Presenter: Norman Kaplan, M.D.

1. Presenter:Norman Kaplan, M.D. DISCLOSURE Dr. Kaplan is a consultant to almost all of the major pharmaceutical companies that market antihypertensive drugs. He has received funding for studies, seminars, and travel from such companies.

2. HYPERTENSION IN THE ELDERLY

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

4. LIFETIME RISK OF DEVELOPING HYPERTENSION IN FRAMINGHAM SUBJECTS NORMOTENSIVE AT AGE 55 OR 65 Vasan et al. JAMA 2002;287:1003

7. Postural Fall in BP in Elderly People Lipsitz et al. Clin Sci 1985;69:337

8. 72 y/o w/m professional BP age 50 = 130/80 BP age 60 = 145/90 BP age 72 = 175/75 Your Diagnosis is: What should you do?

9. HISTORY: Weight change Physical activity Alcohol intake Medications Memory Sexual function +10 lbs in the last year Minimal Occasional beer NSAID 3-4 times/week Good Borderline

10. PHYSICAL EXAM: BP supine and standing Fundoscopy Pulses (carotid, aortic, femoral, dorsalis pedis) Thyroid size Heart size and rhythm Abdominal bruit Cognitive and emotional state 180/85 – 155/75 Arteriolar narrowing Intact Non-palpable Normal None Normal

11. LABORATORY: Hematocrit Urinalysis with microalbuminuria Serum Na+, K+, creatinine, glucose Lipid profile: LDL, HDL, triglycerides ECG 42% Negative 140, 3.8, 1.2, 90 122, 45, 128 Normal

12. If the above are all fairly normal, What next? 24-hour ambulatory blood pressure monitoring or multiple home BPs under varying conditions

13. White-Coat Effect with Age Mansoor et al. J Hum Hypertens 1996;10:87

15. DAY 1 7:00 a.m. 180/80, 172/80, 165/76 12 noon 172/76, 165/80, 160/72 5:00 p.m. 198/94 5:02 p.m. 163/80, 155/74, 158/76 10:00 p.m. 150/74, 143/72, 140/70

16. DAY 14 7:30 a.m. 160/84, 155/80, 154/74 7:31 a.m. 130/68 7:32 a.m. 145/76 7:33 a.m. 155/80

17. DAY 18 5:00 p.m. 160/85, 154/80, 155/82 5:45 p.m. 132/72 6:30 p.m. 145/84

18. DAY 30 7:00 p.m. 165/85, 160/80, 156/82 What should you do? Diagnose Isolated Systolic Hypertension Re-emphasize healthy lifestyles Advise protection against postural falls Start antihypertensive therapy

20. Odds Ratio for Incidence of Dementia According to Alcohol Consumption Among Older People (Average Age: 77) From Mukamal KJ et al. JAMA 2003;289;1405

21. Wine and Beer Consumption in Relationto Risk of Heart Attach and Stroke WINE : 13 studies involving 209,418 people Relative risk = 0.68 (95% CI 0.59-0.77) versus nondrinkers with maximal effect at 150 ml/day BEER : 15 studies involving 208,036 people Relative risk = 0.78 (95% CI 0.70-0.86) without relation between amount of intake and risk From DiCastelnuovo A, et al. Circulation 2002;105:2836

