Hypertension In elderly population

JNC VII

BP Classification

SBP mmHg DBP mmHg

Normal <120 <80

Prehypertension 120–139 80–89

Stage 1 Hypertension

140–159 90–99

Stage 2 Hypertension

>160 >100

Relook at hypertension

Hypertension is a major cardiovascular risk factor, but knowledge about the real magnitude of the problem and its determinants is lacking.

Hypertension is poorly controlled in most patients with a high risk of cardiovascular disease.

Uncontrolled hypertension is frequently associated with poor control of other risk factors.

Swedish trialScreened: 27,936 subjects (10,953 men and 16,983

women), 45 to 73 years old

16 648 subjects (60%) had hypertension

23 % received

treatment 77 % untreated

88.2% had BP levels > or =140/90 mm Hg

49.5% had BP levels >or =160/100 mm Hg

Li C et al, Stroke. 2005 Apr;36(4):725-30. Epub 2005 Mar 3

US study

According to the third National Health and Nutrition Examination Survey (NHANES III), approximately 60% of the 50 million Americans with hypertension are at increased risk for cardiovascular disease resulting from uncontrolled hypertension.

This is because only 53% of hypertensive patients are being treated and only 24% have their hypertension under control.

Dosh SA et al, J Fam Pract. 2002 Jan;51(1):74-80

Patient awareness- US study91% reported that a health care provider had told them that they have hypertension or high BP

41% of patients did not know their BP level, while 28% of all patients correctly identified the meaning of HTN as "high blood pressure."

34% of patients correctly identified SBP as the "top" number of their reading; 32% correctly identified diastolic blood pressure (DBP) as the "bottom“

Oliveria SA et al, J Gen Intern Med. 2005 Mar;20(3):219-25

Impact of uncontrolled hypertension

Sudden death

Congestive heart failure

(CHF)

Peripheral vascular diseases

StrokeCoronary artery disease

(CAD)

Hypertension is dreadful.

Renal failureLVH

Risk of complications

For individuals aged 40 to 70 years, each increment of 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP doubles the risk of CVD across the entire BP range from 115/75 to 185/115 mm Hg.

JNC VII

Higher incidence of stroke

0

100

200

300

400

500

600

700

800

Controlledhypertensives

Uncontrolledhypertensive

Crude inidenceof stroke

Per 100 000 person-year

2.5 times higher

Li C et al, Stroke. 2005 Apr;36(4):725-30. Epub 2005 Mar 3

Elderly hypertensives

Framingham Heart Study suggest that individuals who are normotensive at 55 years of age have a 90% lifetime risk for developing hypertension.

Hypertension and the presence of other cardiovascular risk factors in older persons (i.e., obesity, left ventricular hypertrophy, sedentary lifestyle, hyperlipidemia, and diabetes) make this population at high risk for morbidity and mortality.

Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

Isolated systolic hypertension

Multiple studies have demonstrated that isolated elevated systolic blood pressure is more prevalent in older persons because of increased large-artery stiffness.

Recommendations from the JNC state that systolic blood pressure should be the primary target for the diagnosis and care of older persons with hypertension.

Goals of Therapy

Treating systolic BP and diastolic BP to targets that are less than 140/90 mm Hg is associated with a decrease in CVD complications.

In patients with hypertension with diabetes or renal disease, the BP goal is less than 130/80 mm Hg.

JNC VII

What is the goal BP?

What is the goal BP?

Although most data support the treatment of older patients with stage 2 isolated systolic hypertension (systolic blood pressure higher than 160 mm Hg), JNC 7 recommends treating older patients with stage 1 isolated systolic hypertension (systolic blood pressure 140 to 159 mm Hg) equally aggressively.

Benefits of Lowering BP

In clinical trials, antihypertensive therapy has been associated with 35% to 40% mean reductions in stroke incidence; 20% to 25% in myocardial infarction; and more than 50% in HF.

It is estimated that in patients with stage 1 hypertension and additional cardiovascular risk factors, achieving a sustained 12-mm Hg

decrease in systolic BP for 10 years will prevent 1 death for every 11 patients treated.

JNC VII

Evidence based medicine

STOP-2Swedish Trial in Old Patients with Hypertension-2 study

Mean age in years

Mean follow up in years

Initial blood pressure (mm of Hg)

Blood pressure after treatment (mm of Hg)

Regimens

76 5 194/98 ~158/80 in both groups

Beta blocker or thiazide (older drugs) vs. ACE inhibitor or calcium channel blocker (newer drugs)

Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

STOP-2

Regimens did not differ in rates of stroke, cardiovascular events, or mortality.

ACE inhibitor better than calcium channel blocker for myocardial infarction (NNT = 26) and congestive heart failure (NNT = 28).

