Hypertension in the Elderly
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Hypertension in the Elderly
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Hypertension in the Elderly
- 1. THE RISE AND FALL: Hypertension in the Elderly Marc Evans M. Abat, MD, FPCP, FPCGM Internal Medicine-Geriatric Medicine Head, Center for Healthy Aging, The Medical City Consultant, Philippine General Hospital, Manila Doctors Hospital, St. Luke’s Medical Center
- 2. Issues to Address • Epidemiology of Hypertension in the Elderly • Diagnosis of Hypertension: Any Difference for the Elderly? • Treatment Considerations for the Elderly? • Benefits of Treatment? • Which Drugs to Choose?
- 3. EPIDEMIOLOGY OF HYPERTENSION IN THE ELDERLY
- 4. Top 10 Leading Causes of Mortality MORTALITY: TEN (10) LEADING CAUSES, NUMBER AND RATE/100,000 POPULATION CAUSES 5-Year Average (2001-2005) 2006* Number Rate Number Rate 1. Diseases of the Heart 69,741 85.5 83,081 95.5 2. Diseases of the Vascular System 52,106 64.0 55,466 63.8 3. Malignant Neoplasms 39,634 48.6 43,043 49.5 4. Accidents** 33,650 41.4 36,162 41.6 5. Pneumonia 33,764 41.5 34,958 40.2 6. Tuberculosis, all forms 27,017 33.2 25,860 29.7 7. Chronic lower respiratory diseases 19,024 23.3 21,216 24.4 8. Diabetes Mellitus 15,123 18.5 20,239 23.3 9.Certain conditions originating in the 13,931 17.2 12,334 14.2 perinatal period 10. Nephritis, nephrotic syndrome and nephrosis 9,785 12.0 11,981 13.8
- 5. MORBIDITY: 10 Leading Causes, Number and Rate Diseases 5-Year Average (1955- 1959) 2005 Number Rate Number Rate 1. Acute Lower Respiratory Tract Infection and Pneumonia 694,209 884.6 690,566 809.9 2. Bronchitis/Bronchiolitis 669,800 854.7 616,041 722.5 3. Acute watery diarrhea 726,211 928.3 603,287 707.6 4. Influenza 459,624 587.0 406,237 476.5 5. Hypertension 314,175 400.5 382,662 448.8 6. TB Respiratory 109,369 139.7 114,360 134.1 7. Diseases of the Heart 43,945 56.1 43,898 51.5 8. Malaria 35,970 46.1 36,090 42.3 9. Chicken Pox 79,236 41.1 30,063 36.3 10. Dengue fever 15,383 19.6 20,107 23.6
- 6. Prevalence of Hypertension 70 50 40 30 20 10 0 60 50-59 60-69 ≥70 Percent Prevalence Within Group Age Group Males Females N=3901 patients PJC Vol. 35, No.1 January - June 2007
- 7. PhilHealth-Reimbursed Hospitalizations for Hypertension 2002-2005 0 20 40 60 all HPN-related diagnosis Hypertensive Heart or Renal Disease Other Definite Consequences 60-79 80-100 N=444528 admissions BMC Health Services Research 2008, 8:161
- 8. Risk Factors for Hypertension in the Elderly • Agevery important risk factor
- 9. Age-Related Changes Gradual elongation and stiffening of the aortic wall Increased luminal diameter of the aorta Endothelial cells enlarge, become irregular in shape size and contour Medial hypertrophy Subintimal increase in collagen, smooth muscle and calcification Sodium and intravascular volume responsiveness of blood pressure with aging Noncompliant older aorta is less able to buffer pulsatile output of the heart Decreased β-adrenergic (vasodilator) Suppression of RAS, decreased renin euvolemic elderly Decreased nitric oxide production Autonomic dysfunction Vasoconstriction Lability of BP response
- 10. Other Risk Factors Odds ratio prehypertension 3.5 Current alcohol drinker 1.2 overweight 1.5 Obesity 1.9 Parental history of HPN 1.2 Parental history of DM 1.3 Diabetes mellitus 2.3 microalbuminuria 2.1 macroalbuminuria 4.5 Insulin resistance 1.4-2.7 Insulin levels 1.4-2.0 hypertriglyceridemia 1.3 Hypertension 2006;47;403-409;
- 11. DIAGNOSIS OF HYPERTENSION: ANY DIFFERENCE FOR THE ELDERLY?
- 12. Joint National Commission 7 SBP DBP Normal <120 and <80 Prehypertension 120-139 or 80-89 Hypertension stage 1 140-159 90-99 Hypertension stage 2 ≥160 ≥100
- 13. Diagnosis • Taken on at least 3 BP measurements, on 2 or more office visits • Taken after resting for at least 5 minutes • Proper equipment and instrumentation J Am Coll Cardiol 2011;57:xxx–xx.
- 14. Correct Cuff Sizes 2005, RNAO
- 15. Correct Positioning 2005, RNAO
- 16. White Coat Hypertension • Persistent in-office BP elevations with no evidence of end-organ damage • Out-of-office BP < 140/90 • Intermittent ambulatory BP monitoring may be more appropriate for diagnosis J Am Coll Cardiol 2011;57:xxx–xx.
