Hypertension Management for Elderly Patients
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Transcript of Hypertension Management for Elderly Patients
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Hypertension Management for Elderly Patients
Mark A. Supiano, M.D.
Professor and Chief,
University of Utah Geriatrics Division
Director, VA Salt Lake City GRECC
Executive Director, University of Utah Center on Aging
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LEARNING OBJECTIVES
Identify the core components of the hypertension syndrome characteristic of older patients.
Describe how these core components of the hypertension syndrome contribute to elevated systolic blood pressure and pulse pressure.
Specify the current treatment recommendations for geriatric hypertension.
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OUTLINE
Epidemiology Physiology of BP Regulation Diagnosis and Evaluation Treatment
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Hypertension Prevalence by Age and Gender
35-44 45-54 55-64 65-74 >750
25
50
75
100Men
Women
Age
NHANES III; 1999-2002; CDC NCHS Data
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Residual lifetime risk for developing hypertensionWill you live long enough to develop hypertension?
Time (years)
Women age 55% (95% confidence interval)
Women age 65% (95% confidence interval)
10 52 (46-58) 64 (60-69)
15 72 (68-76) 81 (77-84)
20 83 (80-86) 89 (86-92)
25 91 (89-93) –
Vasan et al.; JAMA 287:1003, 2002
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AgingAging
InsulinInsulinresistanceresistance
Sympathetic Sympathetic Nervous Nervous
System ActivationSystem Activation
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Characteristics of Geriatric Hypertension
Decreased vascular compliance Decreased baroreceptor sensitivity Salt-sensitivity of blood pressure Increased total and central adiposity Neurohumoral characteristics
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Aging: Vascular Changes
Increased thickness of intima and media.
Matrix collagen deposition increased fibronectin crosslinking (Advanced
Glycosylation Endproducts)
Net result is increased vascular stiffness.
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Consequences of decreased vascular compliance
Relative increase in systolic pressure. Increase in pulse pressure (SBP – DBP) Decreased baroreceptor sensitivity?
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Consequences of Decreased Baroreceptor Sensitivity
Increased BP variability Impaired BP homeostasis
Hypertension Postural (orthostatic) hypotension Post-prandial hypotension
Increase in sympathetic nervous system activity
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Dengel et al., Am J Physiol 274:E403, 1998
Salt Sensitivity of Blood Pressure
Definition: Mean arterial blood pressure on high vs. low Na+ diet > 5 mm Hg increase => Sodium Sensitive < 5 mm Hg increase => Sodium Resistant
Two thirds of older hypertensives are sodium sensitive.
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Obesity (BMI > 30 kg/m2) by age and gender
20-34 35-44 45-54 55-64 65-74 >750
10
20
30
40
50Men
Women
Age (years)
NHANES III; 1999-2002; CDC NCHS Data
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Characteristics of Geriatric Hypertension -2-
Neurohumoral Characteristics Metabolic insulin resistance Sympathetic nervous system function
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0
2
4
6
8
10
12
14
60 70 80 90 100 110 120 130
Normotensive n=46 Hypertensive n=14
SI
(10
-5
/min/pM)
Mean Arterial BP (mm Hg)
SI=16.1 - (0.113)(MABP) S
I=16.0 - (0.113)(MABP)
r= - 0.487; P=0.004
Su
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Hypertension and Insulin Resistance
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Aging and SNS Function
Compared with younger people:
sympathetic nervous system activity increases.
adrenergic receptor responsiveness is reduced. Decreased chronotropic
response to -agonists.
Shannon et al., NEJM 342:541, 2000
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Hypertension and SNS Function
Compared to normotensive older people, older hypertensives are characterized with: Further increase in SNS activity Relatively greater -mediated vasoconstriction
Supiano et al., Am J Physiol 276:E519, 1999
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Summary: Vascular and Neurohumoral Characteristics
Decreased vascular compliance.
Decreased baroreceptor sensitivity.
Salt-sensitivity of blood pressure.
Increased total and central adiposity.
Metabolic insulin resistance.
Heightened SNS activity. Increased -adrenergic
receptor responsiveness.
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OUTLINE Epidemiology
Physiology of BP Regulation
Diagnosis and Evaluation Measurement issues
Secondary causes
Classification
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JNC VI. Arch Int Med 157: 2413, 1997
Measurement Matters!Auscultatory BP Measurement Method
Sitting. Bare arm. Arm supported at heart level (5-6 mmHg increase if arm vertical).