LIFELosartan Intervention For Endpoint reduction in hypertension study

Mean age in years

Mean follow up in years

Initial blood pressure (mm of Hg)

Blood pressure after treatment (mm of Hg)

Regimens

70 4 174/98 ~145/81 in both groups

ARB (losartan) vs. beta blocker (atenolol)

Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

LIFE

ARB better than beta blocker for stroke and combined end point of cardiovascular mortality, stroke, and myocardial infarction.

Regimens did not differ in rates of total mortality.

ALLHATAntihypertensive and Lipid-Lowering Treatment to prevent Heart Attack Trial

Mean age in years

Mean follow up in years

Initial blood pressure (mm of Hg)

Blood pressure after treatment (mm of Hg)

Regimens

67 5 146/84 ~134/85 in all groups

Thiazide (chlorthalidone) vs. ACE inhibitor (lisinopril) vs. calcium channel blocker (amlodipine)

Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

ALLHATRegimens did not differ in combined end point of fatal coronary heart disease or nonfatal myocardial infarction.

Thiazide better than calcium channel blocker for congestive heart failure and angina.

Thiazide better than ACE inhibitor for stroke, cardiovascular disease, congestive heart failure, or revascularization.

Regimens did not differ in rates of total mortality.

INVESTInternational Verapamil-Trandolapril study

Mean age in years

Mean follow up in years

Initial blood pressure (mm of Hg)

Blood pressure after treatment (mm of Hg)

Regimens

66 2 150/87 ~131/77 in both groups

Calcium channel blocker (verapamil) plus ACE inhibitor (trandolapril) vs. beta blocker (atenolol) plus thiazide

(hydrochlorothiazide)

Regimens did not differ in rates of cardiovascular outcomes or total mortality.

ANBP-2Second Australian National Blood Pressure study

Mean age in years

Mean follow up in years

Initial blood pressure (mm of Hg)

Blood pressure after treatment (mm of Hg)

Regimens

72 4 168/91 ~142/79 in both groups

ACE inhibitor (enalapril) vs thiazide (hydrochlorthiazide)

Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

ANBP-2

ACE inhibitor better than thiazide for primary end point of all cardiovascular events or total mortality (NNT = 72) and for myocardial infarction (NNT = 125).

Regimens did not differ in rates of total mortality.

Management of hypertension in elderly

Thiazide-type diuretics

Thiazide-type diuretics should be used as initial therapy for most patients with hypertension, either alone or in combination with 1 of the other classes (ACE inhibitors, ARBs, Beta-blockers, CCBs) demonstrated to be beneficial in randomized controlled outcome trials.

JNC VII

Thiazide-type diuretics

Thiazide-type diuretics have been the basis of antihypertensive therapy in most outcome trials.

In these trials, including the recently published Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, diuretics have been virtually unsurpassed in preventing the cardiovascular complications of hypertension.

Diuretics enhance the antihypertensive efficacy of multidrug regimens, can be useful in achieving BP control, and are more affordable than other antihypertensive agents.

JNC VII

Compelling indications

Indications Antihypertensives as initial therapy

Heart failure Diuretic, Beta blocker, ACE inhibitor, ARB, Aldosterone antagonist

Post MI Beta blocker, ACE inhibitor, Aldosterone antagonist

High coronary disease risk

Diuretic, Beta blocker, ACE inhibitor, CCB

JNC VII

Compelling indications

Indications Antihypertensives as initial therapy

Diabetes Diuretic, Beta blocker, ACE inhibitor, ARB, CCB

Chronic kidney disease

ACE inhibitor, ARB

Recurrent stroke prevention

Diuretic, ACE inhibitors

JNC VII

JNC VII - Tips

Treat isolated systolic blood pressure

Thiazide diuretics should be first-line treatment

Second-line treatment should be based on comorbidities and risk factors

JNC VII - Tips

Patients with systolic blood pressure higher than 160 mm Hg or diastolic blood pressure higher than 100 mm Hg usually will require two or more agents to reach goal

Treatment should be initiated with a low dose of the chosen antihypertensive agent, and titrated slowly to minimize side effects such as orthostatic hypotension

JNC VII - Tips

Weight loss and sodium reduction have been shown to be feasible and effective interventions in older patients with hypertension.

To improve adherence with antihypertensive regimens, involve patients in goal setting, and ensure that the patient's cultural beliefs and previous experiences are incorporated in a treatment plan.

Simplify the medication regimen, keeping in mind how much it costs.

Need of an hour

Implementation of guidelines Closing the gap between experts’

recommendations and poor blood pressure control

in medical practice.

Patient behavior change: Motivation improves when patients have positive experiences with and trust in their clinicians.

JNC VII

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