Workshop hypertension: approach in the elderly patient

1
Workshop hypertensionapproach in the elderly
patient

• Johan Rosman
• Renal Physician and Specialist in Hypertension
• North Shore Hospital and the Apollo Health Centre
• North Shore
• Auckland

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Case

• Conny is a 72 year old active widow
• She stopped smoking 5 years ago and uses NSAIDs
  for osteoarthritis
• She has a strong family history of hypertension
• Recently her BP increased, you measure 174/98.
• She would like to know if it is really worth
  treating this

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Questions

• What are the risks and benefits of treating her
  BP ?
• Which agents are most appropriate ?
• Does her age put her at any particular risk apart
  from medication ?

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Facts

• Syst BP rises with age, diast only till age 60,
  after which it tends to decrease. So syst HT is
  very common in the elderly, this is caused by
  decreased compliance of the vascular bed
• The elderly have significant alterations in salt
  sensitivity, enhanced sympathetic nervous system
  activity and baroreceptor responsiveness
  (orthostatic hypotension, especially when
  overtreated !)
• HT is the singlemost important modifiable risk
  factor for vascular disease in the elderly
• Up to 90 of the elderly people are hypertensive
  (is this a physiological response ?)
• 25 of the elderly found with hypertension
  actually have office-white coat hypertension
  (overtreatment risk !)
• Elderly are more prone and at risk to suffer from
  side effects (e.g. falls)

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Benefits ?

• Decrease of heart failure with 50
• Decrease of stroke with 35
• Decrease of Myocardial infarcts with 25
• Slower progression of cognitive decline
• BUT Balance that with the life expectancy and
  the risk of side effects !!!

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Causes of secondary HT in the Elderly

• Obstructive Sleep Apnoea
• Renovascular disease or chronic kidney disease
• High alcohol intake
• Concomitant medications (NSAIDs, decongestants,
  etc)
• Endocrine
• Mineralocorticoid excess
• Thyroid disease
• Hyperparathyroidism
• Steroid use or Cushings syndrome

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Diagnostic steps, global views

• ECG, chest X-ray
• Plasma levels of B-type natriuretic peptide (BNP)
  or NT-proBNP (I have my doubts here, would rather
  go with clinical impression)
• Renal function/proteinuria
• Carotis artery intima thickness excellent
  surrogate marker for developing atherosclerosis
• Fundi !!

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Drug use evidence based

• For all drugs start on a low dose and titrate
  up,
• Elderly patients good old old fashioned drugs
  best
• If our aim is 140/90 start on thiazide
  (problems diabetes, gout, hyperkalaemia).
  Chlortalidone in the elderly to be excluded as
  more neagtive metabolic impact.
• Dihydropyridine CCBs are as effective but have
  more side effects
• ACE/ARB in the elderly were always used if there
  is a second reason to use them, e.g. heart
  failure, proteinuria, diabetes, post MI. Recent
  trials suggest a more prominet place in the
  elderly for ACE/ARB as they are well tolerated
  and have few side effects.
• Beta blockers not attractive unless other
  indications as angina at the same time

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Diagram treatment options
Sec causes CV risk assessment Target organ damage
Special group Alpha blockers in elderly men
with BPH Alpha methyldopamin
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My personal view ?

• We OVERTREAT our elderly with antihypertensives
  as well as with lipid lowering agents. We
  contribute with that to falls, stroke and side
  effects impacting quality of life
• After discharge from a hospital a careful review
  of medication changes that took place is
  warranted, a cut back is likely !!

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New Case

• Jessica is a 82 year old woman, managing well at
  home and taking care of her husband
• Stroke 2 years ago, remains with mild residual
  left sided weakness, mobile with stick
• Med thiazide, inhalers for COPD, and aspirin 100
  mg OD
• She is a non-smoker, no overweight
• eGFR is 48 ml/min, electrolytes normal
• You find her to have persistenly a systolic BP of
  160/74

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Questions

• Is it beneficial to treat this level of BP at her
  age ?
• Are there any risks from drug treatment to lower
  her BP ?
• Which agents are most useful in this age group ?

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Facts

• Most hypertension trials have excluded the
  elderly and those with significant co
  morbidities
• Those that were done until recently only with
  diuretics
• There is good evidence for a relationship between
  the BP and survival in the elderly
• But low BP, especially diastolic is associated
  with lower survival, so small bandwidth to
  operate in
• Most clinical trial have confirmed this, with
  reduction of stroke and heart failure with 30-40
  and MI with 25 but the treatment itself
  increased mortality
• The treshold for treatment is higher than in
  younger people
• The aim should be consider treatment if syst BP
  is over 160, but do not work towards a syst BP
  lower than 140 !

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Benefits-studies (1)

• ANBP Study (Oz) recruited 6083 pat aged 64-84.
• Randomised to enalapril or HCT follow up for
  median time of 4.1 years
• Compared to HCT, the hazard ratio for any CV
  event was 0.89 in the ACE group
• But the protection of the ACE inhibitor was only
  significant in men !

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Benefits-studies (2)

• SCOPE trial (Study of COgnition and Prognosis in
  the Elderly) had 5000 pat aged 70-89 years with
  SBP 160-180 or DBP 90-99
• Randomised to candesartan or diuretic
• In candesartan group reduction of MAP of 22 mmHg
  against 18 in diuretics
• Marked reduction in stroke in candesartan but no
  decrease in overall CV event rate
• Cognitive functional decline similar in both
  groups over the 3.7 years of follow up

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Benefits-studies (3)

• HYVET (HYpertension in the Very Elderly Trial)
  very recently finished
• 4000 Patients over 80 with SBP gt 160
• Randomised to indapamide 1.5 mg or placebo
• If needed perindopril was added in treatment
  group
• 21 reductions of death from any cause, CV deaths
  reduced by 23, Stroke by 30, Heart failure by
  64 over 2 years with a MAP reduction of 15 mmHg
• In a 5 year follow up the advantages of treatment
  are less obvious

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SBP gt 160
BALANCE
Est. longevity
Risk of CV event In next 2-5 yrs
Quality of Life
End organ damage
Target SBPgt140
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Target SBP gt 140
Treatment Preference
Monitor U/E
Diuretics
Less metabolic risk
Indapamide
ACE / ARB
LVH, CCF, CKD
If dementia risk
CCB
Angina or MI
Beta Blockers
Caution if DBPlt80