Presentation Htn Elderly
Transcript of Presentation Htn Elderly
HYPERTENSION IN ELDERLYHYPERTENSION IN ELDERLY
Dr. Kunal KothariDr. Kunal Kothari Emeritus Professor of Medicine and Clinical Cardiology Emeritus Professor of Medicine and Clinical Cardiology
Director Primary Health Care and Strategic Director Primary Health Care and Strategic initiativeinitiative
HYPERTENSION
K I L L E R
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Sphygmanometer- Sphygmanometer- size of the cuffssize of the cuffs
Food Food ExerciseExercise CaffeineCaffeine Smoking Smoking
200
140
160
120
180
20
40
60
80
100
0
A softer blowing sound
A sharp thump
A softer thump
A blowing or whooshing sound
K1
K2
K3
K4
K5
Benefits of Lowering Blood Benefits of Lowering Blood PressurePressure
Antihypertensive Therapy has been Antihypertensive Therapy has been associated with reductions in:associated with reductions in:
Stroke Incidence (35-40 %).
MI (20-25 %).
Heart Failure ( averaging > 50 %).
GuidelinesGuidelines
The Seventh Report of the Joint National Committee The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults:guidelines to define HTN in adults:
CategoryCategory SystolicSystolic DiastolicDiastolic
NormalNormal <120<120 andand <80<80Pre-hypertensionPre-hypertension 120-139120-139 oror 85-8985-89
Stage 1 Stage 1 hypertensionhypertension
140-159140-159 oror 90-9990-99
Stage 2 Stage 2 hypertensionhypertension
>>160160 oror >>100100
135/85 Ambulatory Pressure
140/90
Clinic Pressure Sustained
HypertensionWhite Coat Hypertension
True Normotension
Masked Hypertension
Pseudo HypertensionPseudo Hypertension
Recording of high B.P. but do not Recording of high B.P. but do not havehave
Common cause of this is brachial Common cause of this is brachial artery compression artery compression
WHITE COAT WHITE COAT HYPERTENSIONHYPERTENSION
BP recording in office or clinic is BP recording in office or clinic is high while at home is normotensivehigh while at home is normotensive
"white coat" hypertension appear "white coat" hypertension appear to have no greater risk than people to have no greater risk than people with normal blood pressure with normal blood pressure ( Aug. 2, ( Aug. 2, 2005, American college of cardiology )2005, American college of cardiology )
MASKED HYPERTENSIONMASKED HYPERTENSION
Proposed the term masked hypertensionProposed the term masked hypertension
Pickering et al (Hypertension Pickering et al (Hypertension 2002;102:1139-44)2002;102:1139-44)
Documented by Ohkubo et al Documented by Ohkubo et al (N Engl J (N Engl J Medicine 2003;348:2407-15)Medicine 2003;348:2407-15)
MASKED HYPERTENSIONMASKED HYPERTENSION
HYPERTENSION IS NOT DETECTED BY THE HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. "UNDETECTED AMBULATORY ROUTINE METHODS. "UNDETECTED AMBULATORY HYPERTENSION" HYPERTENSION"
UNUSUALLY HIGH AMBULATORY PRESSURE OR A UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION OCCASION
SHOW MORE EXTENSIVE TARGET ORGAN SHOW MORE EXTENSIVE TARGET ORGAN
DAMAGE THAN TRUE NORMOTENSIVE SUBJECTSDAMAGE THAN TRUE NORMOTENSIVE SUBJECTS
Blood Pressure in 347,978 men Blood Pressure in 347,978 men aged 35-57 screened for MRFITaged 35-57 screened for MRFIT
6.5
19
28
23
13
75
0
5
10
15
20
25
30
35
<110 110-119 120-129 130-139 140-149 150-159 >160
% of Men
Systolic pressure mmHg
¼ ½ ¼
Lifetime Risk of Developing Lifetime Risk of Developing Hypertension in Middle Aged Hypertension in Middle Aged
(Vasan et al, JAMA 2002; 287: 1010(Vasan et al, JAMA 2002; 287: 1010))
Risk for Hypertension in a 55 year oldRisk for Hypertension in a 55 year old
Time, yrTime, yr WomenWomen MenMen
1010 52%52% 56% 56%
1515 72%72% 78% 78%
2020 83% 88%83% 88%
25 91% 93% 25 91% 93%
Diagnostic Evaluation of the Hypertensive Diagnostic Evaluation of the Hypertensive
Patient- Patient- How much is enough?How much is enough?
How high is the blood pressure?How high is the blood pressure?
Why is it high?Why is it high?
