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Rudi Westendorp Dept. of Gerontology and Geriatrics

Rudi Westendorp Dept. of Gerontology and Geriatrics. agenda…. proper medical care for older people reflects in a continuous increase of life expectancy what to expect of cholesterol lowering ? how to treat hypertension in the elderly ?. life expectancy 1600-2000.

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Rudi Westendorp Dept. of Gerontology and Geriatrics

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  1. Rudi Westendorp Dept. of Gerontology and Geriatrics

  2. agenda….. • proper medical care for older people reflects in a continuous increase of life expectancy • what to expect of cholesterol lowering ? • how to treat hypertension in the elderly ?

  3. life expectancy 1600-2000 development of life expectancy at birth Science 2002;296:1029 Science 2002;296:1029

  4. the champions UN estimate 2000 UN estimate 1990 UN estimate 1980

  5. GDP driving life expectancy Science 2002;296:1029

  6. mortality decline at all ages males males females females age 80-84 newborns age 60-64 males mortality (% per year) females calendar time calendar time calendar time calendar time calendar time

  7. differences in 1st world countries OECD Health data 2004

  8. stagnation of life expectancy females males

  9. period mortality in Japan all causes (males and females) Data source: http://www.mortality.org

  10. period mortality in the US all causes (males and females) Data source: http://www.mortality.org

  11. period mortality in the Netherlands all causes (males and females) Data source: http://www.mortality.org

  12. guidelines 57 year; angina pectoris

  13. period mortality in the Netherlands ischaemic heart disease (males) Data source: Central Bureau of Statistics

  14. how are you doing ? females males

  15. period mortality in Australia all causes (males and females) Data source: http://www.mortality.org

  16. period mortality in New Zealand all causes (males and females) Data source: http://www.mortality.org

  17. agenda….. • proper medical care for older people reflects in a continuous increase of life expectancy • what to expect of cholesterol lowering ? • how to treat hypertension in the elderly ?

  18. observational studies 85 86 87 88 89 90 years

  19. risk and LDL cholesterol Arch Intern Med 2003; 163:1549

  20. LDL cholesterol, coronary heart disease and age Framingham study Adapted from: R.A. Kronmal et al in Arch Intern Med 1993

  21. cholesterol, coronary heart disease and age From van Vliet et al. Exp Gerontol 2008

  22. risk and HDL cholesterol Arch Intern Med 2003; 163:1549

  23. HDL cholesterol, coronary heart disease and age From van Vliet et al. Exp Gerontol 2008

  24. joined forces Glasgow Leiden Cork

  25. statins in old age Double-blind, randomized placebo-controlled trial in: 5804 men (48%) and women (52%; 70-82 years) • Total cholesterol 4–9 mmol/L • 50% at high risk of vascular disease • 50% with vascular disease • Good cognitive function Placebo (N=2913) Pravastatin 40 mg qd (N=2891) Average Follow-up: 3.2 years Primary Endpoint: CHD Death, Nonfatal MI, Fatal or Nonfatal Stroke PROSPER study. Lancet 2002

  26. pravastatin and vascular risk 20 Placebo Events = 473/2913 (16.2%) 15% RRR (P = 0.014) 15 10 % With Event NNT=48 Pravastatin Events = 408/2891 (14.1%) 5 0 0 1 2 3 Years PROSPER study. Lancet 2002

  27. fatal events 0.85 vascular disease 0.76 coronary events non-vascular disease 1.11 0.97 mortality 1.5 1.25 1.0 0.75 0.5 pravastatin better placebo better PROSPER study. Lancet 2002

  28. statin use, cognitive impairment and age Longitudinal studies Cross-sectional studies From van Vliet et al. Exp Gerontol 2008

  29. pravastatin and cognitive function LDT (executive function) WLT (memory) change (numbers) change (words) months stroop test (attention) stroop test (attention) change (seconds) placebo pravastatin months From: J Sheperd et al in Lancet 2002

  30. agenda….. • proper medical care for older people reflects in a continuous increase of life expectancy • what to expect of cholesterol lowering ? • how to treat hypertension in the elderly ?

  31. metanalysis of antihypertensive trials in middle age Psaty et al. JAMA 1997

  32. blood pressure and survival systolic blood pressure systolische bloodpressure 0,8 log rank p<0.001 0,6 cumulative mortality (all causes) 0,4 0,2 < 140 mmHg >= 140 mmHg <160 mmHg >= 160 mmHg 0,0 85 86 87 88 89 90 91 92 age (years) J Hypertension. 2006;24:287

  33. blood pressure and survival diastolic blood pressure 0,8 log rank p<0.001 0,6 cumulative mortality (all causes) 0,4 0,2 <70 mmHg >= 90 mmHg >=70 mmHg <90 mmHg 0,0 85 86 87 88 89 90 91 92 age (years) J Hypertension. 2006;24:287

  34. imminent heart failure 60 P<0.05 P<0.05 50 40 Stroke Volume Index (ml/min/m2) 30 20 10 120 140 160 180 200 mean systolic blood pressure (mmHg) Van bemmel et al. J Hypertension 2008

  35. reflex tachycardia P<0.001 110 100 90 80 heart rate (beats/min) 70 60 50 40 20 30 40 50 Stroke Volume Index (ml/m2) Van bemmel et al. J Hypertension 2008

  36. systolic function is conserved (HFPEF) 90 P<0.05 80 70 Left Ventricular Ejection Fraction (%) 60 50 40 30 120 140 160 180 200 220 mean systolic blood pressure (mmHg) Van bemmel et al. J Hypertension 2008

  37. bloodpressure and renal function ≤ 70 70-79 80-89 ≥ 90 mmHg n=135 n=219 n=148 n=48 P=0.01 P=0.03 P=0.32 reference J Am Soc Nephrol. 2006;17:2561

  38. HYpertension in theVery Elderly Trial Hyvet. NEJM 2008;358:1887

  39. HYpertension in theVery Elderly Trial Hyvet. NEJM 2008;358:1887

  40. metanalysis of antihypertensive trials in old age Treatment better Treatment better Control better Control better 0,0 0,2 0,4 0,6 0,8 1,0 1,2 1,4 1,6 1,8 2,0 RR 1.11; p 0.42 Cardiovascular deaths Total mortality RR 1.14; p 0.05 Major coronary events RR 0.85; p 0.45 Heart failure RR 0.56; p 0.01 Stroke RR 0.67; p 0.01 Major cardiovascular events RR 0.77; p 0.03 Lancet 1999;353:993-6.

  41. blood pressure in old age 140 / 90 organ damage _ + organ function blood pressure (mmHg)

  42. autoregulation of cerebral blood flow CBF 60 200 blood pressure (mmHg)

  43. HYVET cognition cumulative proportion with dementia (%) follow-up (years) Hyvet. Lancet Neurol NEJM 2008;7:683

  44. imaging of flow scanplane basilar artery internal carotid arteries vertebral arteries sagittal view coronal view J Magn Reson Imaging 2002;16:1

  45. perfusion of the brain J Magn Reson Imaging 2002;16:1

  46. blood pressure and cognition later in life ERGO study age 65-74 ERGO study age 75-84 Leiden 85+ study age 85 better worse better worse unpublished

  47. HYpertension in theVery Elderly Trial Hyvet. NEJM 2008;358:1887

  48. conclusions w • a gain in average life expectancy lower than 2-3 year per decade suggests ‘old age’ problems • cholesterol lowering in old age is good for the heart but not for the brain • treatment of hypertension in the elderly needs subtlety

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