- 17. Pseudohypertension • Sclerotic, calcified arteries causing non-compressibility • Suspected in those with – Persistent BP elevation – No end-organ damage – Symptoms of overtreatment • May be screened by the “Osler Maneuver” • Intraarterial BP measurement J Am Coll Cardiol 2011;57:xxx–xx.
- 18. Auscultatory Gap • Disappearance of the Korotkoff sounds between Phase 2-3 • May be 10-60 mmHg • Related to arterial stiffness Measure the palpatory blood pressure first then measure the auscultatory blood pressure starting at a level above the previous reading. Unawareness of this phenomenon may lead to an underestimation of the true systolic blood pressure J Am Coll Cardiol 2011;57:xxx–xx.
- 19. Isolated Systolic Hypertension N Engl J Med 2007;357:789-96.
- 20. Other Diagnostic Considerations • BP determination in sitting and standing positions • Detailed Medical History and Physical Examination – Medication Review – Dietary Review – Tobacco, alcohol and other substance abuse
- 21. Work-Up • To assess target organ damage – urinalysis – BUN, creatinine, electrolytes – Lipid profile – FBS and possibly HgbA1C – ECG • Other labs to rule out secondary causes J Am Coll Cardiol 2011;57:xxx–xx.
- 22. Secondary Hypertension • Sleep apnea • Drug-induced • Chronic kidney disease • Primary aldosteronism • Renovascular disease • Chronic steroid therapy or Cushing’s syndrome • Pheochromocytoma • Coarctation of the aorta • Thyroid or parathyroid disease
- 23. TREATMENT CONSIDERATIONS FOR THE ELDERLY?
- 24. The Geriatric Syndromes dementia inappropriate prescribing of medications osteoporosis depression incontinence sensory alterations including hearing and visual impairment delirium iatrogenic problems immobility and gait disturbances falls failure to thrive pressure ulcers sleep disorders
- 25. Target Organ Damage/Compelling Indications • Cerebrovascular disease • Dementia • CAD • LVH and heart failure • cardiac rhythm disorders (atrial fibrillation [AF] and sudden death) • aortic and peripheral arterial disease • CKD • ophthalmologic disorders • Diabetes mellitus • quality of life (QoL) issues (e.g. sexual function) J Am Coll Cardiol 2011;57:xxx–xx.
- 26. Therapeutic Goals • Less than 140 mm Hg systolic and/or 90 mm Hg diastolic – Uncomplicated hypertension – Healthy elderly – <80 years old • For those >80 years old, or frail older patients, targets are unclear J Am Coll Cardiol 2011;57:xxx–xx.
- 27. Lifestyle Modification J Am Coll Cardiol 2011;57:xxx–xx.
- 28. The Difficult Patient • Unable to bring down the blood pressure despite > 4 drugs • Adverse reactions (e.g. falls) • Diastolic blood pressure goes down to <65 mm Hg may have to settle for a higher BP level control J Am Coll Cardiol 2011;57:xxx–xx.
- 29. Diastolic Blood Pressure Figure 1. Percentage of (a) all-cause death and (b) CV death by DBP strata of 10 mm Hg. Protogerou A D et al. Hypertension 2007;50:172-180
- 30. WHICH DRUGS TO CHOOSE?
- 32. Comparison of blood pressure lowering regimens against placebo or less intensive control. BMJ 2008;336:1121-1123
- 33. Blood pressure lowering regimens based on different drug classes for the outcome total major cardiovascular events and age groups <65 versus ≥65. BMJ 2008;336:1121-1123
- 34. Sublingual Antihypertensives • May lead to sudden and drastic BP drops • Complications – Cerebral ischemia – Myocardial ischemia – Falls
- 36. Subgroup analysis: FEVER Study European Heart Journal (2011) 32, 1500–1508
- 37. Subgroup analysis: FEVER Study European Heart Journal (2011) 32, 1500–1508
- 38. Strict vs. Moderate Systolic BP Control Hypertension. 2010;56:196-202;
- 39. BP Nadir by Age and Risk of Events Am J Med. 2010 August ; 123(8): 719–726
Notes de l'éditeur
- Osler maneuver-radial pulse still palpable when cuff is inflated above systolic blood pressure
- Implications: Systolic hypertension is the one more directly correlated with cardiovascular morbidity and mortality Degree of control is now being limited by the corresponding diastolic blood pressure (i.e. level of systolic BP lowering may be limited by excessively low diastolic pressures—important since coronary perfusion occurs during diastole)
- Figure 1. Percentage of (a) all-cause death and (b) CV death by DBP strata of 10 mm Hg.