What is the risk?What is the risk?
Clinical Manifestations IClinical Manifestations I
Physical exam:Physical exam:AbdomenAbdomenFunduscopicFunduscopicVascularVascularCardiacCardiacPulmonaryPulmonaryNeurologicalNeurological
Lab tests:Lab tests:UrinalysisUrinalysisBlood ChemistryBlood ChemistryECGECGRenal ultrasoundRenal ultrasoundEchocardiogramEchocardiogramVascular studiesVascular studies
Differential DiagnosisDifferential Diagnosis
1.1. Rule out isolated incident of increased Rule out isolated incident of increased blood pressure.blood pressure.
2.2. Rule out secondary hypertension related Rule out secondary hypertension related to:to:
Renal diseaseRenal disease
Cushing's diseaseCushing's disease
PheochromocytomaPheochromocytoma
HyperthyroidismHyperthyroidism
HyperparathyroidismHyperparathyroidism
ComplicationsComplicationsComplications as a result of HTN Complications as a result of HTN
include:include:
StrokeStroke
DementiaDementia
Myocardial InfarctionMyocardial Infarction
Congestive Heart FailureCongestive Heart Failure
Retinal VasculopathyRetinal Vasculopathy
Aortic DissectionAortic Dissection
Renal Disease or FailureRenal Disease or Failure
ManagementManagementMedicationsMedications
DiureticsDiuretics- Thiazides (HCTZ), Loop (Furosemide), - Thiazides (HCTZ), Loop (Furosemide), Potassium-sparing (Spironolactone)Potassium-sparing (Spironolactone)
Beta-BlockersBeta-Blockers- Atenolol, Nadolol, Propranolol- Atenolol, Nadolol, Propranolol
ACEACE InhibitorsInhibitors-- Benezapril, Captopril, Cilizapril Benezapril, Captopril, Cilizapril
ARBsARBs-- Losartan, ValsartanLosartan, Valsartan
Ca+ Channel BlockersCa+ Channel Blockers-- Nifedipine, Verapamil Nifedipine, Verapamil
Alpha blockers-Alpha blockers- Prazosin, Terazosin Prazosin, Terazosin
VasodilatorsVasodilators-- Apresoline Apresoline
ManagementManagementPrimary goalPrimary goal is to reduce is to reduce
cardiovascular and renal morbidity cardiovascular and renal morbidity and mortality.and mortality.
Other keysOther keys to management are: to management are:
PreventionPrevention
Patient educationPatient education
Life-style modificationLife-style modification
MedicationMedication
Hospitalization should be Hospitalization should be considered ifconsidered if
Very high BPVery high BP
Severe headacheSevere headache
Chest pain Chest pain
Neurologic symptomsNeurologic symptoms
Altered mental statusAltered mental status
Acutely worsening renal failureAcutely worsening renal failure
S & S of hypertensive emergencyS & S of hypertensive emergency
DOES ELDERLY DOES ELDERLY HYPERTENSION HAVE HYPERTENSION HAVE
SPECIFIC SPECIFIC CHARACTERISTICS?CHARACTERISTICS?
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
Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.
Stroke Volume
Aorta
Resistance Arterioles
Pressure (Flow)
Young Artery
Systole Diastole
Elastic Vessel
Arteriosclerotic Artery
Stiff Vessel
Systole Diastole
Arterial Wall Compliance and Pulse Pressure Wave
Do lifestyle measures Do lifestyle measures really work for elderly really work for elderly
hypertension?hypertension?
ModificationModificationApproximate SBP Approximate SBP
ReductionReduction(range)(range)
Weight ReductionWeight Reduction 5-10 5-10 mmHg/10kgmmHg/10kg
Adopt DASH eating planAdopt DASH eating plan 8-14 mmHg8-14 mmHg
Dietary sodium reductionDietary sodium reduction 2-8 mmHg2-8 mmHg
Physical activityPhysical activity 4-9 mmHg4-9 mmHg
Moderation of alcohol Moderation of alcohol consumptionconsumption
2–4 mmHg2–4 mmHg
Lifestyle ModificationsLifestyle Modifications
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.
42
0
-2-4
-6
-8-10
-12
-14
-16-18
-20 20-30 31-40 41-50
AGE [yrs]
Weinberger M. Hypertens 1991; 18:69
51-60 >60
Cha
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in M
ean
Art
eria
l Blo
od P
ress
ure
Weinberger M. Hypertens 1991; 18:69
Effect of 30 minute walk 3 days a weekAge 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
What is the effect of drug What is the effect of drug therapy related to age? Are therapy related to age? Are
the recommendations the recommendations different?different?
