htn in the elderly

7/30/2019 HTN in the Elderly

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Managing Hypertension in the

Elderly: How to Best Achieve

Control


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Objectives

Review the pathophysiology of

hypertension in the elderly

Review the benefits of treatment

Relate unique aspects of management for

older patients


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Epidemiology

Most common primary care diagnosis

35 million office visits per year

Improved awareness, treatment andcontrol 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 > 50 years


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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


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BP Measurement

Home BP checks

Helpful

>135/85 = 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


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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


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Classification of BP

Normal

100


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Classification

Isolated systolic hypertension

Systolic BP of > 140 mm Hg

AND

Diastolic BP < 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


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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


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Pathophysiology


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


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 anddocumented BP readings below 134/90 out of clinic

Prognosis and end-organ damage same as

normotensive patients


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Pathophysiology


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


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Treatment

Goals of therapy

Reduce CV and renal morbidity

and mortality

Reduce vascular dementia in elders

Focus on reducing SBP

Goal is


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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


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Evidence for Elderly and ISH

Treat 19 for 5 years

Prevent 1 CV event


Prevent 1 CV death


Prevent 1 all cause death


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Benefits of Therapy

Outcome Age >60 5y NNT Age


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Treatment

Treatment goals in elderly

ControversialHow low is too low?

HOT trial1998 (mean age 61.5)

Best effect at 130-140/80-85

SHEP trial2000 (mean age 71.6)

No increase stroke protection from 150-140 SBP

DBP


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Ogihara et al. Guidelines for treatment of hypertension in the elderly - 2002 revisedversion. Hypertens Res 2003;26:1-36.

Treatment

Possible goals

Age (years) 60-69 70-79 >80

SBP 140 150 160

DBP 90 90 90


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Case #1



No nephropathy

No CV history



Treatment?

Lifestyle, medications


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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
http://www.nhlbi.nih.gov/http://www.nhlbi.nih.gov/


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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!


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Treatment

Pharmacologic treatment

These meds have been shown to work

ACE inhibitors

Thiazide diuretics

Beta blockers

Calcium channel blockers

Angiotensin-receptor blockers


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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


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Treatment

First line medicationsuncomplicated

hypertension

THIAZIDE DIURETICS!!!

Consider

ACE Inhibitor

ARB

CCB Beta-blocker

Combination


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Treatment

Second line medications

THIAZIDE DIURETICS!!!

Addition of

ACE Inhibitor

ARB

CCB

Beta-blockerConsider 2 drugs initially when BP is

more than 20/10 above goal


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Treatment Trials

ALLHATDouble blind RCT

Sponsored by NHLBI

42,418 age >55 with one CHD risk factor

Amlodipine or lisinopril or doxazosin

VS.

Chlorthalidone

Step 2Atenolol 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


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Treatment Trials

ANBP2Open 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 blocker or blocker or CCB

Step 3Nonstep 2 drugs or diuretic in ACEI

Step 4Nonstep 2 or 3 drugs


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Sawicki. Have ALLHAT, ANBP2 ASCOT-BPLA, and so forth improved our knowledgeabout better hypertension care? Hypertension 2006;48:1-7.

Treatment Trials

ANBP2

Followed for median 4.1 years

Primary endpoint changed

Initial protocolTotal CV events including CV

death; secondary endpoints-death & CHD events

Final pubAll 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


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Treatment Trials

ASCOT-BPLAOpen label RCT

Sponsored by Pfizer

19,257 40-79, > 3 CV risk factors

Amlodipine vs. atenolol

Step 2Add 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 per1000 PY, p = 0.105

Reduction noted in all cause mortalitysecondary endpoint

Amlodipine 13.9 per 1000 PY vs. atenolol 15.5per 1000 PY, p = 0.025

Improved BP control in amlodipine arm led tobetter stroke, CV mortality, PAOD, totalcoronary endpoint and total CV events


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Sawicki. Have ALLHAT, ANBP2, ASCOT-BPLA and so forth improved our knowledgeabout better hypertension care? Hypertension 2006;48:1-7.

