Management of Hypertension in Older Persons

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Management of Hypertensionin Older Persons
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Introduction

• By 2030, the U.S. population of persons who older
  than 65 yrs is expected to double to more than 60
  million.
• 65 of Americans 60 yrs and older have HT.

Only 27 have adequate BP control
Projected population of the United States, by age
and sex 2000 to 2050. Accessed online September
29, 2004,
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Introduction

• Normotensive at 55 age have 90 lifetime risk for
  developing HT.
• HT and other cardiovascular risk factors in older
  persons
• make high risk for
• morbidity
• mortality.

Obesity, LVH, Sedentary lifestyle, Hyperlipidemia,
DM
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Blood Pressure Measurement

• Isolated elevated SBP is more prevalent in older
  persons because of increased large-artery
  stiffness.
• JNC 7 - SBP should be the primary target for the
  diagnosis and care of older persons with HT.

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Blood Pressure Measurement

• BP should be based on the average of 2 or more
  properly measured readings, in the sitting
  position, on 2 or more office visits.
• Age-related decreases in baroreflex response may
  lead to orthostatic hypotension, so BP should be
  monitored in the sitting and standing positions.

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Blood Pressure Measurement

• Pseudohypertension
• - BP cuff fails to compress a
• calcified artery.

Pt. with resistant HT (Pt. with inadequate BP
control despite tx with appropriate 3 drug
regimen, Esp. orthrostatic hypotension)
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Blood Pressure Measurement

• Resistant hypertension
• - white-coat hypertension
• ambulatory blood pressure monitoring may
  be useful in documenting
• white-coat hypertension and verifying
  hypotensive symptoms in patients receiving
  antihypertensive agents.

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Blood Pressure Goals

• Recommended by JNC 7
• - less than 140/90 mm Hg.
• - less than 130/80 mm Hg in patients with DM
  or chronic kidney disease.
• - associated with a decrease in
  cardiovascular disease complications.

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Blood Pressure Goals

• JNC 7 recommends treating older patients with
• stage 1 isolated systolic hypertension
  (systolic blood pressure 140 to 159 mm Hg)
• stage 2 isolated systolic hypertension
  (systolic blood pressure higher than 160 mm Hg)

equal
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Blood Pressure Goals

• Systolic Hypertension in the Elderly Program
  (SHEP)
• - no definitive evidence of an increase
  in risk from aggressive use of anti-hypertensive
  therapy unless the diastolic blood pressure was
  lowered to less than 60 mm Hg.

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Evidence Supporting Treatment of Hypertension

• In 2000, a meta-analysis of eight trials was
  published that included 15,693 older patients
  with isolated systolic hypertension.
• - treated with conventional therapy (i.e.,
  thiazide diuretic, beta blocker, calcium channel
  blocker) or placebo for four years.

Risks of untreated and treated isolated systolic
hypertension in the elderly meta-analysis of
outcome trials published erratum appears in
Lancet 2001357724. Lancet 2000355865-72.
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Evidence Supporting Treatment of Hypertension

• Active treatment was shown to reduce
• - total mortality (NNT 59)
• - cardiovascular mortality (NNT 79)
• - fatal or nonfatal cardiovascular events (NNT
  26)
• - fatal or nonfatal stroke (NNT 48)

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Evidence Supporting Treatment of Hypertension

• Cochrane review found similar results, concluding
  that treating healthy older persons with
  hypertension is highly efficacious.
• Recent trials have evaluated the effects of
  different antihypertensive regimens on the
  treatment of hypertension in older persons.

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Evidence Supporting Treatment of Hypertension

• Meta-analyses have documented
• - reduction in stroke in patients older
• than 80 years.
• - reduction of cardiovascular events
• in patients older than 70 years.

