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Projected Increases in U.S. Population >65

Projected Increases in U.S. Population >65. Data from U.S. Census Bureau Figure adapted from Redfield MM. N Engl J Med. 2002;347:1442-1444. Residual Lifetime Risk of Hypertension in Women and Men Aged 65 Years. 100. Men. 80. 60. Women. Risk of Hypertension (%). 40. 20. 0. 0. 2. 4.

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Projected Increases in U.S. Population >65

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  1. Projected Increases in U.S. Population >65 Data from U.S. Census Bureau Figure adapted from Redfield MM. N Engl J Med. 2002;347:1442-1444

  2. Residual Lifetime Risk of Hypertension in Women and Men Aged 65 Years 100 Men 80 60 Women Risk of Hypertension (%) 40 20 0 0 2 4 6 8 10 • 12 14 16 18 20 Follow-up (y) Adapted with permission from Vasan RS, et al. JAMA. 2002;287:1003-1010.

  3. Frequency of Untreated Hypertension According to Subtype and Age Adapted with permission from Franklin et al. Hypertension 2001;37:869.

  4. Risks of Hypertension in the Elderly

  5. Odds for the likelihood of a cardiovascular event with combined SBP and DBP categories in the Framingham Heart Study Source: Adapted from Franklin et al. Circulation 2009; 119:243

  6. Elastic Properties of Human Aorta Figure adapted from Hallock & Benson. J Clin Invest 1937;16:595

  7. Aortic Pressure Waveform

  8. Increased Central Pulse Pressure D PP IncreasedLV Load Decreased Coronary Artery Perfusion Pressure in Diastole The Impact of the Early Wave Reflection • The earlier return to the heart of the reflected pressure wave changes the central blood pressure waveform, with 3 key clinical implications • Central pulse pressure increases ... increasing risk of stroke and renal failure • LV Load increases…. increasing LV mass, and accelerating progress towards LV hypertrophy and heart failure • Coronary artery perfusion pressure in diastole reduces…. increasing risk of myocardial ischemia

  9. Mr. G.B., age 78, retired financial advisor History: • Progressively rising systolic BP over past 10 years • Initial therapy with a CCB but bothered with pedal edema • Now taking atenolol, 100 mg q AM • Bothered with recurrent transient dizzy spells, diagnosed as TIAs

  10. Physical Exam: • BP = 17O/85(supine); • 135/70(standing) • Fundi: silver wiring, moderate A/V nicking • Carotid pulses: 3+ systolic bruits bilaterally • Pedal pulses: diminished

  11. Laboratory • Hematocrit - 47% • Urine - 2+ proteinuria • Serum K - 4.2, creatinine - 1.4 estimated GFR= 58 • LDL- cholesterol = 170; HDL- cholesterol =38 • ECG - left ventricular hypertrophy

  12. 24-Hour ABPM of a 78 y/o Man

  13. Non-Drug Therapies • Moderate dietary sodium reduction • Increase physical activity after correcting his postural hypotension • Follow a healthier diet • Encourage moderate alcohol consumption

  14. Weight Loss with Various Therapies

  15. Change in Mean Blood Pressure with Acute Increases in Sodium Excretion Figure adapted from Weinberger and Fineburg. Hypertension 1991;18:67

  16. How Much Sodium at McDonalds • Chicken Selects 3,100 mg • Caesar Salad with Chicken 1,410 mg • Quarter Pounder with cheese 1,390 mg • McVeggie Burger 1,200 mg • Chicken McGrill 1,010 mg • French fries, medium 430 mg

  17. Contributions of different Components of the Mediterranean Diet to Lower Mortality Moderate alcohol consumption 24% Low consumption of meat 17% High consumption of vegetables 16% Other 4 components 10% each Source: Trichopoulou et al. BMJ 2009;338:b2337.

  18. Anti-hypertensive Drug Therapies

  19. Coronary events and strokes in drug comparison trials Figure adapted from Law et. BMJ 2009;338:b1665

  20. Coronary events and strokes in drug comparison trials Figure adapted from Law et. BMJ 2009;338:b1665

  21. CARDIOVASCULAR RISK REDUCTION AND ACHIEVED SYSTOLIC BLOOD PRESSURE IN LARGE PROSPECTIVE RANDOMIZED TRIALS Figure adapted from Kalaitzidis, R et al. J Clin Hypertens 2009; 11:345

  22. Ambulatory BP Change With HCTZ 50 mg or Chlorthalidone 25 mg 6 2 - 2 - 6 Change in Systolic BP (mm Hg)(week 8 – week 0) - 10 - 14 - 18 HCTZ - 22 Chlorthalidone - 26 - 30 6AM 8AM 10AM 12PM 2PM 4PM 6PM 8PM 10PM 12AM 2AM 4AM 8 vs 11 6 vs 13 Ernst ME et al. Hypertension. 2006;47:352-358. (with permission)

  23. β-Blockers and Clinical Outcomes Figure adapted from Lindholm LH, et al. Lancet. 2005;366:1545-1553.

  24. Ouzan Nishizaka Mahmud Chapman -9.5 -10 -12 -13 -21.9 -24 -25 -28 Spironolactone, 25-50mg/d, in Resistant Hypertensives Blood Pressure reductior (mm Hg)

  25. The hypertension-promoting effects of aldosterone Figure adapted from Stas S et al. Journal of Clinical Hypertension. 2008;10:94.

  26. Advantages of Combinations of Drugs with Different Modes of Action • Achieve greater BP reduction • Modify multiple mechanisms of hypertension • Induce fewer dose-dependent side effects • Improve adherence to therapy • Reduce cost of medications

  27. BP and Edema with CCB ± ACEI Data from A.H. Gradman et al. Am J Cardiol 1997;79:431

  28. Meta-Analysis of Statins on Stroke Figure adapted from Heart Protection Study Group. Lancet 2004;363:757

  29. ABPM of a 78 y/o Man on atenolol

  30. Management of This Elderly Hypertensive • Overcome postural and post-prandial hypotension • Discontinue atenolol • Start low dose chlorthalidone with spironolactone or eplerenone • Add long –acting CCB or ARB • Encourage physical activity • Drink 1 or 2 glasses of an alcohol-containing beverage every day • Start a low-dose statin • Measure home blood pressures

  31. A Polypill:The Best Solution forPre- and Post-Hypertension

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