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1 HYPERTENSION 2 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 3 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 4 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 5 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 6 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 7 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 8 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) 9 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 10 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 11 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) 12 13 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 14 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 15 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 16 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 17 18 -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 19 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 20 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 21 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 22 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 23 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 24 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) 25 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 26 27 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 28 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. 29 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 30 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 31 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. 32 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 33 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 34 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 SlideSlide 34 34