Resting for five minutes. Proper cuff size. Use calibrated aneroid manometer. Palpate SBP. Record phase 1 (first sound) and phase 5
(disappearance) Korotkoff sounds as SBP and DBP. Two or more readings taken several minutes apart
should be averaged.
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Blood pressure must be measured in older persons with special care ...
In addition, older patients are more likely than younger patients to exhibit an orthostatic fall in blood pressure and hypotension; thus, in older patients, blood pressure should always be measured in the standing as well as seated or supine positions.
JNC VI. Arch Int Med 157: 2413, 1997
Measurement Issues: Posture
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Measurement Issues: Multiple Measurements
Hypertension should not be diagnosed on the basis of a single measurement.
BP variability is higher in older hypertensive individuals. Decreased baroreceptor sensitivity.
Diagnosis of hypertension should be based on: Average of readings from three visits. Three separate readings recorded at each visit.
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Evaluation of Patient with White-coat Hypertension: Ambulatory (24 hour) Monitoring
Advantages: BP profile over 24 hour period.
Nocturnal dipper pattern. BP load: correlates with target organ damage. Useful to evaluate white coat hypertension, drug
resistance, secondary causes, hypotensive symptoms.
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Evaluation: Secondary Causes
Primary hypertension is the most common form of hypertension in older persons.
A sudden increase in DBP, malignant HTN or resistant HTN should prompt an evaluation for secondary causes.
Renovascular disease and medication interactions are most common secondary causes.
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Blood Pressure ClassificationJNC 7
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 Hypertension 140–159 or 90–99
Stage 2 Hypertension >160 or >100
BP Classification SBP mmHg DBP mmHg
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Role of SBP in Classification
In the older hypertensive population, the level of SBP will correctly classify the stage of hypertension in 99% of patients. Lloyd-Jones Hypertension 34:381, 1999
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Simplified JNC 7 Classification
BP Classification SBP
Normal < 120
Pre-hypertension 120-139
Stage 1 Hypertension 140-159
Stage 2 Hypertension ≥ 160
JNC 7 Report. JAMA. 2003:2560
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OUTLINE
Treatment Efficacy Systolic BP and Pulse Pressure Matter Treatment Goals Non-pharmacological therapy Pharmacological therapy
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Treatment of hypertension in older persons has
demonstrated major benefits.
JNC 7 Report. JAMA. 2003:2560
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SHEP Study; JAMA 265:3255; 1991
35% reduction in stroke rate
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Treating hypertension reduces cardiovascular risk and mortality
0.4 0.6 0.8 1.0 1.2 1.4
Total Mortality
CVD MortalityCVD Events
Stroke
CHF
CHD
Favors Diuretics Favors Placebo
Relative Risk
Psaty et al.; JAMA 289: 2534, 2003
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Which is the more dangerous BP?
SBP/DBP MABP Pulse Pressure
Patient 1 140/ 94 109 46
Patient 2 158/84 109 74
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Especially among older persons,
SBP is a better predictor of events
(coronary heart disease,
cardiovascular disease, heart failure,
stroke, end-stage renal disease, and
all-cause mortality) than is DBP. JNC VI, 1997
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Pulse Pressure as CV Risk Factor Framingham data: in those >50 yrs., CV mortality
independently related best to pulse pressure; for given SBP, lower DBP associated with higher mortality. Franklin et al. Circulation 100:354, 1999.
SHEP data analysis: stroke and total mortality associated with pulse pressure independent of mean BP. Domanski et al. Hypertension 34:375, 1999.
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The goal of treatment in older patients should be the same as in younger patients (to
below140/90 mm Hg if at all possible), although an interim goal of SBP below 160 mm Hg may be necessary in those patients
with marked systolic hypertension.
JNC VI, 1997
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Treatment Implications
Optimal anti-hypertensive therapy will: Lower blood pressure. Improve vascular compliance. Increase baroreceptor sensitivity. Decrease central fat mass. Increase insulin sensitivity. Decrease SNS activity. Decrease RAAS activity.
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Non-pharmacological Therapy
CHARACTERISTIC Overweight – central
adiposity Sedentary Salt-sensitive
LIFE STYLE MODIFICATION Weight loss
Exercise program Dietary salt restriction
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Modification Approximate SBP reduction(range)
Weight reduction 5–20 mmHg/10 kg weight loss
Adopt DASH eating plan 8–14 mmHg
Dietary sodium reduction 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg
Lifestyle Modification
JNC 7 Report. JAMA. 2003:2560
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DASH Fact Sheet
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What about exercise?