Treatment Trials

ASCOTBPLA

Validity issues

Protocol listed statistical significance for

secondary endpoints as 0.01 Lipophilic blockerless effective

Only 55% of patients with blocker + diuretic

Open label design may have introduced bias

Premature termination of trial may influenceoutcome

Does not prove superiority of amlodipinebased regimen


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Thiazide Diuretics

Bendroflumethiazide

Chlorothiazide

Chlorthalidone

Hydrochlorothiazide

Hydroflumethiazide

Methyclothiazide

Metolazone Polythiazide

Quinethazone

Trichlormethiazide


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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


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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


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SHEP 1991, 4739 patients, 57% women

SBP 160-190, DBP


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Sys-China 1998, 2394 patients, 35% women SBP 160-219, DBP


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Choice of Medications

STOP2 - 2000

6614 patients, 70-84 years old

Diuretics/Beta vs. ACEI vs. CCB

No difference in outcomes or BP lowering

SHELL - 2003

1882 patients, >60

Diuretic vs CCB



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NICSEH - 1999

414 patients, > 60 years

CCB vs. diuretic


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


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Treatment of the Old Old

HYVET2008

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 24 mg


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HYVET

Primary endpointany stroke

Secondaryall cause mortality, CVmortality, cardiac death

Beneficial effects seen within 1 year

No increase in serious adverse events Different from pilot study reported in 2006


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HYVET

Total of 2.1 years of therapy

Lowered BP by 15/6 mm Hg

30% decrease in primary endpoint (p=0.06)

39% decrease in stroke deaths (p=0.046)

21% decrease in all cause deaths (p=0.02)

23% decrease in CV deaths (p=0.06)

64% decrease in rate of HF (p


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HYVETRecommendations

Screen for HTN in elderly like anyone else

Begin treatment if SBP is >160 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?


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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


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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

Cognitiondementia and memory, not learning

or perceptual processing

Sexual activity


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SOLVD/SAVE, CIBIS, CAPRICORN, COPERNICUS, RALES, EPHESUS, MERIT-HF,CHARM

Special Consideration

Hypertension with heart failure

Diuretic - A

Beta blocker - A

ACE inhibitorA, NNT = 43

ARB - A

Aldosterone antagonistA, NNT = 50


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BHAT, Norwegian Multi Center Study, PEACE, TRACE, SMILE, HOPE, EUROPA


Hypertension post MI

Beta blockerStd of Care - A

ACE inhibitorA, stable & normal LV fxn

Aldosterone antagonistB


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Hypertension with high CAD risk

Diuretic - A

Beta blocker - A

ACE inhibitor - B

CCB - B


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Hypertension with diabetes

Diureticthiazide induced DM is more benign

Beta blocker - B

ACE inhibitor - A

CCB - B

ARB - A


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Hypertension with chronic kidney disease

ACE inhibitor - A

ARBA

Combine ARB and ACEI


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PROGRESS


Hypertension & recurrent CVA prevent

Diuretic - A

ACE inhibitor - B

Perindopril + indapamideB, 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


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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


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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


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BPLTTC, STOP-2

Conclusions

Persons over 50, SBP is more important

Thiazide diuretics are the mainstay of

treatment, tailor to medical conditionsMost patients will need 2 or more drugs

Patients and providers must be motivated

Lowering BP in patients and populations

is more important than agent


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Case #1



No nephropathy

No CV history



Diagnosis?

Evaluation?

Treatment


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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


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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?


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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


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Question 3


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HTN and LVH

PRESERVE

Enalapril = nifedipine gts

LIVE

Indapamide SR > enalapril

LIFE

Losarten > atenolol

In reversing hypertensive LVH


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Case #3

69 year old white male

No medical history

BP 145/105, 147/102

No meds

Diagnosis?

Evaluation?

Treatment?


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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


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Case #3

Treatment

Sodium restriction

Antimineralocorticoids

Sprinonolactone 25-100 mg tid

If adenoma seen, surgery

BP normal for last two years

htn in the elderly

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