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Management of Hypertension in the Elderly. Leslie Bittner, Pharm.D ., BCPS Leslie.bittner@va.gov NEONP Conference April 25, 2014. Disclosure. No conflicts of interest to disclose. Objectives. Describe impact of hypertension (HTN) on the elderly
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Management of Hypertension in the Elderly Leslie Bittner, Pharm.D., BCPS Leslie.bittner@va.gov NEONP Conference April 25, 2014
Disclosure • No conflicts of interest to disclose
Objectives • Describe impact of hypertension (HTN) on the elderly • Review evidence for management of HTN in the elderly • Discuss treatment goals and medication recommendations from current guidelines • Assess limitations to achieving treatment goals • Apply to a patient case
Prevalence and Outcomes • Number of elderly Americans expected to increase • Prevalence of HTN increases with age • Framingham Heart Study • 90% with normal blood pressure (BP) at age 55 years went on to develop hypertension • Multiple end-organ effects • Cardiovascular disease, cerebrovascular disease, kidney disease, eye impairment Lloyd-Jones D. Circulation. 2009;119:e21-181 Aronow WS. Circulation. 2011;123:2434-2506
Pathophysiology of HTN in the Elderly Isolated systolic HTN O’Rourke MF.J Am Coll Cardiol. 2007 Jul 3;50(1):1-13. Epub 2007 Jun 18. Aronow WS. Circulation. 2011;123:2434-2506.
Isolated Systolic HTN • Increasing prevalence with age • 65% with HTN > 60 years old • 90% with HTN > 70 years old • Changes related to aging have been noted to be lesser in populations NOT exposed to: • High-sodium diet • High-calorie diet • Low physical activity • High rates of obesity Aronow WS. Circulation. 2011;123:2434-2506.
Other Factors to Consider in the Elderly • Decreased baroreflex function • Increased venous insufficiency • Increased salt sensitivity • Renal dysfunction • Lifestyle Factors • Substance use (tobacco, alcohol, caffeine, etc.) • High-salt diet • NSAID use Aronow WS. Circulation. 2011;123:2434-2506
Systolic Hypertension in the Elderly Program (SHEP) • Multicenter, randomized, double-blind, placebo controlled • 4,736 patients, ≥ 60 years with isolated systolic HTN • Mean age = 72 years • Baseline Average SBP = 170mmHg; Average DBP = 77mmHg • Target SBP < 160mmHg if SBP > 180mmHg and goal to decrease SBP by at least 20mmHg if SBP 160-170mmHg • Intervention: • Chlorthalidone 12.5mg – 25mg/day vs. Placebo • Chlorthalidone could be doubled, then atenolol could be added to achieve target if needed (reserpine was used if atenolol was contraindicated) • Primary Outcome: Nonfatal and fatal stroke • Average follow-up = 4.5 years SHEP Research Group. JAMA. 1991;265:3255-3264.
Systolic Hypertension in the Elderly Program (SHEP) • Results • Total stroke: relative risk 0.64 (95% CI 0.50 – 0.82) • Nonfatal myocardial infarction + coronary death: relative risk 0.73 (95% CI 0.57 – 0.94) • Study Conclusion • Decreasing blood pressure using low-dose chlorthalidone as initial medication showed reduced risk of stroke and cardiovascular events over a 5-year follow-up SHEP Research Group. JAMA. 1991;265:3255-3264.
Hypertension in the Very Elderly Trial (HYVET) • Multicenter, randomized, double-blind, placebo controlled • 3845 patients, ≥ 80 years with SBP ≥ 160mmHg • Mean age = 83.6 years • Baseline average BP = 173/90.8mmHg • Intervention: • Diuretic (indapamide) vs. Placebo • Perindopril may be added to achieve target BP <150/80 mmHg • Primary Outcome: Nonfatal and fatal stroke Beckett NS, et al. N Engl J Med. 2008;358:1887-98
Hypertension in the Very Elderly Trial (HYVET) • Results • Study Conclusion • Trial ended early due to benefits seen at interim analysis • Treatment with indapamide +/- perindopril to a treatment goal of < 150/80mmHg in a very elderly population showed reduced risk of death from stroke and overall mortality. Beckett NS, et al. N Engl J Med. 2008;358:1887-98
Literature Review:Other Key Evidence Guiding Treatment Choices
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) • Randomized, double-blind, active control trial • > 33,000 enrolled, ≥ 55 years old with hypertension • Interventions: • Chlorthalidone vs. Amlodipine vs. Lisinopril vs. Doxazosin • Outcome: Combined fatal CHD or non-fatal MI • Results • Doxazosin arm terminated early • Thiazide found to be superior in preventing 1 or more forms of cardiovascular disease and has low cost considered 1st line ALLHAT Study Group. JAMA. 2002;288:2981-97.