- Risks of untreated and treated isolated
systolic hypertension in the elderly
meta-analysis of outcome trials published
erratum appears in Lancet 2001357724. Lancet
2000355865-72. - Antihypertensive drugs in very
old people a subgroup meta-analysis of
randomised controlled trials. Lancet
1999353793-6.
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Special Considerations When Treating HT

• JNC 7 recommendations for treating hypertension
  are similar in the general population and older
  persons.
• (1) treat isolated SBP.
• (2) thiazide diuretics should be first line
  treatment.
• (3) second-line treatment should be based on
  comorbidities and risk factors.

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Special Considerations When Treating HT

• (4) patients with SBP higher than 160 mm Hg or
  DBP higher than 100 mm Hg usually will require
  two or more agents to reach goal.
• (5) treatment should be initiated with a low dose
  of the chosen antihypertensive agent, and
  titrated slowly to minimize side effects such as
  orthostatic hypotension.

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Special Considerations When Treating HT

• (6) weight loss and sodium reduction have been
  shown to be feasible and effective interventions
  in older patients with HT.
• - recommended lifestyle modifications.
• - JNC 7 recommends adoption of the Dietary
  Approaches to Stop Hypertension (DASH) diet,
  which has been shown to produce blood pressure
  reductions similar to single-drug therapy.

- Randomized controlled trial of nonpharmacologic
interventions in the elderly (TONE) published
erratum appears in JAMA 19982791954. JAMA
1998279839-46. - Effects on blood pressure of
reduced dietary sodium and the Dietary Approaches
to Stop Hypertension (DASH) diet. N Engl J Med
20013443-10.
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Special Considerations When Treating HT

• (7) to improve adherence with antihypertensive
  regimens
• - involve patients in goal setting.
• - ensure the patients cultural beliefs and
  previous experiences are incorporated in a
  treatment plan.
• - simplify the medication regimen.
• - keeping in mind how much it costs.

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Specific Agents THIAZIDE DIURETICS

• Older patients are more prone to thiazide-induced
  dehydration and orthostatic changes.
• - check for orthostatic hypotension for
  preventing falls.
• - serum electrolyte levels should be
  monitored frequently.
• - hypokalemia should be treated with
  potassium administration, the addition of a
  potassium-sparing diuretic.

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Specific Agents THIAZIDE DIURETICS

• SHEP trial, older patients with potassium levels
  less than 3.5 mg per dL (0.9 mmol per L) lost the
  cardiovascular protective benefit from the
  thiazide.
• Uric acid and thiazides compete for excretion at
  the level of the renal tubule, so caution is
  necessary in patients with a history of gout.

- Hypokalemia associated with diuretic use in
cardiovascular events in the Systolic
Hypertension in the Elderly Program. Hypertension
2000351025-30.
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Specific Agents THIAZIDE DIURETICS

• Thiazide diuretic may be at increased risk of
  digoxin toxicity.
• NSAIDs may reduce diuretic and anti- hypertensive
  effects of thiazides.
• ACE inhibitor or ARB to existing diuretic
  therapy, there is a possibility of first-dose
  hypotension and the risk of acute renal
  insufficiency.

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Specific Agents BETA BLOCKERS

• Reduce mortality and morbidity in older patients
  with hypertension.
• In older persons that high risk for coronary
  disease and prevention of a second myocardial
  infarction and heart failure.
• Atenolol, bisoprolol, and metoprolol are
  cardioselective beta blockers with low lipid
  solubility, and have a preferable side effect
  profile in older persons.

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Specific Agents BETA BLOCKERS

• Beta blockers that are lipophilic e.g.,
  propranolol cross the blood-brain barrier,
  possibly causing more sedation, depression, and
  sexual dysfunction in older patients.
• Cause bradycardia, conduction abnormalities, and
  development of heart failure if started too
  aggressively in patients with preexisting left
  ventricular dysfunction.

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Specific Agents BETA BLOCKERS

• Should be used with caution in combination with
  other negative chronotropes, such as diltiazem,
  verapamil, or digoxin.
• Contraindicated in patients with severe reactive
  airway disease, especially the nonselective
  agents.

