Managing Hypertension in the Elderly: How to Best Achieve Control

1
Managing Hypertension in the Elderly How to Best
Achieve Control

• John R. Holman, MD, MPH
• Naval Hospital Camp Pendleton
• USAFP 2009

2
Disclaimer

• The opinions disclosed are those of the presenter
  and should not be construed as official or as
  reflecting the views of the Department of the
  Navy or the Department of Defense

3
Objectives

• Review the pathophysiology of hypertension in the
  elderly
• Review the benefits of treatment
• Relate unique aspects of management for older
  patients

4
Epidemiology

• Most common primary care diagnosis
• 35 million office visits per year
• Improved awareness, treatment and control over
  last 25 years
• 51 70 percent aware of HTN
• 31 59 percent treated for their HTN
• 10 34 percent with controlled HTN
• Goal is to achieve 50 percent in control
• More important to control SBP gt 50 years

5
Epidemiology

• HTN affects 50 million US, 1 billion world
• If normotensive at 55, 90 lifetime risk to
  develop HTN
• The higher the BP, the greater the risk of MI,
  CHF, stroke, kidney disease.
• Age 40-70, BP 115/75 to 185/115
• Increase in 20 mm SBP doubles CVD risk
• Increase in 10 mm DBP doubles CVD risk

6
BP Measurement

• Home BP checks
• Helpful
• gt135/85 HTN
• Check for accuracy
• Ambulatory BP
• Evaluate white-coat HTN etc
• HTN 135/85 awake
• HTN 120/75 asleep
• Normal BP falls 10-20
• Better correlation with end-organ injury

7
Case 1

• 68 year Afri-Amer male
• Type 2 diabetes mellitus for 5 years
• No nephropathy
• No CV history
• On atorvastatin 80 mg and LDL is 80
• BP is 148/98 last visit and now 150/98
• Diagnosis?
• Stage 1 hypertension

8
Classification of BP

• Normal
• lt120 and lt80
• Prehypertension Rx for DM or CRF
• 120-139 or 80-89
• Stage 1 Hypertension begin Rx here
• 140-159 or 90-99
• Stage 2 Hypertension
• gt 160 or gt 100

9
Classification

• Isolated systolic hypertension
• Systolic BP of gt 140 mm Hg
• AND
• Diastolic BP lt 90 mm Hg
• 76 percent of HTN patients
• Widened pulse pressure (more than 50)
• Independent CV risk factor
• Low diastolic BP (lower than 70)
• Independent CV risk factor

10
Pathophysiology

• Hypertension in the Elderly
• Increase in arterial stiffness (large arteries)
• Sympathetic activation
• Large arteries dilate and thicken
• Intimal hyperplasia
• Leads to increased systolic BP and widened pulse
  pressure CV mortality and morbidity

11
Pathophysiology

• Hypertension in the Elderly
• Increased total PVR
• Decrease in cardiac output
• Lability of BP due to decreased baroreceptor
  function
• Dysfunction of autoregulation in brain, heart and
  kidneys
• Affects choice of treatment for HTN

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Pathophysiology

• Hypertension in the Elderly
• Average BP 65-94 years old
• Men 133 /- 19 / 77 /- 11
• Women 134 /- 19 / 76 /- 10
• White coat hypertension
• Occurs in 42 of patients over 65
• Hypertension at an outpatient clinic and
  documented BP readings below 134/90 out of clinic
• Prognosis and end-organ damage same as
  normotensive patients

13
Pathophysiology

• Hypertension in the Elderly
• Pseudohypertension
• Advanced arterial stiffness
• Arteries not compressed by arm cuff
• BP readings higher than direct
• Oslers sign
• Pump arm cuff and feel brachial artery
• If palpable but without beats, may indicate
  pseudohypertension
• Difficult to reproduce

14
Treatment

• Goals of therapy
• Reduce CV and renal morbidity and mortality
• Reduce vascular dementia in elders
• Focus on reducing SBP
• Goal is lt140/90, lt130/80 with diabetes, renal
  disease

15
Benefits of Therapy

• Treatment decreases
• Stroke by 35-40
• MI by 20-25
• CHF by 50
• NNT for stage 1
• 11 patients in 10 years with a 12 mm decrease in
  SBP to prevent 1 death.
• NNT with CVD etc.
• 9 patients

16
Evidence for Elderly and ISH

• Treat 19 for 5 years
• Prevent 1 CV event
• Treat 50 for 5 years
• Prevent 1 CV death
• Treat 63 for 5 years
• Prevent 1 all cause death