ACCOMPLISH • Randomized, double-blind study • 11,506 enrolled, ≥ 55 years with HTN & high risk for cardiac event • Intervention: • Benazepril + Amlodipine vs. Benazepril + Hydrochlorothiazide • Target BP < 140/90mmHg (or 130/80mmHg if diabetes or kidney disease) • Primary outcome: Composite of cardiovascular (CV) disease states • Results • Study terminated early at interim analysis • Benazepril + amlodipine combination was superior in reducing CV events Jamerson KA, et al. N Engl J Med. 2008;359:2417-28.
Relationship Between BP and Cardiovascular Outcome (from INVEST) Denardo S. Am J Med. 2010;123:719-26.
Systolic Blood Pressure Intervention Trial (SPRINT) • STUDY UNDERWAY • Study Question: "Will lower blood pressure reduce the risk of heart and kidney diseases, stroke, or age-related declines in memory and thinking?” • Will compare SBP target <120mmHg vs. 140mmHg • SUBGROUPS: • SPRINT – MIND will look at memory and cognition • SPRINT – SENIOR Will include patients 75 and older https://www.sprinttrial.org
Target Blood Pressure Recommendations * If treatment lowers BP further (for example SBP < 140), but no adverse effects or quality of life impact – no need to adjust treatment James PA. JAMA. 2014;311(5):507-520.
Trial lifestyle modification and continue throughout • Medication selection *Guideline states no evidence for use in age > 75; may be beneficial in age group but THIAZ or CCB also option **Avoid use of ACE-I and ARB together James PA. JAMA. 2014;311(5):507-520.
Some key changes from JNC 7 Guidelines Chobanian AV. JAMA. 2003;289:2560-2572. James PA. JAMA. 2014;311(5):507-520.
Elderly – specific guidelines * “In those elderly patients in whom a SBP < 150mmHg is readily and safely obtained with just 1 or 2 drugs, a further modest intensification of treatment to achieve a value < 140mmHg could be considered, even though there is no firm evidence to support this target.” ** “There is no evidence in older people to support the use of lower BP targets in patients at high risk because of conditions such as diabetes mellitus, CKD, or CAD.” • Special circumstances for SBP goal of ≥ 150mmHg: • Already on 4 well-selected and appropriately dosed drugs • Unacceptable side effects, especially postural changes • DBP drops to ≤ 65 in effort to achieve SBP goal Aronow WS. Circulation. 2011;123:2434-2506
Consider general health & frailty when deciding whether to treat • Trial lifestyle modification first • Medication selection in the general population Aronow WS. Circulation. 2011;123:2434-2506
Special Population Treatment Recommendations Aronow WS. Circulation. 2011;123:2434-2506
The Statistics • Almost half of patients become non-adherent to their antihypertensive medication within 1 year of initiating therapy • In patients with hypertension, 10% of poor compliance was due to adverse effects of prescribed medication Aronow WS. Circulation. 2011;123:2434-2506 Choudry NK. Circulation. 2011;123:1584-1586.
What may influence a patient? • Adverse effects (actual or fear of experiencing) • Complexity of therapeutic regimen • Cognitive impairment • Misperceptions of benefits or risks of treatment • Poor provider–patient relationship • Cost • Difficulties accessing physicians or pharmacies Aronow WS. Circulation. 2011;123:2434-2506 Choudry NK. Circulation. 2011;123:1584-1586.
Adverse Effects Aronow WS. Circulation. 2011;123:2434-2506
Ways to Help Promote Adherence • ASK: about adherence and any difficulties the patient may be having with their medication • CONSIDER: possible patient concerns such as complexity or cost. Try to use once – daily regimens and lower cost generics/formulary items if able. • REMIND: the patient about possible, but transient side effects to reduce unnecessary discontinuation Choudry NK. Circulation. 2011;123:1584-1586.
