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Hypertension Management for Elderly Patients

Hypertension Management for Elderly Patients. Mark A. Supiano, M.D. Professor and Chief, University of Utah Geriatrics Division Director, VA Salt Lake City GRECC Executive Director, University of Utah Center on Aging. LEARNING OBJECTIVES.

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Hypertension Management for Elderly Patients

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  1. Hypertension Management for Elderly Patients Mark A. Supiano, M.D. Professor and Chief, University of Utah Geriatrics Division Director, VA Salt Lake City GRECC Executive Director, University of Utah Center on Aging

  2. LEARNING OBJECTIVES • Identify the core components of the hypertension syndrome characteristic of older patients. • Describe how these core components of the hypertension syndrome contribute to elevated systolic blood pressure and pulse pressure. • Specify the current treatment recommendations for geriatric hypertension. GRECC Audioconference January 2007

  3. OUTLINE • Epidemiology • Physiology of BP Regulation • Diagnosis and Evaluation • Treatment GRECC Audioconference January 2007

  4. Hypertension Prevalence by Age and Gender NHANES III; 1999-2002; CDC NCHS Data GRECC Audioconference January 2007

  5. Residual lifetime risk for developing hypertensionWill you live long enough to develop hypertension? Vasan et al.; JAMA 287:1003, 2002 GRECC Audioconference January 2007

  6. Sympathetic Nervous System Activation Aging Insulin resistance GRECC Audioconference January 2007

  7. Characteristics of Geriatric Hypertension • Decreased vascular compliance • Decreased baroreceptor sensitivity • Salt-sensitivity of blood pressure • Increased total and central adiposity • Neurohumoral characteristics GRECC Audioconference January 2007

  8. Aging: Vascular Changes • Increased thickness of intima and media. • Matrix • collagen deposition • increased fibronectin • crosslinking (Advanced Glycosylation Endproducts) Net result is increased vascular stiffness. GRECC Audioconference January 2007

  9. Consequences of decreased vascular compliance • Relative increase in systolic pressure. • Increase in pulse pressure (SBP – DBP) • Decreased baroreceptor sensitivity? GRECC Audioconference January 2007

  10. Consequences of Decreased Baroreceptor Sensitivity • Increased BP variability • Impaired BP homeostasis • Hypertension • Postural (orthostatic) hypotension • Post-prandial hypotension • Increase in sympathetic nervous system activity GRECC Audioconference January 2007

  11. Salt Sensitivity of Blood Pressure • Definition: Mean arterial blood pressure on high vs. low Na+ diet • > 5 mm Hg increase => Sodium Sensitive • < 5 mm Hg increase => Sodium Resistant • Two thirds of older hypertensives are sodium sensitive. Dengel et al., Am J Physiol 274:E403, 1998 GRECC Audioconference January 2007

  12. Obesity (BMI > 30 kg/m2) by age and gender NHANES III; 1999-2002; CDC NCHS Data GRECC Audioconference January 2007

  13. Characteristics of Geriatric Hypertension -2- • Neurohumoral Characteristics • Metabolic insulin resistance • Sympathetic nervous system function GRECC Audioconference January 2007

  14. Hypertension and Insulin Resistance Supiano et al., J Gerontol 48: M237, 1993 GRECC Audioconference January 2007

  15. Aging and SNS Function Compared with younger people: • sympathetic nervous system activity increases. • adrenergic receptor responsiveness is reduced. • Decreased chronotropic response to b-agonists. Shannon et al., NEJM 342:541, 2000 GRECC Audioconference January 2007

  16. Hypertension and SNS Function • Compared to normotensive older people, older hypertensives are characterized with: • Further increase in SNS activity • Relatively greater a-mediated vasoconstriction Supiano et al., Am J Physiol 276:E519, 1999 GRECC Audioconference January 2007

  17. Decreased vascular compliance. Decreased baroreceptor sensitivity. Salt-sensitivity of blood pressure. Increased total and central adiposity. Metabolic insulin resistance. Heightened SNS activity. Increased -adrenergic receptor responsiveness. Summary: Vascular and Neurohumoral Characteristics GRECC Audioconference January 2007

