Hypertension in the Very Elderly Lisheng LIU

1. Hypertension in the Very ElderlyLisheng LIU

2. Epidemiology • HYVET Study

4. The prevalence of hypertension in elderly population for China & Japan from the national surveys conducted in 1992 & 1993 Japan definition: 160/95 mmHg; China definition: 160/95 mmHg or under antihypertensive treatment XH Zhang, BHLI 2009

5. The effect of SBP on stroke mortality by age groups in Chinese elderly populations 16.0 Age>=78y Age=74-77y Age=70-73y 8.0 4.0 RR of stroke mortality 2.0 1.0 0.5 <140 140-159 160-179 >=180 SBP (mmHg) XH Zhang, BHLI 2009

6. 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 1986 1991 1996 2001 2006 Stroke mortality in Asian menfrom 1987 to 2007 Mortality, per 100,000 Year Japan Korea Hong Kong Singapore China_rural China_urban

7. 4000 3500 3000 2500 Mortality, per 100,000 2000 1500 1000 500 0 1986 1991 1996 2001 2006 Hong Kong Japan Korea Singapore China_rural China_urban Stroke mortality in Asian womenfrom 1987 to 2007 Year

8. Blood pressure and stroke mortality in the Chinese elderly cohort (n=4814) XH Zhang, BHLI 2009

9. Blood pressure and stroke mortality in the Chinese elderly cohort (n=4814) XH Zhang, BHLI 2009

10. The effects of BP on the risk of stroke mortality by age gr. in the elderly (Cox proportional hazard regression model, controlled for age and smoking, stratified by sex) XH Zhang, BHLI 2009

11. Stroke mortality (per 100,000 population per year) of elderly (≧80yrs) in Asia in the latest available year XH Zhang, BHLI 2009

12. Thedevelopment trend of the elderly population( number in 100 million ) Data source：Du P. Policy research on aging in 21 century in China ,1999

13. BMI & Hypertension Prevalence （3257 sub., Beijing) Prevalence（％） BMI age XH Fang, Chinese J. of Epidemiology, 2002；23：28-31

14. Metabolic Syndrome in Beijing（1827 sub., 2000） ％ SC Guan. Chinese J. of Geriatrics, 2006;25(3):219-221

15. Overweight & Obesity in Beijing（1827 sub., 2000） ％ SC Guan. Chinese J. of Geriatrics, 2006;25(3):219-221

16. BMI & 5 Yr. All Cause Mortality <75岁 >=75岁 ％ BMI XH Fang, et al. Chinese J. of Epidemiology, 2002;23:28-31

17. Cognitive Function & 5 Yr. Survival Rate ％ FU (mon.) S. Meng, Chinese J. of Geriatrics, 2004;23:507-509

18. Renal Function (CISC cohort)

19. GFR in each age group (weighted and not)

20. Conclusions • The over-80’s are the fastest-growing group on the planet • Age and SBP are two major components of CV risk • Antihypertensive therapy reduces CV risk and mortality in patients under 80

21. Epidemiology • HYVET Study

28. Baseline data ‡ Fall in SBP ≥ 20mmHg and/or fall in DBP ≥ 10mmHg

29. Baseline Data (Previous Cardiovascular History)

30. Baseline data (Cardiovascular Risk factors)

31. Reported characteristics of subjects at entry to the HYVET 1) in China and 2) in the other Countries. Statistical comparisons include a gender x region interaction term CHF=Congestive Heart Failure; ‡Gender difference (P<0.01);﹡﹡Regional difference (P<0.01);￥Statistically significant interaction term (P<0.05)

32. Measurements on subjects entered in the HYVET at baseline †Gender difference(P<0.05); ‡Gender difference（P<0.0 I）;＊＊Regional difference (P<0.01)＊Regional difference (P<0.05);￥Gender regional interaction term (P<0.05) ￥￥ Gender regional interaction term (P<0.01)

33. Chinese subjects in HYVET • Were slightly younger, had less previous hypertension but more previous strokes. • Smoked more than the other trial participants but drank less alcohol. • Less previous episodes of MI, lighter & shorter. • Had lower mean concentrations of blood urea, uric acid and Cr & higher concentrations of HDLC. Blood glucose & TC lower. Serum Na & K, blood haematocrit & Hb were all lower.

34. Blood pressure separation 15 mmHg Median follow-up 1.8 years 6 mmHg

35. All stroke (30% reduction) Placebo P=0.055 Indapamide SR ±perindopril Placebo IndapamideSR ±perindopril

36. Total Mortality (21% reduction) Placebo P=0.019 Indapamide SR ±perindopril Placebo IndapamideSR ±perindopril

37. Fatal Stroke (39% reduction) Placebo Indapamide SR ±perindopril P=0.046 Placebo IndapamideSR ±perindopril

38. Heart Failure (64% reduction) Placebo P<0.0001 IndapamideSR ±perindopril Placebo IndapamideSR ±perindopril

39. 0.1 0.2 0.5 0 2 ITT – Summary

40. Per-Protocol

41. Biochemical Changes from Baseline (2 year cohort) • In 2 year cohort there were no significant • differences between the groups with regard • to change in serum…. • Potassium • Uric acid • Glucose • Creatinine • At 2 years 73.4% on combination • treatment in act. (85.2% pl.)

42. Safety Reported serious adverse events (after randomisation) 448 in the placebo group vs 358 in active (p=0.001) Only 5 categorised by the local investigator possible SADRs (3 in placebo group, 2 being in active)

43. Conclusions Antihypertensive treatment based on indapamide (SR) 1.5mg (± perindopril) reduced stroke mortality and total mortality in a very elderly cohort. NNT (2 years) = 94 for stroke 40 for mortality Large and significant benefit in reduction of heart failure events and for combined endpoint of cardiovascular events Benefits seen early Treatment regime employed was safe

44. Cautions Subjects recruited generally healthier than those within a general population Benefit from treating systolic pressures less than 160mmHg requires further research Target BP was 150/80 mmHg Benefit from lower targets still needs to be established

46. Characteristics of Very Elderly Hypertensive Patients with Atrial Fibrillation (AF) in HYVET J. of Hypertension, 2006, Abstract Book

47. Atrial fibrillation in ChineseNo.29,079 ,Age 30-85, ( 2001)

48. Overweight in 1575 subjects (May, 2004)

49. Standing BP fall in untreated by age (95% CI) N. Beckett, et al., J. of Hypertens 2004;22(Suppl. 2):S291

50. Co-Morbidity for 2216 patients in HYVET(Age 83.8 yrs. & mean sitting BP was 173.7 mmHg)