22. What drug therapy should you prescribe? Low-dose thiazide: HCTZ, 12.5 mg

23. Reduction in Cardiovascular Events with BP Lowering 1.50 1.25 1.00 0.75 .50 0.25 1.50 1.25 1.00 0.75 .50 0.25 P<0.001 P<0.001 • UKPDS C vs A ALLHAT •  ALLHAT/Lis Blacks  ALLHAT/Lis ≥60 y  ALLHAT/Lis CAPPP •  ALLHAT/Aml • MIDAS/NICS NORDIL •  ABCD/NT L vs H CONVINCE   HOT M vs H STOP2/CCBs •  DIABHYCAR INSIGHT •  PROGRESS/Per Odds ratio (experimental/reference) ANBP2  Odds ratio (experimental/reference) HOT L vs H   IDNT2 STOP2/ACEIs •  RENAAL  SCOPE  AASK L vs H LIFE/ALL  PREVENT   MRC2 ELSA   MRC1 PATS  HOPE   ATMH LIFE/DM   NICOLE  EWPHE Syst China   Syst Eur  HEP  SHEP PART2/SCAT  RCT70-80  STOP1 UKPDS L vs H   PROGRESS/Com STONE  -5 0 5 10 15 20 25 -5 0 5 10 15 20 25 Difference (reference minus experimental) in systolic pressure (mmHg) Staessen JA, et al. J Hypertens. 2003; 21:1055–1076.

24. Low Dose Diuretics vs. Others From Psaty BM et al. JAMA 2003;289:2534

26. The Reasons Why Low-Dose Diuretics Should be Initial Therapy 1.    They reduce cardiovascular morbidity and mortality. 2.    They lower blood pressure, particularly in patients consuming excessive sodium. 3.    They enhance the antihypertensive efficacy of all other antihypertensive drugs. 4.    They rarely cause side effects. 5.    They reduce calcium loss and osteoporosis. 6.    They are relatively inexpensive.

27. If urine analysis found microalbumin, what would you recommend? Quantify level of proteinuria Prescribe a long-acting ACEI

28. If SBP remains above 140 mmHg, what next? Long-acting CCB

29. Random Therapy of Elderly with Systolic Hypertension From Morgan et al.Am J Hypertension 2001;14:241

30. What else would you recommend? Aspirin 81 mg, every other day Alcohol, 1 usual portion per day Statin

31. Sever PS, Dahlöf B, Poulter N, Wedel H, et al, for the ASCOT Investigators. Lancet. 2003;361:1149-58

32. Baseline Characteristics Atorvastatin (n=5168) Placebo (n=5137) Characteristic Age* (years) Male (%) Caucasian (%) SBP* (mm Hg) DBP* (mm Hg) TC* (mmol/L [mg/dL]) LDL-C* (mmol/L [mg/dL]) TG* (mmol/L [mg/dL]) HDL-C* (mmol/L [mg/dL]) Number of risk factors* 63.1 ± 8.5 81.1 94.6 164.2 ± 17.7 95.0 ± 10.3 5.5 ± 0.8 (213 ± 31) 3.4 ± 0.7 (131 ± 27) 1.7 ± 0.9 (150 ± 80) 1.3 ± 0.4 (50 ± 27) 3.7 ± 0.9 63.2 ± 8.6 81.3 94.7 164.2 ± 18.0 95.0 ± 10.3 5.5 ± 0.8 (213 ± 31) 3.4 ± 0.7 (131 ± 27) 1.6 ± 0.9 (142 ± 80) 1.3 ± 0.4 (50 ± 27) 3.7 ± 0.9 *Mean ± SD

33. The ASCOT Trial:Atorvastatin vs. Placebo on CHDin Hypertensives From Sever et al. Lancet 2003;361:1149

34. Sudden Deaths by Time of Day Peckova et al. Circulation 1998;98:31

35. Celebrex vs Vioxx on Blood Pressure Whelton et al. Am J Cardiol. 2002;90:959-963

36. CONCLUSIONS 1. Get adequate out-of-office BP measurements. 2. Perform a limited but appropriate work-up. 3. Strongly encourage and monitor necessary lifestyle changes. 4. Initiate drug therapy if BP usually >140 or 90 regardless of age and >130 or 80 in diabetics, renal, or cardiac patients. 5. Start with a low-dose diuretic and sequentially add drugs appropriate to individual patient’s needs. 6. Use home BP measurements to guide therapy and avoid overtreatment. 7. Reach the goal of <140 or 90; if BP still >140 or 90 with adequate diuretic plus 2 more drugs, consider referral to a Hypertension Specialist.