  18. OUTLINE • Epidemiology • Physiology of BP Regulation • Diagnosis and Evaluation • Measurement issues • Secondary causes • Classification GRECC Audioconference January 2007

  19. Measurement Matters!Auscultatory BP Measurement Method • Sitting. Bare arm. Arm supported at heart level (5-6 mmHg increase if arm vertical). • Resting for five minutes. • Proper cuff size. • Use calibrated aneroid manometer. • Palpate SBP. • Record phase 1 (first sound) and phase 5 (disappearance) Korotkoff sounds as SBP and DBP. • Two or more readings taken several minutes apart should be averaged. JNC VI. Arch Int Med 157: 2413, 1997 GRECC Audioconference January 2007

  20. Measurement Issues: Posture Blood pressure must be measured in older persons with special care ... In addition, older patients are more likely than younger patients to exhibit an orthostatic fall in blood pressure and hypotension; thus, in older patients, blood pressure should always be measured in the standing as well as seated or supine positions. JNC VI. Arch Int Med 157: 2413, 1997 GRECC Audioconference January 2007

  21. Measurement Issues: Multiple Measurements • Hypertension should not be diagnosed on the basis of a single measurement. • BP variability is higher in older hypertensive individuals. • Decreased baroreceptor sensitivity. • Diagnosis of hypertension should be based on: • Average of readings from three visits. • Three separate readings recorded at each visit. GRECC Audioconference January 2007

  22. Evaluation of Patient with White-coat Hypertension:Ambulatory (24 hour) Monitoring • Advantages: • BP profile over 24 hour period. • Nocturnal dipper pattern. • BP load: correlates with target organ damage. • Useful to evaluate white coat hypertension, drug resistance, secondary causes, hypotensive symptoms. GRECC Audioconference January 2007

  23. Evaluation: Secondary Causes • Primary hypertension is the most common form of hypertension in older persons. • A sudden increase in DBP, malignant HTN or resistant HTN should prompt an evaluation for secondary causes. • Renovascular disease and medication interactions are most common secondary causes. GRECC Audioconference January 2007

  24. Blood Pressure ClassificationJNC 7 GRECC Audioconference January 2007

  25. Role of SBP in Classification • In the older hypertensive population, the level of SBP will correctly classify the stage of hypertension in 99% of patients. • Lloyd-Jones Hypertension 34:381, 1999 GRECC Audioconference January 2007

  26. Simplified JNC 7 Classification JNC 7 Report. JAMA. 2003:2560 GRECC Audioconference January 2007

  27. OUTLINE • Treatment • Efficacy • Systolic BP and Pulse Pressure Matter • Treatment Goals • Non-pharmacological therapy • Pharmacological therapy GRECC Audioconference January 2007

  28. Treatment of hypertension in older persons has demonstrated major benefits. JNC 7 Report. JAMA. 2003:2560 GRECC Audioconference January 2007

  29. 35% reduction in stroke rate SHEP Study; JAMA 265:3255; 1991 GRECC Audioconference January 2007

  30. Treating hypertension reduces cardiovascular risk and mortality Psaty et al.; JAMA 289: 2534, 2003 GRECC Audioconference January 2007

  31. Which is the more dangerous BP? SBP/DBP MABP Pulse Pressure Patient 1 140/ 94 109 46 Patient 2 158/84 109 74 GRECC Audioconference January 2007

  32. Especially among older persons, SBP is a better predictor of events (coronary heart disease, cardiovascular disease, heart failure, stroke, end-stage renal disease, and all-cause mortality) than is DBP. JNC VI, 1997 GRECC Audioconference January 2007

  33. Pulse Pressure as CV Risk Factor • Framingham data: in those >50 yrs., CV mortality independently related best to pulse pressure; for given SBP, lower DBP associated with higher mortality. • Franklin et al. Circulation 100:354, 1999. • SHEP data analysis: stroke and total mortality associated with pulse pressure independent of mean BP. • Domanski et al. Hypertension 34:375, 1999. GRECC Audioconference January 2007

