
-10
-12
-14
-16
-18
-20
20-30
31-40
41-50
51-60
>60
AGE [yrs]
We inbe r ge r M. Hy p e rte ns 1991; 18:69
Bar graph shows change in mean arterial blood pressure used to define salt responsivity
as a function of age in normotensive [open bars] and hypertensive [color bars] subjects.
Weinberger M. Hypertens 1991; 18:69
Effect of 30 minute walk 3 days a week
Age 70 - 79
Systolic
Diastolic
Baseline
156 ± 10 mm Hg
86 ± 8 mm Hg
3 months
151 ± 15 mm Hg
80 ± 6 mm Hg
Baseline
153 ± 7 mm Hg
85 ± 8 mm Hg
3 months
156 ± 10 mm Hg
85 ± 6 mm Hg
Exercise Group
Control Group
Conone et al. Med Scl in Sports and Exercise. 1991
What is the effect of drug
therapy related to age? Are the
recommendations different?
Antihypertensive Drugs
AACEI, ARBs
Dlow dose HCTZ
BBeta Blocker
A
CCCB
B
DDiuretic
C
Algorithm for Management of the Elderly Primarily Systolic Hypertension
1) Lifestyle changes
2) Low dose diuretic (12.5 mg HCTZ)
+
CCB
+
+
+
B-Blocker
3) Stop, Look & Listen before
Let the Baroreceptors reset
4)
Rx until goal achieved
+
ACE or ARB
dosages
ALLHAT
The Antihypertensive and Lipid Lowering
Treatment to Prevent Heart Attack Trial
(ALLHAT) suggests that low dose thiazide
diuretics have a better cardiovascular
protective effect
Result Highlights



21% reduction in relative risk death from
any cause
64% reduction relative risk heart failure
39% reduction relative risk of death from
stroke
Syst-Eur
A study called the Systolic-Hypertension
Trial in Europe (Syst-Eur) showed that
aggressive treatment of hypertension
reduces the risk of stroke by 42% and
dementia is prevented.
Trials Examining Treatment of Hypertension in the Elderly
EWPHE
MRC-Elderly
SHEP
STOP-H
Syst-China
Syst-Eur
(N = 840)
(N = 4396)
(N = 4736)
(N = 1627)
(N = 2394)
(N = 4695)
Stroke reduction, %
-36
-25
-33
-47
-38
-42
CAD change, %
-20
-19
-27
-13
+6
-26
CHF reduction, %
-22
Not stated
-55
-51
-58
-27
% of Patients receiving
35
52 (b-blocker)
44
67
11-26
26-36
combination drug therapy
38 (diuretic)
Prisant, Moser M. Arch Int Med 2000; 160:284
Major Clinical Trials Showing Benefit of Treating Isolated Systolic Hypertension
SHEP
(n=4736)
Syst-Eur
(n=4695)
Syst-China
(n=2394)
Baseline
160-219/
160-219/
160-219/
SBP/DBP (mm Hg)
<90
<95
<95
BP reduction:
27/9
23/7
20/5
Chlorthalidone
Atenolol
Nitrendipine
Enalapril
HCTZ
Nitrendipine
Captopril
HCTZ
Stroke
33
42
38
CAD
27
30
27
CHF
55
29
—
All CVR disease
32
31
25
SBP/DBP (mm Hg)
Drug therapy
Outcomes (%)
Journal of Clinical Hypertension Vol II, No. 5, page 336, September/October 2000.
Independent Predictors of Using Antihypertensives Medications in 2000
Variable
Adjusted OR (95% CI) of Using Antihypertensives
Comorbid conditions
Asthma/COPD
0.43
(0.40-0.47)
Depression
0.50
(0.45-0.55)
GI disorders
0.59
(0.54-0.64)
Osteoarthritis
0.63
(0.59-0.67)
Coronary artery disease
1.31
(1.23-1.40)
Cerebrovascular disease
1.03
(.97-1.10)
Congestive heart failure
1.05
(0.99-1.11)
Diabetes
1.16
(1.10-1.22)
Cardiovascular conditions
Wang PS et al. Hypertension 2005; 46:273-279
Barriers to Optimal Control of Hypertension
Inaccurate measurement of blood pressure (BP)
Focusing on diastolic BP rather than systolic BP goal
Failure to consider absolute global risk
Failure to advocate lifestyle modifications
Failure to use polypharmacy
Failure to use effective drug combinations
Failure to titrate doses upward
Fear of reaching excessively low diastolic BP
The patient with truly resistant hypertension
Behavioral barriers
Franklin S. JCH 2006; 8:524
What is the systolic
blood pressure goal?
Blood Pressure in SHEP and Syst-Eur (mm Hg)
Entry
SHEP
160-219/<90
Syst-Eur
160-219/<95
Goal (SBP)
<160 + ≥20 
<150 + ≥20 
Baseline
170/77
174/86
Achieved: Rx
143/68
151/79
Achieved: Placebo
155/72
161/84
Difference: Rx-Placebo
12/4
10/5
Journal of Clinical Hypertension, Vol II, No. 5, page 336. March/April 2000.
REDUCTION OF STROKES WITH BP LOWERING - SHEP TRIAL
No. of Patients:
Follow-up:
4736
4.5 years
37% in ischemic strokes
47% in lacunar infarcts
54% in hemorrhagic strokes
Lower BPs - fewer strokes
Am J Hypertension 2000;13:724-733
Hypertension in the Very Elderly Trial
NEJM 2008;358(18):1887-1898




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Double blind,
placebo-controlled
International,
multicenter
3845 patients
Mean age 83.6 yrs
BP range 160-219/90109
Mean BP 173.0/90.8





f/u median of 1.8 yrs
Primary endpoints –
fatal or non fatal
stroke
Indapamide 1.5mg
Perindopril prn (2mg
or 4mg)
Mean BP fall 15.0/6.1
at 2 yrs
Result Highlights



21% reduction in relative risk death from
any cause
64% reduction relative risk heart failure
39% reduction relative risk of death from
stroke
GOALS OF TREATMENT



To achieve a target BP of <140/ 90 mm Hg.
In patients with Hypertension & Diabetes or Renal
disease, BP Goal is < 130/80 mm Hg.
To reduce cardiovascular morbidity & mortality.
Thiazide Myths

Sulfa cross reactivity

Gout

Renal stones
Thiazide Related Gout



Thiazide related hyperuricemia is dose
related
HDFP Trial: 15 episodes of gout over 5
years in 3693 patients treated with
chlorthalidone 25-100mg (equivalent to
50-200 mg HCTZ)
Low dose thiazide (HCTZ 12.5-25 mg) is
not contraindicated in gout
Treatment Recommendations
for the Elderly in JNC 7
Recommendations are no different
according to age for:
 BP
classification
 BP
goals
 Lifestyle
interventions
 Selection
of medications
JNC 7: New Features and Key
Messages
 For persons over age 50, SBP is a more important than DBP as CVD risk
factor.
 Starting at 115/75 mmHg, CVD risk doubles with each increment of
20/10 mmHg throughout the BP range.
 Persons who are normotensive at age 55 have a 90% lifetime risk for
developing HTN.
 Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be
considered prehypertensive who require health-promoting lifestyle
modifications to prevent CVD.
Thank You
Dr. Kunal Kothari
Emeritus Professor of medicine and Clinical Cardiology
Director Primary Health care and Strategic initiative