17
Benefits of Therapy
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Treatment

• Treatment goals in elderly
• Controversial How low is too low?
• HOT trial 1998 (mean age 61.5)
• Best effect at 130-140/80-85
• SHEP trial 2000 (mean age 71.6)
• No increase stroke protection from 150-140 SBP
• DBP lt55 twice the rate of CV events
• PATE-Hypertension 2000
• SBP lt130 increase CV events

19
Treatment

• Possible goals

20
Case 1

• 68 year Afri-Amer male
• Type 2 diabetes mellitus for 5 years
• No nephropathy
• No CV history
• On atorvastatin 80 mg and LDL is 80
• BP is 148/98 last visit and now 150/98
• Treatment?
• Lifestyle, medications

21
Treatment

• Lifestyle modifications
• Weight reduction - C
• DASH eating plan (rich in K and Ca)
  www.nhlbi.nih.gov - A
• Reduce dietary sodium
• Increase physical activity - A
• Moderate alcohol consumption
• Smoking cessation - A
• DASH eating plan is similar to monotherapy for BP
  reduction

22
Treatment

• Paced breathing
• 14/8 mm Hg reduction after 4 weeks
• Evidence
• Case reports
• Uncontrolled studies
• Not better than placebo with T2DM
• All studies small
• Very low risk!

23
Treatment

• Pharmacologic treatment
• These meds have been shown to work
• ACE inhibitors
• Thiazide diuretics
• Beta blockers
• Calcium channel blockers
• Angiotensin-receptor blockers

24
Treatment

• Thiazide diuretics
• Basis of most outcome trials
• Unsurpassed in preventing CV complications of
  HTN. JNC VII
• Enhance the efficacy of multidrug regimens
• Do not widen pulse pressure in ISH
• Affordable but underused

25
Treatment

• First line medications uncomplicated
  hypertension
• THIAZIDE DIURETICS!!!
• Consider
• ACE Inhibitor
• ARB
• CCB
• Beta-blocker
• Combination

26
Treatment

• Second line medications
• THIAZIDE DIURETICS!!!
• Addition of
• ACE Inhibitor
• ARB
• CCB
• Beta-blocker
• Consider 2 drugs initially when BP is more than
  20/10 above goal

27
Treatment Trials

• ALLHAT Double blind RCT
• Sponsored by NHLBI
• 42,418 age gt55 with one CHD risk factor
• Amlodipine or lisinopril or doxazosin
• VS.
• Chlorthalidone
• Step 2 Atenolol or clonidine or reserpine
• Step 3 - Hydralazine

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Treatment Trials

• ALLHAT
• Doxazosin terminated early due to much higher
  incidence of CHF
• Nearly 5 year follow up of other arms
• No difference in primary endpoint of combined
  fatal CHD or nonfatal MI
• Diverse population, high percent with DM
• 35 African American
• 47 women

29
Treatment Trials

• ANBP2 Open label RCT
• Sponsored by Australian Dept of Health and Merck,
  Sharp, Dohme
• 6083 65-84 with low CV risk profile
• ACEI (enalapril) vs. Diuretic (HCTZ)
• Step 2 ß blocker or a blocker or CCB
• Step 3 Nonstep 2 drugs or diuretic in ACEI
• Step 4 Nonstep 2 or 3 drugs

30
Treatment Trials

• ANBP2
• Followed for median 4.1 years
• Primary endpoint changed
• Initial protocol Total CV events including CV
  death secondary endpoints-death CHD events
• Final pub All CV events and all cause death
• Marginally lower primary endpoint for ACEI
• 56.1 vs 59.8 per 1000 patient years
• Lower stroke rate for diuretic

31
Treatment Trials

• ANBP2
• Validity issues
• Question of primary endpoints measured
• Open label design may have induced bias as data
  collection supported by sponsor/maker of ACEI
• Diuretic use was permitted in the ACEI group
• Superiority of ACEI over diuretics not
  demonstrated

32
Treatment Trials

• ASCOT-BPLA Open label RCT
• Sponsored by Pfizer
• 19,257 40-79, gt 3 CV risk factors
• Amlodipine vs. atenolol
• Step 2 Add perindopril vs. thiazide K
• Step 3 - Doxazosin

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Treatment Trials

• ASCOT-BPLA
• Followed for 5.5 years, terminated early
• Primary endpoint nonfatal MI fatal CHD
• Amlodipine 8.2 per 1000 PY vs. atenolol 9.1 per
  1000 PY, p 0.105
• Reduction noted in all cause mortality
  secondary endpoint
• Amlodipine 13.9 per 1000 PY vs. atenolol 15.5 per
  1000 PY, p 0.025
• Improved BP control in amlodipine arm led to
  better stroke, CV mortality, PAOD, total coronary
  endpoint and total CV events