  34. GRECC Audioconference January 2007

  35. The goal of treatment in older patients should be the same as in younger patients (to below140/90 mm Hg if at all possible), although an interim goal of SBP below 160 mm Hg may be necessary in those patients with marked systolic hypertension. JNC VI, 1997 GRECC Audioconference January 2007

  36. Treatment Implications • Optimal anti-hypertensive therapy will: • Lower blood pressure. • Improve vascular compliance. • Increase baroreceptor sensitivity. • Decrease central fat mass. • Increase insulin sensitivity. • Decrease SNS activity. • Decrease RAAS activity. GRECC Audioconference January 2007

  37. CHARACTERISTIC Overweight – central adiposity Sedentary Salt-sensitive LIFE STYLE MODIFICATION Weight loss Exercise program Dietary salt restriction Non-pharmacological Therapy GRECC Audioconference January 2007

  38. Lifestyle Modification JNC 7 Report. JAMA. 2003:2560 GRECC Audioconference January 2007

  39. DASH Fact Sheet GRECC Audioconference January 2007

  40. What about exercise? GRECC Audioconference January 2007

  41. Classification and Management of BP for adults *Treatment determined by highest BP category. †Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. JNC 7 Report. JAMA. 2003:2560 GRECC Audioconference January 2007

  42. Without Compelling Indications With Compelling Indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 Hypertension (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist. Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices JNC 7 Report. JAMA. 2003:2560 GRECC Audioconference January 2007

  43. Adverse Effects Common to Antihypertensive Drugs • Orthostatic hypotension • postural dizziness or lightheadedness • risk factor for falls • Many produce metabolic and/or electrolyte changes • Interactions with other medications GRECC Audioconference January 2007

  44. Overview of Pharmacologic Treatment • All antihypertensive drug classes are effective in older hypertensives. • Thiazide-type diuretics recommended by JNC-7. • Avoid direct vasodilators and central adrenergic drugs. • Drug selection should be an individualized decision. • Start low; go slow! GRECC Audioconference January 2007

  45. General Treatment Recommendations for Stage 1, Simple Hypertension • Begin with nonpharmacological approach – weight loss, exercise, salt restriction. • Consider low dose diuretic as initial drug selection; an ACE inhibitor is an alternative. • Base alternative drug selection or combination therapies on individual patient characteristics. • When initiating drug therapy, begin at half of the usual dose, increase dose slowly, and continue non-pharmacological therapies. GRECC Audioconference January 2007

  46. General Treatment Recommendations for Stage 1, Simple Hypertension -2- • Focus treatment goal on systolic blood pressure reduction to 135-140 mm Hg. • Avoid excessive reduction in diastolic blood pressure (below 70 mm Hg). • Aggressive therapy is not appropriate if adverse side effects (e.g., postural hypotension) cannot be avoided. GRECC Audioconference January 2007

  47. BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6. GRECC Audioconference January 2007

  48. SUMMARY • Hypertension is a common condition among the elderly. • Treating high blood pressure lowers the risks of heart attack, heart failure and stroke. • Systolic BP and pulse pressure matter. • Optimal blood pressure control should be achieved using the treatment which is least likely to produce side effects. GRECC Audioconference January 2007

  49. Unanswered Questions • Treatment goals in very old. • Conflicts between practice guidelines and treatment related risks. • How to further improve blood pressure control rate. GRECC Audioconference January 2007

  50. Questions... About our logo... The bristlecone pine tree (Pinus longaeva) - the earth’s oldest inhabitant with a life span of 4,000 years - is found only in Utah and five other western states. Its extraordinary longevity and ability to adapt and survive in extremely harsh environmental conditions above 10,000 feet embodies the investigative spirit and mission of the Utah Center on Aging. GRECC Audioconference January 2007

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