Download GRS8Hypertension - Geriatrics Care Online

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HYPERTENSION
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OBJECTIVES
Know and understand:
• How the diagnosis and treatment of
hypertension differ in older adults
• When to recommend lifestyle modification
• How to choose among the various classes of
antihypertensive agents
• The principles of adjusting therapy
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TOPICS COVERED
• Epidemiology and Physiology
• Clinical Evaluation
• Treatment
 Lifestyle Modification
 Pharmacologic Treatment
 Follow-up Visits
• Special Considerations
 Hypertensive Emergencies and Urgencies
 Hypertension in the Long-term-care Setting
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EPIDEMIOLOGY
• BP increases with age, especially SBP and pulse
pressure (difference between SBP and DBP)
• 67% of non-institutionalized Americans ≥60 years
have hypertension (HTN):
 Highest among blacks
 Higher in women than men
• BP is poorly controlled in many older people despite
treatment
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CLASSIFICATION OF BP LEVELS
Category
Normal
Systolic
(mm Hg)
Diastolic
(mm Hg)
<120
and
<80
Prehypertension
120–39
or
80–89
Hypertension
Stage 1
Stage 2
140–159
>160
or
90–99
>100
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PHYSIOLOGIC CHANGES WITH AGE
• Increased arterial stiffness
• Decline in baroreflex sensitivity
• Increase in sympathetic nervous system activity
• Heightened vasoconstriction
• Alterations in renal function and neurohumoral systems
involved in sodium balance  sodium-sensitive HTN
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DIAGNOSIS OF HYPERTENSION
• Use the average of several readings taken at each of
2-3 visits
• Consider ambulatory BP monitoring for patients with
extreme BP variability or possible “white coat” HTN
• Determine SBP by palpation to avoid auscultatory gap
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CLINICAL EVALUATION
• Exclude secondary forms of HTN
• Identify target organ damage
• Determine CVD risk factors and identify comorbidities
• Inquire about lifestyle (smoking history, dietary intake of
sodium and fat, alcohol intake, physical activity, social
stressors)
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BENEFITS OF TREATMENT
• Treatment reduces overall mortality, CVD
events, heart failure, and stroke
• Mortality benefit has been consistently
demonstrated in those between 65-75 years old
• The Hypertension in the Very Elderly Trial
(HYVET) study also showed decreased
mortality in those older than 80 years
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TREATMENT TARGETS
• Balance benefits of treatment with potential impact on
functional status and quality of life
• Treatment approach to target:
 SBP < 140 mm Hg
 DBP < 90 mm Hg
 Diabetics: same target as above
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LIFESTYLE MODIFICATION
• Adjunct to drug therapy for all hypertensive
patients
• Components:
 Weight reduction
 Increased physical activity
 Stress reduction
 Reduction in sodium intake
 Increased intake of potassium in the form of
fruits and vegetables
GENERAL TREATMENT RECOMMENDATIONS
FOR HYPERTENSION
• Begin with a nonpharmacologic approach
• Base drug selection or combination therapies on individual patient
characteristics
• Diuretics ( thiazide-like), calcium channel blockers, ACEI or ARBs
can all be used as initial therapy.
• When starting drug therapy, begin at half the usual dosage,
increase dosage slowly, and continue nonpharmacologic
therapies
• Gauge treatment goals by SBP
• Avoid excessive reduction in DBP (<50 mmHg)
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DIURETICS
• Significant benefits in mortality, stroke and CV
events
• Chlorthalidone is preferred over HCTZ
• Adverse event profile: hypokalemia, hyperuricemia,
hypomagnesemia, hyponatremia and possible
glucose intolerance
 More likely with higher dosages
• Potassium replacement is important to prevent
arrhythmias, minimize glucose intolerance
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ACE INHIBITORS
• Can be used as initial monotherapy for HTN in
older patients
• Adverse event profile: cough (higher in Asians),
hyperkalemia, angioedema, renal insufficiency
(especially in renal artery stenosis) and rare
neutropenia and agranulocytosis
• Well suited to patients with diabetes and those
with LV systolic dysfunction
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ANGIOTENSIN-RECEPTOR BLOCKERS
• Block the effect of angiotensin II on the type 1
angiotensin receptor
• Use as first-line therapy or as an alternative to
ACE inhibitor, especially in those with
diabetes, heart failure, or microalbuminuria
• An option for patients who cannot tolerate
ACE inhibitors
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RENIN INHIBITORS
• As effective as ACE inhibitors or ARBs in
blood-pressure lowering effects– long-term
data are still not robust.