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Specific Agents ACE INHIBITORS AND ARBS

• Indications for use in heart failure, diabetes
  mellitus, chronic kidney disease, after
  myocardial infarction, high risk for coronary
  disease, and for recurrent stroke prevention.
• Incidence of side effects is low.
• - angioedema frequent in blacks.
• - cough occurs in up to 25

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Specific Agents ACE INHIBITORS AND ARBS

• ARBs (i.e., candesartan, irbesartan, losartan,
  valsartan are reasonable alternatives for those
  with ACE inhibitorassociated cough.
• First-dose hypotension is a concern in
  dehydrated, decompensated patients with heart
  failure, and those with bilateral renal artery
  stenosis.

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Specific Agents ACE INHIBITORS AND ARBS

• In older patients, hypotension and renal function
  should be monitored closely upon initiation.
• Acute elevation in serum creatinine above 30
  percent warrants a temporary discontinuation or
  lowering of the dose.
• ACE inhibitors also may cause hyperkalemia, serum
  electrolytes and creatinine should be monitored.

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Specific Agents CALCIUM CHANNEL BLOCKERS

• Dihydropyridines and nondihydropyridines are
  effective treatments for hypertension in older
  patients.
• Indications for use in patients at high risk for
  coronary disease and those with diabetes
  mellitus.
• Short-acting agents are not recommended in
  clinical practice.

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Specific Agents CALCIUM CHANNEL BLOCKERS

• Nondihydropyridines (e.g., diltiazem, verapamil)
  exhibit negative inotropic and chronotropic
  effects in atrial fibrillation and
  supraventricular tachyarrythmias.
• Dihydropyridines (i.e., amlodipine, felodipine)
  are safe for use in patients with heart failure,
  hypertension, or chronic stable angina.

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Specific Agents CALCIUM CHANNEL BLOCKERS

• Systematic reviews generally have found calcium
  channel blockers to be equivalent or inferior to
  other antihypertensive agents.
• Antihypertensive and Lipid-Lowering Treatment to
  Prevent Heart Attack Trial (ALLHAT), amlodipine
  was found to be inferior to chlorthalidone in
  preventing heart failurerelated events.

- Health outcomes associated with various
antihypertensive therapies used as first-line
agents a network meta-analysis. JAMA
20032892534-44. - Major outcomes in high-risk
hypertensive patients randomized to
angiotensin-converting enzyme inhibitor or
calcium channel blocker vs diuretic the
Antihypertensive and Lipid-Lowering Treatment to
Prevent Heart Attack Trial (ALLHAT) JAMA
20022882981-97.
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Specific Agents CALCIUM CHANNEL BLOCKERS

• Effective in salt sensitive hypertensive
  patients, such as blacks and older persons.
• Dihydropyridines, especially nifedipine, can
  cause orthostatic hypotension, peripheral edema,
  and gingival hyperplasia.
• Verapamil often is a cause of constipation in
  older persons.

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MISCELLANEOUS - ANTIHYPERTENSIVE AGENTS

• Peripheral alpha blockers, centrally acting
  agents, and vasodilators have limited use in
  older persons because of significant side effect
  profiles.
• Have not been associated with reductions in
  morbidity and mortality in patients with
  hypertension.

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MISCELLANEOUS - ANTIHYPERTENSIVE AGENTS

• Central alpha agonists (include clonidine,
  guanfacine, methyldopa, and reserpine) act
  centrally and may cause significant sedation, dry
  mouth, and depression.
• Many patients experience hypotension in addition
  to sodium and water retention.

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MISCELLANEOUS - ANTIHYPERTENSIVE AGENTS

• Abrupt cessation of high doses of (e.g., greater
  than 1.2 mg daily of clonidine) may cause rebound
  hypertension.
• Vasodilators hydralazine and minoxidil cause
  sodium and water retention and reflex
  tachycardia, so they are not useful as
  monotherapy.

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