HYPERTENSION%20IN%20ELDERLY

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HYPERTENSION IN ELDERLY

• Dr. Kunal Kothari
• Emeritus Professor
  of Medicine and Clinical Cardiology
• Director Primary Health Care and
  Strategic initiative

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HYPERTENSION
3

200

• Sphygmanometer- size of the cuffs
• Food
• Exercise
• Caffeine
• Smoking

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
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Benefits of Lowering Blood Pressure
Antihypertensive Therapy has been associated with
reductions in

• Stroke Incidence (35-40 ).
• MI (20-25 ).
• Heart Failure ( averaging gt 50 ).

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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

Category Systolic Diastolic
Normal lt120 and lt80
Pre-hypertension 120-139 or 85-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 hypertension gt160 or gt100
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Clinic Pressure
Sustained Hypertension
White Coat Hypertension
140/90
True Normotension
Masked Hypertension
135/85 Ambulatory Pressure
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Pseudo Hypertension

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

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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 )

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MASKED HYPERTENSION

• Proposed the term masked hypertension
• Pickering et al (Hypertension 20021021139-44)
• Documented by Ohkubo et al (N Engl J Medicine
  20033482407-15)

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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

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Blood Pressure in 347,978 men aged 35-57 screened
for MRFIT
¼ ½ ¼
of Men
lt110 110-119 120-129 130-139
140-149 150-159 gt160
Systolic pressure mmHg
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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

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Diagnostic Evaluation of the Hypertensive
Patient- How much is enough?

• How high is the blood pressure?
• Why is it high?
• What is the risk?

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Clinical Manifestations I

• Physical exam
• Abdomen
• Funduscopic
• Vascular
• Cardiac
• Pulmonary
• Neurological

• Lab tests
• Urinalysis
• Blood Chemistry
• ECG
• Renal ultrasound
• Echocardiogram
• Vascular studies

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Differential Diagnosis

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

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Complications

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

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Management

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

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Management

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

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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

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DOES ELDERLY HYPERTENSION HAVE SPECIFIC
CHARACTERISTICS?
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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 512
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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
30352-359.
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Do lifestyle measures really work for elderly
hypertension?
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Lifestyle Modifications
Modification Approximate SBP Reduction (range)
Weight Reduction 5-10 mmHg/10kg
Adopt DASH eating plan 8-14 mmHg
Dietary sodium reduction 2-8 mmHg
Physical activity 4-9 mmHg
Moderation of alcohol consumption 24 mmHg
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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 1869
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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
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What is the effect of drug therapy related to
age? Are the recommendations different?
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Antihypertensive Drugs

• AACEI, ARBs
• BBeta Blocker
• CCCB
• DDiuretic

• Dlow dose HCTZ
• A
• B
• C

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• 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

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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

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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

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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.

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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) Pris
ant, Moser M. Arch Int Med 2000 160284
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Major Clinical Trials Showing Benefit of Treating
Isolated Systolic Hypertension SHEP Syst-Eur Sys
t-China (n4736) (n4695) (n2394) Baseline 160-
219/ 160-219/ 160-219/ SBP/DBP (mm Hg)
lt90 lt95 lt95 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 C
HF 55 29 All CVR disease 32 31 25 Journal of
Clinical Hypertension Vol II, No. 5, page 336,
September/October 2000.
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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 46273-279
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Barriers to Optimal Control of Hypertension Inacc
urate 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 8524
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What is the systolic blood pressure goal?
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Blood Pressure in SHEP and Syst-Eur (mm
Hg) SHEP Syst-Eur Entry 160-219/lt90 160-219/lt95
Goal (SBP) lt160 20 ? lt150 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.
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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 200013724-733
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Hypertension in the Very Elderly TrialNEJM
2008358(18)1887-1898

• 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

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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

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GOALS OF TREATMENT

• To achieve a target BP of lt140/ 90 mm Hg.
• In patients with Hypertension Diabetes or Renal
  disease, BP Goal is lt 130/80 mm Hg.
• To reduce cardiovascular morbidity mortality.

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Thiazide Myths

• Sulfa cross reactivity
• Gout
• Renal stones

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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

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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

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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 120139 mmHg or DBP 8089 mmHg
  should be considered prehypertensive who require
  health-promoting lifestyle modifications to
  prevent CVD.

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