Presenter: Norman Kaplan, M'D'

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PresenterNorman 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.
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HYPERTENSION IN THE ELDERLY
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Projected Increases in U.S. Population gt65
Data from U.S. Census Bureau Redfield MM. N Engl
J Med. 20023471442-1444
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LIFETIME RISK OF DEVELOPING HYPERTENSION IN
FRAMINGHAM SUBJECTS NORMOTENSIVE AT AGE 55 OR 65
Vasan et al. JAMA 20022871003
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Postural Fall in BP in Elderly People
Lipsitz et al. Clin Sci 198569337
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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?
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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
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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
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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
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If the above are all fairly normal, What next?
24-hour ambulatory blood pressure
monitoring or multiple home BPs under varying
conditions
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White-Coat Effect with Age
Mansoor et al. J Hum Hypertens 19961087
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DAY 1 700 a.m. 180/80, 172/80, 165/76 12
noon 172/76, 165/80, 160/72 500
p.m. 198/94 502 p.m. 163/80, 155/74,
158/76 1000 p.m. 150/74, 143/72, 140/70
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DAY 14 730 a.m. 160/84, 155/80, 154/74 731
a.m. 130/68 732 a.m. 145/76 733 a.m. 155/80
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DAY 18 500 p.m. 160/85, 154/80, 155/82 545
p.m. 132/72 630 p.m. 145/84
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DAY 30 700 p.m. 165/85, 160/80, 156/82
What should you do?
Diagnose Isolated Systolic Hypertension Re-emphasi
ze healthy lifestyles Advise protection against
postural falls Start antihypertensive therapy
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Odds Ratio for Incidence of Dementia According to
Alcohol Consumption Among Older People (Average
Age 77)
From Mukamal KJ et al. JAMA 20032891405
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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
20021052836
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What drug therapy should you prescribe?
Low-dose thiazide HCTZ, 12.5 mg
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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
Plt0.001
Plt0.001
UKPDS C vs A
ALLHAT
? ALLHAT/Lis Blacks
? ALLHAT/Lis 60 y
? ALLHAT/Lis
CAPPP
MIDAS/NICS
? ALLHAT/Aml
NORDIL
? ABCD/NT L vs H
? HOT M vs H
CONVINCE ?
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 ?
? MRC2
PREVENT ?
ELSA ?
? MRC1
PATS ?
HOPE ?
? ATMH
LIFE/DM ?
? NICOLE
? EWPHE
Syst China ?
? Syst Eur
? HEP
PART2/SCAT ?
? SHEP
RCT70-80 ?
UKPDS L vs H ?
?STOP1
? PROGRESS/Com
STONE ?
-5
0
5
10
15
20
25
-5
0
5
10
15
20
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Difference (reference minus experimental) in
systolic pressure (mmHg)
Staessen JA, et al. J Hypertens. 2003
2110551076.
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Low Dose Diuretics vs. Others
From Psaty BM et al. JAMA 20032892534
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If urine analysis found microalbumin, what would
you recommend?
Quantify level of proteinuria Prescribe a
long-acting ACEI
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If SBP remains above 140 mmHg, what next?
Long-acting CCB
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Random Therapy of Elderly with Systolic
Hypertension
From Morgan et al.Am J Hypertension 200114241
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What else would you recommend?
Aspirin 81 mg, every other day Alcohol, 1 usual
portion per day Statin
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Sever PS, Dahlöf B, Poulter N, Wedel H, et al,
for the ASCOT Investigators. Lancet.
20033611149-58
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Baseline Characteristics
Atorvastatin (n5168)
Placebo (n5137)
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
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The ASCOT TrialAtorvastatin vs. Placebo on
CHDin Hypertensives
From Sever et al. Lancet 20033611149
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Sudden Deaths by Time of Day
Peckova et al. Circulation 19989831
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Celebrex vs Vioxx on Blood Pressure
Whelton et al. Am J Cardiol. 200290959-963
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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 gt140 or 90
regardless of age and gt130 or 80 in diabetics,
renal, or cardiac patients.
5. Start with a low-dose diuretic and
sequentially add drugs appropriate to individual
patients needs.
6. Use home BP measurements to guide therapy and
avoid overtreatment.
7. Reach the goal of lt140 or 90 if BP still gt140
or 90 with adequate diuretic plus 2 more drugs,
consider referral to a Hypertension Specialist.