34
Treatment Trials

• ASCOT BPLA
• Validity issues
• Protocol listed statistical significance for
  secondary endpoints as 0.01
• Lipophilic ß blocker less effective
• Only 55 of patients with ß blocker diuretic
• Open label design may have introduced bias
• Premature termination of trial may influence
  outcome
• Does not prove superiority of amlodipine based
  regimen

35
Thiazide Diuretics

• Bendroflumethiazide
• Chlorothiazide
• Chlorthalidone
• Hydrochlorothiazide
• Hydroflumethiazide
• Methyclothiazide
• Metolazone
• Polythiazide
• Quinethazone
• Trichlormethiazide

36
Thiazide Diuretics

• Chlorthalidone vs HCTZ
• Chlorthalidone basis of landmark studies
• HCTZ more commonly prescribed
• Chlorthalidone longer acting
• Chlortalidone 1.5-2 times more potent
• More effective BP control
• No head to head studies

37
Treatment Trials in Elderly

• 12 Studies reviewed
• Average BP drop 17/8 mm Hg
• 30 decrease in relative risk for
• CV disease
• CAD
• CHF
• Total CV diseases

38
Treatment Trials in Elderly

• SHEP 1991, 4739 patients, 57 women
• SBP 160-190, DBPlt90
• 72 years
• 177/77 143/68, plt0.001
• NNT to prevent stroke is 50
• NNT to prevent CV event is 20
• Agents
• Chlorthalidone, atenolol, reserpine

39
Treatment Trials in Elderly

• Sys-Eur 1997, 4695 patients, 67 women
• SBP 160-219, DBPlt95
• 70 years
• 174/85 151/78, plt0.001
• NNT to prevent stroke is 100
• NNT to prevent CV event is 50
• Agents
• Nitrendipine, enalapril, HCTZ

40
Treatment Trials in Elderly

• Sys-China 1998, 2394 patients, 35 women
• SBP 160-219, DBPlt95
• 66 years
• 170/86 150/81, plt0.001
• NNT to prevent stroke is 50
• NNT to prevent CV event is 50
• Agents
• Nitrendipine, captopril, HCTZ

41
Choice of Medications

• STOP 2 - 2000
• 6614 patients, 70-84 years old
• Diuretics/Beta vs. ACEI vs. CCB
• No difference in outcomes or BP lowering
• SHELL - 2003
• 1882 patients, gt60
• Diuretic vs CCB
• No difference in outcomes or BP lowering

42
Choice of Medications

• NICS EH - 1999
• 414 patients, gt 60 years
• CCB vs. diuretic
• No difference in outcomes or BP lowering
• SCOPE - 2003
• 4964 patients, 70-89 years
• Candesarten vs. placebo and usual care
• No difference in BP lowering
• Decrease in non-fatal stroke in ARB

43
Treatment of the Old Old

• HYVET 2008
• Nearly 4000 patients
• Over 80 years old
• Systolic BP at least 160 mm Hg
• Target BP was 150/80
• Agents vs. placebo
• Indapamide SR 1.5 mg
• /-
• Perindopril 2 4 mg

44
Treatment of the Old Old

• HYVET
• Primary endpoint any stroke
• Secondary all cause mortality, CV mortality,
  cardiac death
• Beneficial effects seen within 1 year
• No increase in serious adverse events
• Different from pilot study reported in 2006

45
Treatment of the Old Old

• HYVET
• Total of 2.1 years of therapy
• Lowered BP by 15/6 mm Hg
• 30 decrease in primary endpoint (p0.06)
• 39 decrease in stroke deaths (p0.046)
• 21 decrease in all cause deaths (p0.02)
• 23 decrease in CV deaths (p0.06)
• 64 decrease in rate of HF (plt0.001)
• Fewer adverse events in Rx group (p0.001)

46
Treatment of the Old Old

• HYVET Recommendations
• Screen for HTN in elderly like anyone else
• Begin treatment if SBP is gt160 mm Hg
• Indapamide /- perinodopril
• Questions
• Indapamide HCTZ or chlorthalidone?
• Perindopril lisinopril or ramipril?
• Is there a better agent for old old?
• Are results due to BP lowering alone?
• What is the ideal BP for old old?