Aging Exercise Training
Aerobic Capacity Blood Pressure Insulin Sensitivity Adiposity SNS activity Í
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Classification and Management of BP for adults
BP classification SBP*
mmHg DBP*
mmHg Lifestyle
modification
Initial drug therapy
Without compelling indication With compelling indications
Normal <120 and <80 Encourage
Prehypertension 120–139 or 80–89 Yes No antihypertensive drug indicated. Drug(s) for compelling indications. ‡
Stage 1 Hypertension 140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.
Drug(s) for the compelling indications.‡
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.
Stage 2 Hypertension >160 or >100 Yes Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).
*Treatment determined by highest BP category.†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
JNC 7 Report. JAMA. 2003:2560
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Algorithm for Treatment of Hypertension
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)
as needed.
With Compelling Indications
Lifestyle Modifications
Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB, or combination.
Without Compelling Indications
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
JNC 7 Report. JAMA. 2003:2560
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Adverse Effects Common to Antihypertensive Drugs
Orthostatic hypotension postural dizziness or lightheadedness risk factor for falls
Many produce metabolic and/or electrolyte changes
Interactions with other medications
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Overview of Pharmacologic Treatment
All antihypertensive drug classes are effective in older hypertensives.
Thiazide-type diuretics recommended by JNC-7. Avoid direct vasodilators and central adrenergic
drugs. Drug selection should be an individualized
decision. Start low; go slow!
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General Treatment Recommendations for Stage 1, Simple Hypertension
Begin with nonpharmacological approach – weight loss, exercise, salt restriction.
Consider low dose diuretic as initial drug selection; an ACE inhibitor is an alternative.
Base alternative drug selection or combination therapies on individual patient characteristics.
When initiating drug therapy, begin at half of the usual dose, increase dose slowly, and continue non-pharmacological therapies.
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General Treatment Recommendations for Stage 1, Simple Hypertension -2-
Focus treatment goal on systolic blood pressure reduction to 135-140 mm Hg.
Avoid excessive reduction in diastolic blood pressure (below 70 mm Hg).
Aggressive therapy is not appropriate if adverse side effects (e.g., postural hypotension) cannot be avoided.
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BP Control RatesTrends in awareness, treatment, and control of high
blood pressure in adults ages 18–74
National Health and Nutrition Examination Survey, Percent
II1976–80
II(Phase 1)1988–91
II(Phase 2)1991–94 1999–2000
Awareness 51 73 68 70
Treatment 31 55 54 59
Control 10 29 27 34Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.
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SUMMARY
Hypertension is a common condition among the elderly.
Treating high blood pressure lowers the risks of heart attack, heart failure and stroke.
Systolic BP and pulse pressure matter. Optimal blood pressure control should be
achieved using the treatment which is least likely to produce side effects.
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Unanswered Questions
Treatment goals in very old. Conflicts between practice guidelines and
treatment related risks. How to further improve blood pressure control
rate.
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Questions...About our logo...
The bristlecone pine tree (Pinus longaeva) - the earth’s oldest inhabitant with a life span of 4,000 years - is found only in Utah and five other western states. Its extraordinary longevity and ability to adapt and survive in extremely harsh environmental conditions above 10,000 feet embodies the investigative spirit and mission of the Utah Center on Aging.
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References Chobanian, A.V., Bakris, G.L., Black, H.R., et al. The Seventh Report of The Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; The JNC 7 Report. JAMA. 2003;289(19): 2560-2572.
Domanski MJ, Davis BR, Pfeffer MA, et al. Isolated systolic hypertension: prognostic information provided by pulse pressure. Hypertension. 1999;34:375–380.
Psaty, B.M., Lumley, T., Furberg, C.D., et al. Health outcomes associated with various antihypertensive therapies used as first-line agents. A network meta-analysis. JAMA. 2003;289:2534-2544.
The ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuretic. JAMA. 2002;288:2918-2997.
Vasan R.S., Beiser A, Seshadri, S., et al. Residual lifetime risk for developing hypertension in middle-aged women and men. JAMA. 2002;287:1003-1010.
Wing, L.M.H., Reid, C.M., Ryan, P. et al. A comparison of outcomes with angiotensin-converting-enzyme inhibitors and diuretics for hypertension in the elderly. NEJM. 2003;348:583-592.