5. 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; 5:12
6. Men, Age (y) Women, Age (y) Pulse pressure Pulse pressure Mean Systolic and Diastolic BP by Age and Race/Ethnicity for Men and Women (US Population ³Age 18 Years, NHANES III) Burt VI, et al. Hypertension . 1995;25:305-313. 18-29 30-39 40-49 50-59 60-69 70-79 80+ 0 70 80 110 130 150 18-29 30-39 40-49 50-59 60-69 70-79 80+ 0 70 80 110 130 150 0 70 80 110 130 150 0 70 80 110 130 150 DBP (mm Hg) SBP (mm Hg) DBP (mm Hg) SBP (mm Hg) DBP (mm Hg) SBP (mm Hg) DBP (mm Hg) SBP (mm Hg) Non-Hispanic Black Non-Hispanic White Mexican American
7. Control to SBP goal, DBP goal, or both by age group among 1189 treated subjects with hypertension. Open columns represent subjects ≤60 years old (n=295); gray bars, subjects 61 to 75 years old (n=533); filled columns, subjects >75 years old (n=361). Age ≤60 Age 61-75 Age >75 Lloyd-James et al. Hypertens 2000; 36:594-599
10. Relationship between basal supine systolic blood pressure and postural change in systolic blood pressure for aggregate data from older subjects. Postural change in systolic blood pressure (mm Hg) Clin Sci 1985;69:337-341
11. “ If the standing blood pressure is consistently much lower than the sitting blood pressure, the standing blood pressure should be used to titrate drug dosages during treatment.” National High Blood Pressure Education Program Working Group Report on Hypertension in the Elderly.
12. Cerebral Blood flow Percent of Control Strandgaard et al. Lanset 1987; 2:658-661
22. 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. Change in Mean Arterial Blood Pressure Weinberger M. Hypertens 1991; 18:69
23. 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
24. Free End of Point, % Time after Withdrawal, mo TONE Study. JAMA 1998;279:844
25. What is the effect of drug therapy related to age? Are the recommendations different?
26. 5 Year NNTs (Number Necessary to Treat) Age <60 Age ≥60 12 trials, n = 33,000 13 trials, n = 16,564 Stroke NNT = 168 Stroke NNT = 43 CHD event NNT = 184 CHD event NNT = 61 Stroke, CHD NNT = n. a. Stroke, CHD NNT = 18 CV mortality NNT = 205 CV mortality NNT = 52 Mulrow et al. JAMA 1994; 272:1932-1938
27. 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) Prisant, Moser M. Arch Int Med 2000; 160:284
35. 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; 46:273-279
36. HDFP 5 Year Incidence ADR’s 29.1 60 – 69 38.0 50 – 59 36.8 40 – 49 34.1 30 – 39 ADR’s/100/5 Years Age
37. Barriers to Optimal Control of Hypertension Inaccurate 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; 8:524
38. Prevalence of Renal Arterial Lesions in Normotensive and Hypertensive Patients Age, Normotensive Hypertensive Years Normal Lesion Normal Lesion 31-40 7 3 6 10 41-50 26 8 14 22 51-60 99 35 28 50 60+ 69 56 15 48 Eyler WR, Clark MD, Garman JE, et al. Radiology 1962; 78:879-892.