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HYPERTENSION IN ELDERLY. Dr. Kunal Kothari Emeritus Professor of Medicine and Clinical Cardiology Director Primary Health Care and Strategic initiative. S. L. O. W. I. K. I. L. E. R. L. E. N. T. HYPERTENSION. Sphygmanometer- size of the cuffs Food Exercise

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hypertension in elderly
HYPERTENSION IN ELDERLY

Dr. Kunal Kothari

Emeritus Professor of Medicine and Clinical Cardiology

Director Primary Health Care and Strategic initiative

slide2

S

L

O

W

I

K

I

L

E

R

L

E

N

T

HYPERTENSION

slide3
Sphygmanometer- size of the cuffs

Food

Exercise

Caffeine

Smoking

200

180

160

140

K1

A sharp thump

K2

120

A blowing or whooshing sound

K3

100

A softer thump

K4

80

A softer blowing sound

60

40

20

0

K5

slide4

Benefits of Lowering Blood Pressure

Antihypertensive Therapy has been associated with reductions in:

  • Stroke Incidence (35-40 %).
  • MI (20-25 %).
  • Heart Failure ( averaging > 50 %).
guidelines
Guidelines

The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults:

slide6

Clinic Pressure

White Coat Hypertension

Sustained Hypertension

140/90

True Normotension

Masked Hypertension

135/85 Ambulatory Pressure

pseudo hypertension
Pseudo Hypertension
  • Recording of high B.P. but do not have
  • Common cause of this is brachial artery compression
white coat hypertension
WHITE COAT HYPERTENSION
  • BP recording in office or clinic is high while at home is normotensive
  • "white coat" hypertension appear to have no greater risk than people with normal blood pressure ( Aug. 2, 2005, American college of cardiology )
masked hypertension

MASKED HYPERTENSION

Proposed the term masked hypertension

Pickering et al (Hypertension 2002;102:1139-44)

Documented by Ohkubo et al (N Engl J Medicine 2003;348:2407-15)

masked hypertension10
MASKED HYPERTENSION
  • HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. "UNDETECTED AMBULATORY HYPERTENSION"
  • UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION
  • SHOW MORE EXTENSIVE TARGET ORGAN DAMAGE THAN TRUE NORMOTENSIVE SUBJECTS
blood pressure in 347 978 men aged 35 57 screened for mrfit
Blood Pressure in 347,978 men aged 35-57 screened for MRFIT

¼ ½ ¼

% of Men

<110 110-119 120-129 130-139 140-149 150-159 >160

Systolic pressure mmHg

lifetime risk of developing hypertension in middle aged vasan et al jama 2002 287 1010

Lifetime Risk of Developing Hypertension in Middle Aged (Vasan et al, JAMA 2002; 287: 1010)

Risk for Hypertension in a 55 year old

Time, yr Women Men

52% 56%

72% 78%

83% 88%

25 91% 93%

diagnostic evaluation of the hypertensive patient how much is enough

Diagnostic Evaluation of the Hypertensive Patient- How much is enough?

How high is the blood pressure?

Why is it high?

What is the risk?

clinical manifestations i
Physical exam:

Abdomen

Funduscopic

Vascular

Cardiac

Pulmonary

Neurological

Lab tests:

Urinalysis

Blood Chemistry

ECG

Renal ultrasound

Echocardiogram

Vascular studies

Clinical Manifestations I
differential diagnosis
Differential Diagnosis
  • Rule out isolated incident of increased blood pressure.
  • Rule out secondary hypertension related to:

Renal disease

Cushing\'s disease

Pheochromocytoma

Hyperthyroidism

Hyperparathyroidism

complications
Complications

Complications as a result of HTN include:

Stroke

Dementia

Myocardial Infarction

Congestive Heart Failure

Retinal Vasculopathy

Aortic Dissection

Renal Disease or Failure

management
Management

Medications

Diuretics- Thiazides (HCTZ), Loop (Furosemide), Potassium-sparing (Spironolactone)

Beta-Blockers- Atenolol, Nadolol, Propranolol

ACEInhibitors- Benezapril, Captopril, Cilizapril

ARBs-Losartan, Valsartan

Ca+ Channel Blockers- Nifedipine, Verapamil

Alpha blockers- Prazosin, Terazosin

Vasodilators- Apresoline

management18
Management

Primary goal is to reduce cardiovascular and renal morbidity and mortality.

Other keys to management are:

Prevention

Patient education

Life-style modification

Medication

hospitalization should be considered if
Hospitalization should be considered if

Very high BP

Severe headache

Chest pain

Neurologic symptoms

Altered mental status

Acutely worsening renal failure

S & S of hypertensive emergency

slide22

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

slide23

Arterial Wall Compliance and Pulse Pressure Wave

Elastic Vessel

Stiff Vessel

Systole

Diastole

Systole

Diastole

Stroke Volume

Aorta

Resistance Arterioles

Pressure (Flow)

Young Artery

Arteriosclerotic Artery

Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.

slide26

Change in Mean Arterial Blood Pressure

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.

