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HYPERTENSION IN ELDERLY

HYPERTENSION IN ELDERLY. Dr. Kunal Kothari Emeritus Professor of Medicine and Clinical Cardiology Director Primary Health Care and Strategic initiative. S. L. O. W. I. K. I. L. E. R. L. E. N. T. HYPERTENSION. Sphygmanometer- size of the cuffs Food Exercise

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HYPERTENSION IN ELDERLY

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  1. HYPERTENSION IN ELDERLY Dr. Kunal Kothari Emeritus Professor of Medicine and Clinical Cardiology Director Primary Health Care and Strategic initiative

  2. S L O W I K I L E R L E N T HYPERTENSION

  3. Sphygmanometer- size of the cuffs Food Exercise Caffeine Smoking 200 180 160 140 K1 A sharp thump K2 120 A blowing or whooshing sound K3 100 A softer thump K4 80 A softer blowing sound 60 40 20 0 K5

  4. Benefits of Lowering Blood Pressure Antihypertensive Therapy has been associated with reductions in: • Stroke Incidence (35-40 %). • MI (20-25 %). • Heart Failure ( averaging > 50 %).

  5. 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:

  6. Clinic Pressure White Coat Hypertension Sustained Hypertension 140/90 True Normotension Masked Hypertension 135/85 Ambulatory Pressure

  7. Pseudo Hypertension • Recording of high B.P. but do not have • Common cause of this is brachial artery compression

  8. 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 )

  9. MASKED HYPERTENSION Proposed the term masked hypertension Pickering et al (Hypertension 2002;102:1139-44) Documented by Ohkubo et al (N Engl J Medicine 2003;348:2407-15)

  10. 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

  11. Blood Pressure in 347,978 men aged 35-57 screened for MRFIT ¼ ½ ¼ % of Men <110 110-119 120-129 130-139 140-149 150-159 >160 Systolic pressure mmHg

  12. 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 Women Men 52% 56% 72% 78% 83% 88% 25 91% 93%

  13. Diagnostic Evaluation of the Hypertensive Patient- How much is enough? How high is the blood pressure? Why is it high? What is the risk?

  14. Physical exam: Abdomen Funduscopic Vascular Cardiac Pulmonary Neurological Lab tests: Urinalysis Blood Chemistry ECG Renal ultrasound Echocardiogram Vascular studies Clinical Manifestations I

  15. Differential Diagnosis • Rule out isolated incident of increased blood pressure. • Rule out secondary hypertension related to: Renal disease Cushing's disease Pheochromocytoma Hyperthyroidism Hyperparathyroidism

  16. Complications Complications as a result of HTN include: Stroke Dementia Myocardial Infarction Congestive Heart Failure Retinal Vasculopathy Aortic Dissection Renal Disease or Failure

  17. Management Medications Diuretics- Thiazides (HCTZ), Loop (Furosemide), Potassium-sparing (Spironolactone) Beta-Blockers- Atenolol, Nadolol, Propranolol ACEInhibitors- Benezapril, Captopril, Cilizapril ARBs-Losartan, Valsartan Ca+ Channel Blockers- Nifedipine, Verapamil Alpha blockers- Prazosin, Terazosin Vasodilators- Apresoline

  18. Management Primary goal is to reduce cardiovascular and renal morbidity and mortality. Other keys to management are: Prevention Patient education Life-style modification Medication

  19. 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

  20. DOES ELDERLY HYPERTENSION HAVE SPECIFIC CHARACTERISTICS?

  21. 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

  22. Arterial Wall Compliance and Pulse Pressure Wave Elastic Vessel Stiff Vessel Systole Diastole Systole Diastole Stroke Volume Aorta Resistance Arterioles Pressure (Flow) Young Artery Arteriosclerotic Artery Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.

  23. Do lifestyle measures really work for elderly hypertension?

  24. Lifestyle Modifications

  25. Change in Mean Arterial Blood Pressure 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

  26. Effect of 30 minute walk 3 days a week Age 70 - 79 Systolic Diastolic Exercise Group Baseline 156 ± 10 mm Hg 86 ± 8 mm Hg 3 months 151 ± 15 mm Hg 80 ± 6 mm Hg Control Group Baseline 153 ± 7 mm Hg 85 ± 8 mm Hg 3 months 156 ± 10 mm Hg 85 ± 6 mm Hg Conone et al. Med Scl in Sports and Exercise. 1991

  27. What is the effect of drug therapy related to age? Are the recommendations different?

  28. AACEI, ARBs BBeta Blocker CCCB DDiuretic Dlow dose HCTZ A B C Antihypertensive Drugs

  29. Algorithm for Management of the Elderly - • Primarily Systolic Hypertension • 1) Lifestyle changes • Low dose diuretic (12.5 mg HCTZ) • CCB B-Blocker ACE or ARB • 3) Stop, Look & Listen before dosages • Let the Baroreceptors reset • 4) Rx until goal achieved + + + + +

  30. 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

  31. 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

  32. 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.

  33. 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

  34. Major Clinical Trials Showing Benefit of Treating Isolated Systolic Hypertension SHEP Syst-Eur Syst-China (n=4736) (n=4695) (n=2394) Baseline 160-219/ 160-219/ 160-219/ SBP/DBP (mm Hg) <90 <95 <95 BP reduction: 27/9 23/7 20/5 SBP/DBP (mm Hg) Drug therapy Chlorthalidone Nitrendipine Nitrendipine Atenolol Enalapril Captopril HCTZ HCTZ Outcomes (%) Stroke 33 42 38 CAD 27 30 27 CHF 55 29 — All CVR disease 32 31 25 Journal of Clinical Hypertension Vol II, No. 5, page 336, September/October 2000.

  35. 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) Cardiovascular conditions 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) Wang PS et al. Hypertension 2005; 46:273-279

  36. 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

  37. What is the systolic blood pressure goal?

  38. Blood Pressure in SHEP and Syst-Eur (mm Hg) SHEP Syst-Eur Entry 160-219/<90 160-219/<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.

  39. REDUCTION OF STROKES WITH BP LOWERING - SHEP TRIAL No. of Patients: 4736 Follow-up: 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

  40. Double blind, placebo-controlled International, multicenter 3845 patients Mean age 83.6 yrs BP range 160-219/90-109 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 Hypertension in the Very Elderly TrialNEJM 2008;358(18):1887-1898

  41. 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

  42. 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.

  43. Thiazide Myths • Sulfa cross reactivity • Gout • Renal stones

  44. 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

  45. 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

  46. 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.

  47. Thank You Dr. Kunal Kothari Emeritus Professor of medicine and Clinical Cardiology Director Primary Health care and Strategic initiative

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