Download CME GP`s Auckland and Northland, 17 October 2009, Omapere

Workshop hypertension:
approach in the elderly patient
Johan Rosman
Renal Physician and Specialist in Hypertension
North Shore Hospital and the Apollo Health Centre
North Shore
Auckland
Case
• Conny is a 72 year old active widow
• She stopped smoking 5 years ago and
uses NSAIDs for osteoarthritis
• She has a strong family history of
hypertension
• Recently her BP increased, you measure
174/98.
• She would like to know if it is really worth
treating this
Questions
• What are the risks and benefits of treating
her BP ?
• Which agents are most appropriate ?
• Does her age put her at any particular risk
apart from medication ?
Facts
• Syst BP rises with age, diast only till age 60, after which it tends to
decrease. So syst HT is very common in the elderly, this is caused
by decreased compliance of the vascular bed
• The elderly have significant alterations in salt sensitivity, enhanced
sympathetic nervous system activity and baroreceptor
responsiveness (orthostatic hypotension, especially when
overtreated !)
• HT is the singlemost important modifiable risk factor for vascular
disease in the elderly
• Up to 90% of the elderly people are hypertensive (is this a
physiological response ?)
• 25% of the elderly found with hypertension actually have ‘officewhite coat’ hypertension (overtreatment risk !)
• Elderly are more prone and at risk to suffer from side effects (e.g.
falls)
Benefits ?
•
•
•
•
Decrease of heart failure with 50%
Decrease of stroke with 35%
Decrease of Myocardial infarcts with 25%
Slower progression of cognitive decline
• BUT: Balance that with the life expectancy
and the risk of side effects !!!
Causes of secondary HT in the
Elderly
•
•
•
•
Obstructive Sleep Apnoea
Renovascular disease or chronic kidney disease
High alcohol intake
Concomitant medications (NSAIDs,
decongestants, etc)
• Endocrine:
–
–
–
–
Mineralocorticoid excess
Thyroid disease
Hyperparathyroidism
Steroid use or Cushing’s syndrome
Diagnostic steps, global views
• ECG, chest X-ray
• Plasma levels of B-type natriuretic peptide
(BNP) or NT-proBNP (I have my doubts here,
would rather go with clinical impression)
• Renal function/proteinuria
• Carotis artery intima thickness excellent
surrogate marker for developing atherosclerosis
• Fundi !!
Drug use – evidence based
• For all drugs: start on a low dose and titrate up,
• Elderly patients ‘good old – old fashioned drugs best’
• If our aim is 140/90: start on thiazide (problems:
diabetes, gout, hyperkalaemia). Chlortalidone in the
elderly to be excluded as more neagtive metabolic
impact.
• Dihydropyridine CCB’s are as effective but have more
side effects
• ACE/ARB in the elderly were always used if there is a
second reason to use them, e.g. heart failure,
proteinuria, diabetes, post MI. Recent trials suggest a
more prominet place in the elderly for ACE/ARB as they
are well tolerated and have few side effects.
• Beta blockers not attractive unless other indications as
angina at the same time
Diagram treatment options
Sec causes
CV risk assessment
Target organ damage
Confirm HT
Lifestyle Modif
Special group:
Alpha blockers in elderly men
with BPH
Alpha methyldopamin
Thiazide or CCB
Dual thiaz/CCB
Beta Blocker or
vasodilator
ACE/ARB
ACE/ARB combo diuretic
My personal view ?
• We OVERTREAT our elderly with
antihypertensives as well as with lipid
lowering agents. We contribute with that to
falls, stroke and side effects impacting
quality of life
• After discharge from a hospital a careful
review of medication changes that took
place is warranted, a cut back is likely !!
New Case
• Jessica is a 82 year old woman, managing well
at home and taking care of her husband
• Stroke 2 years ago, remains with mild residual
left sided weakness, mobile with stick
• Med: thiazide, inhalers for COPD, and aspirin
100 mg OD
• She is a non-smoker, no overweight
• eGFR is 48 ml/min, electrolytes normal
• You find her to have persistenly a systolic BP of
160/74
Questions
• Is it beneficial to treat this level of BP at
her age ?
• Are there any risks from drug treatment to
lower her BP ?
• Which agents are most useful in this age
group ?
Facts
• Most hypertension trials have excluded the elderly and
those with significant co –morbidities
• Those that were done until recently only with diuretics
• There is good evidence for a relationship between the
BP and survival in the elderly
• But; low BP, especially diastolic is associated with lower
survival, so small bandwidth to operate in
• Most clinical trial have confirmed this, with reduction of
stroke and heart failure with 30-40% and MI with 25%
but the treatment itself increased mortality
• The treshold for treatment is higher than in younger
people
• The aim should be: consider treatment if syst BP is over
160, but do not work towards a syst BP lower than 140 !
Benefits-studies (1)
• ANBP Study (Oz) recruited 6083 pat aged
64-84.
• Randomised to enalapril or HCT follow up
for median time of 4.1 years
• Compared to HCT, the hazard ratio for any
CV event was 0.89 in the ACE group
• But: the protection of the ACE inhibitor
was only significant in men !
Benefits-studies (2)
• SCOPE trial (Study of COgnition and Prognosis
in the Elderly) had 5000 pat aged 70-89 years
with SBP 160-180 or DBP 90-99
• Randomised to candesartan or diuretic
• In candesartan group reduction of MAP of 22
mmHg against 18 in diuretics
• Marked reduction in stroke in candesartan but
no decrease in overall CV event rate
• Cognitive functional decline similar in both
groups over the 3.7 years of follow up
Benefits-studies (3)
• HYVET (HYpertension in the Very Elderly Trial) very
recently finished
• 4000 Patients over 80 with SBP > 160
• Randomised to indapamide 1.5 mg or placebo
• If needed perindopril was added in treatment group
• 21% reductions of death from any cause, CV deaths
reduced by 23%, Stroke by 30%, Heart failure by 64%
over 2 years with a MAP reduction of 15 mmHg
• In a 5 year follow up the advantages of treatment are
less obvious
SBP > 160
BALANCE:
Est. longevity
Risk of CV event
In next 2-5 yrs
Quality of Life
End organ
damage
Target SBP>140
Treatment Preference
Target SBP >
140
Diuretics
Monitor U/E
Indapamide
Less metabolic
risk
ACE / ARB
LVH, CCF, CKD
CCB
If dementia risk
Beta Blockers
Angina or MI
Caution if
DBP<80