Weinberger M. Hypertens 1991; 18:69

slide27

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

antihypertensive drugs
AACEI, ARBs

BBeta Blocker

CCCB

DDiuretic

Dlow dose HCTZ

A

B

C

Antihypertensive Drugs
slide30

Algorithm for Management of the Elderly -

  • Primarily Systolic Hypertension
  • 1) Lifestyle changes
  • Low dose diuretic (12.5 mg HCTZ)
  • CCB B-Blocker ACE or ARB
  • 3) Stop, Look & Listen before dosages
  • Let the Baroreceptors reset
  • 4) Rx until goal achieved

+

+

+

+

+

allhat
ALLHAT

The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) suggests that low dose thiazide diuretics have a better cardiovascular protective effect

result highlights
Result Highlights
  • 21% reduction in relative risk death from any cause
  • 64% reduction relative risk heart failure
  • 39% reduction relative risk of death from stroke
syst eur
Syst-Eur

A study called the Systolic-Hypertension Trial in Europe (Syst-Eur) showed that aggressive treatment of hypertension reduces the risk of stroke by 42% and dementia is prevented.

slide34

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

slide35

Major Clinical Trials Showing Benefit of Treating Isolated Systolic Hypertension

SHEP Syst-Eur Syst-China

(n=4736) (n=4695) (n=2394)

Baseline 160-219/ 160-219/ 160-219/

SBP/DBP (mm Hg) <90 <95 <95

BP reduction: 27/9 23/7 20/5

SBP/DBP (mm Hg)

Drug therapy Chlorthalidone Nitrendipine Nitrendipine

Atenolol Enalapril Captopril

HCTZ HCTZ

Outcomes (%)

Stroke 33 42 38

CAD 27 30 27

CHF 55 29 —

All CVR disease 32 31 25

Journal of Clinical Hypertension Vol II, No. 5, page 336, September/October 2000.

slide38

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

slide39

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

slide41

Blood Pressure in SHEP and Syst-Eur (mm Hg)

SHEP Syst-Eur

Entry 160-219/<90 160-219/<95

Goal (SBP) <160 + ≥20  <150 + ≥20 

Baseline 170/77 174/86

Achieved: Rx 143/68 151/79

Achieved: Placebo 155/72 161/84

Difference: Rx-Placebo 12/4 10/5

Journal of Clinical Hypertension, Vol II, No. 5, page 336. March/April 2000.

slide42

REDUCTION OF STROKES WITH BP LOWERING - SHEP TRIAL

No. of Patients: 4736

Follow-up: 4.5 years

37% in ischemic strokes

47% in lacunar infarcts

54% in hemorrhagic strokes

Lower BPs - fewer strokes

Am J Hypertension 2000;13:724-733

hypertension in the very elderly trial nejm 2008 358 18 1887 1898
Double blind, placebo-controlled

International, multicenter

3845 patients

Mean age 83.6 yrs

BP range 160-219/90-109

Mean BP 173.0/90.8

f/u median of 1.8 yrs

Primary endpoints – fatal or non fatal stroke

Indapamide 1.5mg

Perindopril prn (2mg or 4mg)

Mean BP fall 15.0/6.1 at 2 yrs

Hypertension in the Very Elderly TrialNEJM 2008;358(18):1887-1898
result highlights44
Result Highlights
  • 21% reduction in relative risk death from any cause
  • 64% reduction relative risk heart failure
  • 39% reduction relative risk of death from stroke
slide45

GOALS OF TREATMENT

  • To achieve a target BP of <140/ 90 mm Hg.
  • In patients with Hypertension & Diabetes or Renal disease, BP Goal is < 130/80 mm Hg.
  • To reduce cardiovascular morbidity & mortality.
thiazide myths
Thiazide Myths
  • Sulfa cross reactivity
  • Gout
  • Renal stones
thiazide related gout
Thiazide Related Gout
  • Thiazide related hyperuricemia is dose related
  • HDFP Trial: 15 episodes of gout over 5 years in 3693 patients treated with chlorthalidone 25-100mg (equivalent to 50-200 mg HCTZ)
  • Low dose thiazide (HCTZ 12.5-25 mg) is not contraindicated in gout
treatment recommendations for the elderly in jnc 7
Treatment Recommendations for the Elderly in JNC 7

Recommendations are no different according to age for:

  • BP classification
  • BP goals
  • Lifestyle interventions
  • Selection of medications
slide49

JNC 7: New Features and Key Messages

  • For persons over age 50, SBP is a more important than DBP as CVD risk factor.
  • Starting at 115/75 mmHg, CVD risk doubles with each increment of

20/10 mmHg throughout the BP range.

  • Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN.
  • Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.
slide50
Thank You

Dr. Kunal Kothari

Emeritus Professor of medicine and Clinical Cardiology

Director Primary Health care and Strategic initiative

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