47
Follow up

• After treatment begun
• Monthly visits until control achieved
• More frequently as needed
• Check K/Cr 1-2 times a year
• BP in control, F/U 3-6 months
• Low dose ASA ONLY when in control to avoid stroke

48
Choice of Medications

• Quality of Life
• Complex, multifactorial, hard to measure
• Treatment not associated with significant
  impairment in QOL and can improve
• No class is clearly superior
• ACEI and ARBs
• Cognition dementia and memory, not learning or
  perceptual processing
• Sexual activity

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Special Consideration

• Hypertension with heart failure
• Diuretic - A
• Beta blocker - A
• ACE inhibitor A, NNT 43
• ARB - A
• Aldosterone antagonist A, NNT 50

50
Special Consideration

• Hypertension post MI
• Beta blocker Std of Care - A
• ACE inhibitor A, stable normal LV fxn
• Aldosterone antagonist B

51
Special Consideration

• Hypertension with high CAD risk
• Diuretic - A
• Beta blocker - A
• ACE inhibitor - B
• CCB - B

52
Special Consideration

• Hypertension with diabetes
• Diuretic thiazide induced DM is more benign
• Beta blocker - B
• ACE inhibitor - A
• CCB - B
• ARB - A

53
Special Consideration

• Hypertension with chronic kidney disease
• ACE inhibitor - A
• ARB A
• Combine ARB and ACEI

54
Special Consideration

• Hypertension recurrent CVA prevent
• Diuretic - A
• ACE inhibitor - B
• Perindopril indapamide B, RRR 43

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• Question 1

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Improving Control

• Atmosphere of trust in relationship
• Understanding cultural beliefs of patient
• Agreement on BP goals
• Overcome clinical inertia to achieve goals
• Consider cost and complexity of care

57
Improving Control

• Increase knowledge
• In 2001, 41 of primary care providers were not
  familiar with JNC 7
• Identify and treat
• Only 30-49 percent controlled in US
• Less than 10 percent in developing countries
• Focus on widespread and cost-effective HTN care,
  not what agent is best

58
Resistant HTN

• Failure to reach goal on 3 drugs including a
  diuretic
• Exclude potential identifiable causes
• Explore reasons why goal not met
• May need higher doses of diuretics with kidney
  disease
• Consider referral to HTN specialist

59
Conclusions

• Persons over 50, SBP is more important
• Thiazide diuretics are the mainstay of treatment,
  tailor to medical conditions
• Most patients will need 2 or more drugs
• Patients and providers must be motivated
• Lowering BP in patients and populations is more
  important than agent

60
Questions
61
Case 1

• 68 year Afri-Amer male
• Type 2 diabetes mellitus for 5 years
• No nephropathy
• No CV history
• On atorvastatin 80 mg and LDL is 80
• BP is 148/98 last visit and now 150/98
• Diagnosis?
• Evaluation?
• Treatment

62
Case 1

• Diagnosis
• Stage 1 HTN
• Evaluation
• Check for smoking other CV risks
• Exam normal
• Labs are normal (CBC, chem, UA, ECG)
• Treatment
• DASH
• HCTZ vs ACEI vs CCB

63

• Question 2

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Case 2

• 75 year old Latino female
• Type 2 diabetes for 10 years, poor control
• LDL at 167, no treatment
• No CV history, non smoker
• On metformin 1000 bid
• BP is 165/88, then 163/80
• Diagnosis?
• Evaluation?
• Treatment?

65
Case 2

• Diagnosis
• Stage 2 ISH
• Assessment
• Exam normal except obese
• Normal labs except UA for protein and ECG with
  evidence of LVH
• Treatment
• DASH
• HCTZ vs ACEI vs ARB vs CCB

66

• Question 3

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HTN and LVH

• PRESERVE
• Enalapril nifedipine gts
• LIVE
• Indapamide SR gt enalapril
• LIFE
• Losarten gt atenolol
• In reversing hypertensive LVH

68
Case 3

• 69 year old white male
• No medical history
• BP 145/105, 147/102
• No meds
• Diagnosis?
• Evaluation?
• Treatment?

69
Case 3

• Diagnsis
• Stage 2 HTN
• Evaluation
• No CV risk factors
• Exam normal
• Labs normal except K 2.1, repeat 2.0
• No diuretics
• Further work up

70
Case 3

• Diagnosis
• Stage 2 HTN
• Secondary HTN
• Aldosteronism
• Primary adrenal adenoma, hyperplasia
• Secondary high renin, accelerated HTN
• Plasma renin Low
• Saline load high aldosterone
• CT scan no adenoma
• Hyperplasia

71
Case 3

• Treatment
• Sodium restriction
• Antimineralocorticoids
• Sprinonolactone 25-100 mg tid
• If adenoma seen, surgery
• BP normal for last two years