Antihypertensive DrugsAntihypertensive Drugs
AAACEI, ARBsACEI, ARBs
BBBeta BlockerBeta Blocker
CCCCBCCB
DDDiuretic Diuretic
DDlow dose HCTZlow dose HCTZ
AABBCC
Algorithm for Management of the Elderly - Primarily Systolic Hypertension
1) Lifestyle changes
2) 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
++
+
+ +
ALLHATALLHAT
The Antihypertensive and Lipid The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) suggests that Attack Trial (ALLHAT) suggests that low dose thiazide diuretics have a low dose thiazide diuretics have a better cardiovascular protective better cardiovascular protective effecteffect
Result HighlightsResult Highlights
21% reduction in relative risk death 21% reduction in relative risk death from any causefrom any cause
64% reduction relative risk heart 64% reduction relative risk heart failurefailure
39% reduction relative risk of death 39% reduction relative risk of death from strokefrom stroke
Syst-EurSyst-Eur
A study called the Systolic-A study called the Systolic-Hypertension Trial in Europe (Syst-Hypertension Trial in Europe (Syst-Eur) showed that aggressive Eur) showed that aggressive treatment of hypertension reduces treatment of hypertension reduces the risk of stroke by 42% and the risk of stroke by 42% and dementia is prevented. dementia is prevented.
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
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 NitrendipineAtenolol 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.
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
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
What is the systolic What is the systolic blood pressure goal?blood pressure goal?
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.
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 TrialHypertension in the Very Elderly TrialNEJM 2008;358(18):1887-1898NEJM 2008;358(18):1887-1898
Double blind, Double blind, placebo-controlledplacebo-controlled
International, International, multicentermulticenter
3845 patients3845 patients Mean age 83.6 yrsMean age 83.6 yrs BP range 160-BP range 160-
219/90-109219/90-109 Mean BP 173.0/90.8Mean BP 173.0/90.8
f/u median of 1.8 yrsf/u median of 1.8 yrs Primary endpoints – Primary endpoints –
fatal or non fatal fatal or non fatal strokestroke
Indapamide 1.5mgIndapamide 1.5mg Perindopril prn (2mg Perindopril prn (2mg
or 4mg)or 4mg) Mean BP fall Mean BP fall
15.0/6.1 at 2 yrs15.0/6.1 at 2 yrs
Result HighlightsResult Highlights
21% reduction in relative risk death 21% reduction in relative risk death from any causefrom any cause
64% reduction relative risk heart 64% reduction relative risk heart failurefailure
39% reduction relative risk of death 39% reduction relative risk of death from strokefrom stroke
GOALS OF TREATMENTGOALS OF TREATMENT
To achieve a target BP of <140/ 90 mm Hg.To achieve a target BP of <140/ 90 mm Hg.
In patients with Hypertension & Diabetes or In patients with Hypertension & Diabetes or Renal disease, BP Goal is < 130/80 mm Hg.Renal disease, BP Goal is < 130/80 mm Hg.
To reduce cardiovascular morbidity & mortality.To reduce cardiovascular morbidity & mortality.
Thiazide MythsThiazide Myths
Sulfa cross Sulfa cross reactivityreactivity
GoutGout
Renal stonesRenal stones
Thiazide Related GoutThiazide Related Gout
Thiazide related hyperuricemia is Thiazide related hyperuricemia is dose relateddose related
HDFP Trial: 15 episodes of gout over HDFP Trial: 15 episodes of gout over 5 years in 3693 patients treated with 5 years in 3693 patients treated with chlorthalidone 25-100mg (equivalent chlorthalidone 25-100mg (equivalent to 50-200 mg HCTZ)to 50-200 mg HCTZ)
Low dose thiazide (HCTZ 12.5-25 mg) Low dose thiazide (HCTZ 12.5-25 mg) is not contraindicated in goutis not contraindicated in gout
Treatment Treatment Recommendations for the Recommendations for the
Elderly in JNC 7Elderly in JNC 7Recommendations are no different Recommendations are no different
according to age for:according to age for: BP classificationBP classification BP goalsBP goals Lifestyle interventionsLifestyle interventions Selection of medicationsSelection of medications
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.
JNC 7: New Features and Key Messages
Thank YouThank You
Dr. Kunal KothariDr. Kunal KothariEmeritus Professor of medicine and Clinical Emeritus Professor of medicine and Clinical
Cardiology Cardiology Director Primary Health care and Strategic initiativeDirector Primary Health care and Strategic initiative