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Hypertension and The Older Patient

Hypertension and The Older Patient. Debra L. Bynum, MD Assistant Professor Division of Geriatric Medicine University of North Carolina. Outline. Defining Systolic Hypertension Risks of SH in older persons Preventing stroke, CHF, CV events, dementia Review of Major Trials

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Hypertension and The Older Patient

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  1. Hypertension and The Older Patient Debra L. Bynum, MD Assistant Professor Division of Geriatric Medicine University of North Carolina

  2. Outline • Defining Systolic Hypertension • Risks of SH in older persons • Preventing stroke, CHF, CV events, dementia • Review of Major Trials • Choice of Treatment • Pulse Pressure as Risk Marker • Controversial treatment groups • Stage I SH • “Oldest old” those over 85

  3. The History Systolic Hypertension in the Elderly so common once thought to be almost normal part of aging Previously known “Isolated Systolic Hypertension” 1980 JNC on HTN defined ISH as SBP> 160 with DBP <90

  4. Definition • Systolic Hypertension (“isolated” having falsely benign connotation) • JNC defines as SBP >140 with DBP <90 • Stage I SH: SBP 140-159 • 7th report from JNC: SH in patients over 60 much more important than diastolic HTN and treatment should focus on control of SBP

  5. Prevalence • HTN seen in over 60% of those over age 65 • Elevations of SBP with decreases in DBP common with age due to diminished arterial compliance (increased Pulse Pressure) • SH accounts for 65-75% HTN in those over 65

  6. The Importance Of SH • SH associated with increased risks of CAD, LVH, renal insufficiency, stroke and cardiovascular mortality • SH and pulse pressure more closely associated with CV risk than diastolic BP in older patients (even in older patients with diastolic HTN)

  7. The Problem • Still underestimated importance • Fear of treating older patients may interfere with appropriate management • Older patients have most visits to clinics and hospitals but lowest rates of adequate BP control • Up to 75% of older patients being treated for HTN are undertreated

  8. Risks… • Epidemiological studies: • Framingham: Stage I SH: increased risk CVD (RR 1.47), CAD (RR 1.44), stroke (RR 1.42) and CHF (RR 1.6) • Physicians’ Health Study: similar risks • Several Large RCTs demonstrate significant benefits of treating older patients with SH

  9. Risks…The DATA • SHEP trial: 1991 • 5000 patients, SBP 160-190, DBP <90, mean age 72 • Chlorthalidone (thiazide) vs placebo • Second agents: atenolol, reserpine • Primary endpoint: stroke • 5 year incidence stroke: 8.2 % with placebo, 5.2% treatment (ARR 3%)

  10. SHEP… • 32% Relative Risk Reduction and 5% Absolute Reduction in total CV events • NNT: need to treat 18 people over 5 years to prevent 1 major cardiovascular or cerebrovascular event • Underestimation: goal BP reached in only 70% in treatment group; 44% of placebo group treated (intention to treat analysis)

  11. Benefits of Treatment: Additional trials… • Systolic Hypertension in Europe • Systolic Hypertension in China • All demonstrated decreased risk of stroke and combined CV events in older patients treated for systolic hypertension • None powered to demonstrate difference in all cause or cardiovascular mortality

  12. Summary: Prevention of Cardiovascular endpoints… • All trials demonstrated decreased cerebrovascular events, mainly stroke • Trials demonstrate reduction of combined cardiovascular events with 26% relative risk reduction per meta-analysis

  13. The Link with Dementia: SYST-EUR Trial • Does treatment of older patients with SH decrease incidence of vascular disease? • CCB nitrendipine +/- enalapril +/- HCTZ • 2 year f/u (stopped early): significant decrease in strokes

  14. SYST-EUR: additional information… • After termination, patients followed 2 years • Continued difference in BP between original placebo group and initial treatment group (SBP/DBP 7/3 lower) at 4 years • Original treatment group had persistent decreased risk of dementia • 7.4 vs 3.3 cases/1000 patient-years • Decreased both vascular and alzheimer type dementia!