• Significantly more expensive
• Associated with diarrhea and no data on
safety in those with a GFR <30 mL/min
CALCIUM CHANNEL ANTAGONISTS
(CCAs)
• Use at low doses (pharmacokinetics change
with advancing age)
• Do not use short-acting CCAs to treat HTN
• Adverse events: ankle edema, headaches,
postural hypotension, constipation
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-RECEPTOR ANTAGONISTS
• Not recommended for first-line monotherapy
• Compared with placebo, provide no reduction
in all-cause mortality, myocardial infarction, or
stroke
• Use in those with CAD, those with a history of
MI, and certain patients with heart failure
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α-RECEPTOR ANTAGONISTS
• High risk of postural hypotension in older
patients
• When used as monotherapy, associated with a
high rate of CVD events (new-onset heart
failure) in a large-scale clinical trial
• May be considered, usually in combination with
another drug, for older men with prostatism
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OTHER CLASSES
• Direct vasodilators (hydralazine and minoxidil) are
considered last-line therapy due to tachycardia,
arrhythmia, fluid retention
• Centrally acting agents (clonidine) are poorly tolerated
and associated with sedation, bradycardia, and reflex
hypertension (and tachycardia if abruptly stopped)
• Alpha-beta blockers:: Labetalol useful in hypertensive
urgencies and carvedilol in congestive heart failure
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FOLLOW-UP VISITS
• Assess adherence to therapy
• Monitor for adverse effects, especially postural
hypotension
• Measure supine and standing BP
• Encourage BP monitoring outside clinic
• Use interdisciplinary team approach if available
• Adjust dosage cautiously
• Reinforce lifestyle modifications
• Evaluate for refractory hypertension
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FREQUENCY OF FOLLOW-UP
• Should reflect degree of BP elevation at
presentation
• In general, allow 4–6 weeks between visits
• Except in hypertensive emergencies, rapid
reduction of BP is unnecessary and may be
deleterious
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ADJUSTING THERAPY
• Assess adherence to therapy and review other
medications
• If more than 2 antihypertensive medications are
needed, one of them should be a diuretic
• If BP target not attained on 3-drug regimen, evaluate
patient for refractory hypertension
• Consider stepping down treatment once patient has
maintained target BP for >1 year
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HYPERTENSIVE EMERGENCIES
Definition
Vascular compromise of vital organs due to extreme BP
elevation (eg, hypertensive encephalopathy, pulmonary
edema, aortic dissection, unstable angina)
Management
• In hospital with continuous BP monitoring
• Parenteral administration of antihypertensive
• Do not initially target a normal BP level
• Try to achieve 160/100 mm Hg gradually over first 6 hours
HTN IN THE
LONG-TERM-CARE SETTING
• HTN affects about 33% to 66% of residents of
long-term-care facilities
• Postprandial hypotension
 Affects about 33% of residents
 Independent risk factor for falls, syncope,
stroke, mortality
• Increased risk if antihypertensive medications
were given around meal time (pre-breakfast)
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MANAGEMENT OF HTN
IN LONG-TERM-CARE SETTING
• Risk-benefit ratio of treatment is unclear in this
population:
 Patients of advanced age
 Patients with multiple comorbidities, taking
multiple medications
• Some evidence suggest an association between
diuretic use and falls in LTC residents– assess
orthostatic vitals in all LTC residents on
antihypertensive medications
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SUMMARY
• Treatment of HTN reduces the risk of CVD
events and mortality in older adults
• Lifestyle modification is recommended
• first-line drug therapy can include any
antihypertensive class except BB (in noncardiac patients) or alpha blockers.
• “Start low and go slow”—monitor for falls,
postural hypotension, and other adverse events
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CASE 1 (1 of 3)
• A 92-year-old woman comes to the office for follow-up.
History includes osteoarthritis, well-controlled
hypertension, gastroesophageal reflux disease, and a
recent cold. Prescribed medications include
chlorthalidone and lisinopril.
• On examination, blood pressure is 162/70 mmHg and
pulse is 76 beats per minute. On further questioning, the
patient states that her daughter has been giving her
OTC ibuprofen because she has had knee discomfort,
which is now resolved. She has also been taking an
OTC preparation of pseudoephedrine, 30 mg, three
times a day for several days for congestion.
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CASE 1 (2 of 3)
Which of the following is the most likely cause
of her high blood pressure?
A. Pseudoephedrine
B. Arthritic pain
C. NSAIDs
D. Renal artery stenosis
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CASE 1 (3 of 3)
Which of the following is the most likely cause
of her high blood pressure?
A. Pseudoephedrine
B. Arthritic pain
C. NSAIDs
D. Renal artery stenosis
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CASE 2 (1 of 3)
• A 70-year-old man comes to the office because of concern
about increased BP.
• History includes DM that he has controlled with diet,
exercise, and weight loss.
• He checks his BP at home regularly; over the last month, his
systolic BP readings have been consistently >160 mm Hg.
• Blood pressure today is 158/86 mm Hg, up from 148/84
mm Hg at his last office appointment 4 months ago.
• His creatinine level is 1.4.
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CASE 2 (2 of 3)
Which of the following is the most appropriate
antihypertensive drug for this patient?
A. Chlorthalidone
B. Metoprolol
C. Amlodipine
D. Lisinopril
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CASE 2 (3 of 3)
Which of the following is the most appropriate
antihypertensive drug for this patient?
A. Chlorthalidone
B. Metoprolol
C. Amlodipine
D. Lisinopril
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GRS Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Author:
Ihab Hajjar, MD, MS, FACP
GRS8 Question Writer:
Rebecca Boxer, MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society
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