Equip Patients with Equipment • Assess if patient may benefit from equipment. Make recommendations or supply if possible. • Pillbox to help manage medications • Pill splitter if regimen calls for halving tablets • Pill crusher if unable to swallow whole tablets • Blood pressure cuff to monitor home pressures • If patient expresses concerns with remembering, try to tie dosing to another routine daily event
Consider the Risk for Polypharmacy • Always monitor for the prescribing cascade • Pain NSAID started Develops HTN Anti-HTN started • HTN + Hx Gout HCTZ started Gout flare Allopurinol • Ask patients to bring medication bottles and any list to their visits including any herbals or vitamins • “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” Rochon PA. BMJ 1997;315:1096–9. Gurwitz J. Long-Term Care Quality Letter. Providence (RI): Brown University, 1995.
Case Study • BB is an 82 year old African American male presenting to your outpatient clinic for a follow-up. Initial blood pressure on presentation is 170/90. • Past Medical History • Dyslipidemia • Benign prostatic hyperplasia • Hypertension • Diabetes • Current medications: • Glipizide 5mg daily • Terazosin 4mg at bedtime • Atorvastatin 10mg at bedtime • Aspirin 81mg daily
Question 1 • On recheck BB’s blood pressure is 172/90 • What would be your threshold for initiation of pharmacotherapy for BB? • A. 130/80 • B. 140/90 • C. 150/90
Question 2 • Based on multiple, appropriately checked blood pressures above threshold and a trial of lifestyle modification, you decide to treat. • Which treatment option would you choose? • A. Increase terazosin • B. Hydrochlorothiazide • C. Lisinopril + Hydrochlorothiazide • D. Lisinopril + Amlodipine • E. Amlodipine + Hydrochlorothiazide • F. Lisinopril + Losartan
Question 3 • BB expresses concerns regarding managing his new medications at home. • What suggestions can you make to help him to remember to take his medications?
Question 4 – Part 1 • After several weeks on therapy, BB telephones you to follow-up with home BP readings. • He reports the following: • 140/68, 145/72, 146/80, 142/76 • What other questions would you want to ask BB before making decisions regarding treatment?
Question 4 – Part 2 • What is your response to BB’s blood pressure readings from home? • A. Blood pressures are at target, continue therapy • B. Blood pressures not yet at target, titrate therapy • C. Blood pressures too low, decrease dose
Summary of Guidelines and Evidence • Treatment of hypertension in the very elderly has shown significant benefits on stroke and cardiovascular risk • A treatment threshold of 150/90 appears to be reasonable in the elderly • Thiazide diuretic remains a good first-choice option for most • Lowering blood pressure likely more important than choice of add-on agent • Start low and go slow, monitor closely for adverse effects • Consider factors which may impact adherence to medication when choosing the initial medication and add-on therapies
References • Lloyd-Jones D, Adams R, Carnethon M, et al. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119:e21–181. • Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly: A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2011;123:2434-2506. • O’Rourke MF, Hashimoto J. Mechanical Factors in Arterial Aging: a Clinical Perspectives. J Am Coll Cardiol. 2007 Jul 3;50(1):1-13. Epub 2007 Jun 18. • SHEP Cooperative Research Group. 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). JAMA. 1991; 265 (24):3255-64. • Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898. • ALLHAT Study Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. JAMA. 2002;288:2981–97.
References • Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008;359:2417–28. • Denardo S, Gong Y, Nichols WW, et al. Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. Am J Med. 2010;123:719 –26. • Systolic Blood Pressure Intervention Trial. Sprint Trial Website. http://www.sprinttrial.org. Accessed April 1, 2014. • James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. • Chobanian AV, Bakris GL, Black HR, et al. and the National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572. • Choudry NK. Promoting Persistence: Improving Adherence Through Choice of Drug Class. Circulation. 2011;123:1584-1586. • Rochon PA, Gurwitz JH. Optimizing Drug Treatment for Elderly People: the Prescribing Cascade. BMJ. 1997; 315: 1096-9. • Gurwitz J, et al. Long-Term Care Quality Letter. Providence (RI): Brown University, 1995.
Management of Hypertension in the Elderly Leslie Bittner, Pharm.D., BCPS Leslie.bittner@va.gov NEONP Conference April 25, 2014