- Objective To quantify the relative risk reductions achieved with different regimens to lower blood pressure in younger and older adults. Design Meta-analyses and meta-regression analyses used to compare the effects on the primary outcome between two age groups (<65 v ≥65 years). Evidence for an interaction between age and the effects of treatment sought by fitting age as a continuous variable and estimating overall effects across trials. Main outcome measures Primary outcome: total major cardiovascular events. Results 31 trials, with 190 606 participants, were included. The meta-analyses showed no clear difference between age groups in the effects of lowering blood pressure or any difference between the effects of the drug classes on major cardiovascular events (all P≥0.24). Neither was there any significant interaction between age and treatment when age was fitted as a continuous variable (all P>0.09). The meta-regressions also showed no difference in effects between the two age groups for the outcome of major cardiovascular events (<65 v ≥65; P=0.38). Conclusions Reduction of blood pressure produces benefits in younger (<65 years) and older (≥65 years) adults, with no strong evidence that protection against major vascular events afforded by different drug classes varies substantially with age. Fig 1 Comparison of blood pressure lowering regimens against placebo or less intensive control. SBP/DBP difference=overall difference in mean blood pressure during follow-up between treatment groups (actively treated group versus control group), calculated by weighting difference observed in each contributing trial by number of individuals in trial. Negative blood pressure values indicate lower mean follow-up blood pressure in first listed than in second listed groups
- Fig 3 Blood pressure lowering regimens based on different drug classes for the outcome total major cardiovascular events and age groups <65 versus ≥65. SBP/DBP difference=overall difference in mean blood pressure during follow-up between treatment groups (group assigned first listed treatment versus group assigned second listed treatment), calculated by weighting difference observed in each contributing trial by number of individuals in trial. Negative blood pressure values indicate lower mean follow-up blood pressure in first listed than in second listed groups
- Felodipine Event Reduction (FEVER) was a double-blind, randomized trial on 9711 Chinese hypertensives, in whom cardiovascular outcomes were significantly reduced by more intense therapy (low-dose hydrochlorothiazide and low-dose felodipine) achieving a mean of 138 mmHg SBP compared with less-intense therapy (low-dose hydrochlorothiazide and placebo) achieving a mean of 142 mmHg. FEVER included older and younger patients, and patients with and without diabetes or cardiovascular disease. In the analyses here reported, Cox regression models assessed outcome differences between more and less-intense treatments in groups of patients with different baseline characteristics. Significant reductions in stroke were found in uncomplicated hypertensives (239%, P ¼ 0.002), in hypertensives with randomization SBP ,153 mmHg (229%, P ¼ 0.03), and in elderly hypertensives (244%, P , 0.001), when their SBP was lowered by more intense treatment. Significant reductions (between 229 and 247%, P ¼ 0.02 to ,0.001) were also found in all cardiovascular events and all deaths. Achieving mean SBP values ,140 mmHg by adding a small dose of a generic drug prevented 2.1 (uncomplicated hypertensives) and 5.2 (elderly) cardiovascular events every 100 patients treated for 3.3 years.
- The reason for the lack of significant difference in the risk of events for the group < 65 years old was attributed to the already relatively lower risk at baseline compared to the group > 65 years old (which had higher risks for events)
- Abstract—In this prospective, randomized, open-label, blinded end point study, we aimed to establish whether strict blood pressure control (140 mm Hg) is superior to moderate blood pressure control (140 mm Hg to 150 mm Hg) in reducing cardiovascular mortality and morbidity in elderly patients with isolated systolic hypertension. We divided 3260 patients aged 70 to 84 years with isolated systolic hypertension (sitting blood pressure 160 to 199 mm Hg) into 2 groups, according to strict or moderate blood pressure treatment. A composite of cardiovascular events was evaluated for 2 years. The strict control (1545 patients) and moderate control (1534 patients) groups were well matched (mean age: 76.1 years; mean blood pressure: 169.5/81.5 mm Hg). Median follow-up was 3.07 years.
- BACKGROUND—Our understanding of the growing population of very old patients (aged ≥80 years) with coronary artery disease and hypertension is limited, particularly the relationship between blood pressure and adverse outcomes. METHODS—This was a secondary analysis of the INternational VErapamil SR-Trandolapril STudy (INVEST), which involved 22,576 clinically stable hypertensive coronary artery disease patients aged ≥50 years. The patients were grouped by age in 10-year increments (aged ≥80, n = 2180; 70–<80, n = 6126; 60–<70, n = 7602; <60, n =6668). Patients were randomized to either verapamil SR- or atenolol-based treatment strategies, and primary outcome was first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. RESULTS—At baseline, increasing age was associated with higher systolic blood pressure, lower diastolic blood pressure, and wider pulse pressure (P <.001). Treatment decreased systolic, diastolic, and pulse pressure for each age group. However, the very old retained the widest pulse pressure and the highest proportion (23.6%) with primary outcome. The adjusted hazard ratio for primary outcomes showed a J-shaped relationship among each age group with on-treatment systolic and diastolic pressures. The systolic pressure at the hazard ratio nadir increased with increasing age, highest for the very old (140 mm Hg). However, diastolic pressure at the hazard ratio nadir was only somewhat lower for the very old (70 mm Hg). Results were independent of treatment strategy.