  15. Summary: Dementia and Systolic Hypertension… • Observational studies suggest less risk of cognitive decline in older patients treated for SH • Risk of confounding: more frail patients may be less likely to be treated… • 5 RCTs look at dementia and SH • All show significant decrease risk of stroke • Most demonstrate decrease risk of cognitive decline with treatment

  16. How To Treat…

  17. Lifestyle Modifications • DASH (Dietary Approaches to Stop Hypertension) • Effective in decreasing SBP • ?increased Na responsiveness in older patients • Small, subgroup analysis • TONE trial

  18. TONE trial • Older patients with SH, BP< 145/85 on 1 med • Medication stopped • 4 groups: Na restriction, Weight reduction, both Na restriction/wt reduction, usual care • Outcome: remaining free of HTN, medication restart or CV outcome • 25 % in usual care group remained “free” • 38% in Na restriction, almost 40% in weight reduction and 44% of those in Na restriction/weight reduction remained “free”

  19. Lifestyle changes: summary • Evidence that weight loss and Na restriction can be effective for mild SH in older patients • Some literature suggests that this population may be less amenable to such lifestyle changes…

  20. Which agent is best? • Thiazide Diuretics: First Line in large trials • ACE inhibitors • LIFE (Losartan Intervention for Endpoint Reduction): Losartan vs Beta blocker • Losartan decreased risk CV events • HOPE (Heart Outcomes Prevention Evaluation) • Patients with DM, over 55, CVD risk • Ramipril 10/day decreased morbidity/mortality at 5 yrs • Most pronounced effect seen in those over age 65 • Ca Channel Blockers • SHELL (SH in Elderly: Lacidipine Long Term Study) • CCB and thiazide similar effectiveness

  21. Which agent? • Beta Blockers may not be first line… • LIFE study (25 events/1000 patient years in those on losartan vs 35 events/1000 pt yrs on atenolol) • Meta-analysis of 10 trials, 16000 older patients with SH • Diuretic better than B blocker in preventing combined endpoint • Beta blockers and diuretics decreased risk of stroke, BUT • Beta blockers were not effective at preventing CAD, CV mortality or all cause mortality

  22. Beta blockers • Indicated in patients with prior MI/ACS • 2002 prospective study of patients with prior MI and HTN treated with beta blockers, ACE I, diuretic, Ca Channel blockers, or alpha blocker • Incidence of new coronary events lowest in those on beta blockers and ACE I

  23. Which agent? • ALLHAT… • RCT of 45,000 patients • Thiazide vs amlodipine, lisinopril, or doxazosin (doxazosin arm stopped due to increase risk CHF) • Overall no difference! • Trend for thiazide treated patients to have less risk of stroke and CHF

  24. Treatment • Triad: Age, HTN and DM • More aggressive treatment of CV risk factors • Dyslipidemia • HTN • Smoking reduction • Age as the new “CV” equivalent • Treatment goal: reduction of CV events

  25. Summary: Which Antihypertensive? • First Line: Thiazide type diuretics • Second line agents: ACE inhibitors or ARB agents • Long acting calcium channel blockers • Beta blockers in those with CAD or other indications • Not alpha blockers or ca channel blockers in those with prior MI/ ACS • Need to individualize treatment!

  26. Quality of Life • Studies demonstrate no significant impact with treatment • ACE inhibitors/ARBs have better profile • CCBs well tolerated • Sexual dysfunction most commonly reported with thiazides • Nonselective Beta blockers reported to have some subjective negative effects on cognition and mood • Higher risk of Postural hypotension (30%)

  27. The Pulse Pressure: Risk Factor or Marker? • Wide pulse pressure (over 50) may be better marker for cerebrovascular disease and CHF than mean or DBP in older patients • ?Causal or Marker for bad outcomes • Likely due to poor arterial compliance…

  28. The Pulse Pressure… • Trials: those who had CV event on treatment were more likely to have lower DBP and higher pulse pressure (DBP < 68 and PP >50) • Concern: Is “overtreatment” risky? • BUT: the risk of events in patients with lower DBP on treatment was still less than that in the placebo group! • AND: Lower DBP and Higher PP likely more of a MARKER for bad outcomes…

  29. Controversial Groups to Treat… • Stage I (SBP 140-159) • Observational data supports that this group is still at higher risk of bad things… • Not clear that treatment reduces bad outcomes… • Consideration of other RFs (DM, CAD) • Oldest Old (over age 85) • Possibly higher risk of side effects, BUT • Group at highest ABSOLUTE RISK of CV event • Evidence suggests that patients in this age group actually had GREATER absolute benefit with reduction in outcomes compared to younger groups

  30. SUMMARY • SH is not benign and carries increased risk of stroke, CHF, and CV events • SH and pulse pressure more important risk factors for CVA and CVD in this group • Even “mild” SH carries increased risk • SH is a risk factor for all cause dementia • Treatment of SH is well tolerated and associated with reduction in stroke, CHF, CV events, dementia • Patients over 85 have greatest risk of CVA and CV disease and stand to gain most • Lower DBP and higher PP with treatment likely marker and not cause of higher risk • Thiazide diuretics = first line • Other agents: ACEI, ARBs, CCBs

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