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Are the European Practice Guidelines for the
Management of Arterial Hypertension (2007)
adapted to the old and the frail?
Anette Hylen Ranhoff
[email protected]
MD PhD,
Medical Department, Diakonhjemmets Hospital, Oslo
Kavli’s Research Centre for Ageing and Dementia, Bergen
GerIT 19.08.2008
Hypertension – mainly a risk factor, not responsible for
symptoms
• When should it be treated and how – in the old
and the frail ?
• Risk factor for:
 Stroke (1 SD SBP: RR 1.59) Rotterdam studien, Mattace-Raso FU, JAGS
2004
 Myocardial Infarction (1 SD SBP: RR 1.24) Rotterdam studien,
JAGS 2004.
 Cardiac failure (LVH and post infraction)
 Renal failure (hypertensive renal disease)
 Dementia (Vascular and Alzheimer) – but when dementia is
progressing BP is falling Skoog I 2001
Hypertension in the old and the frail:
• Still few studies which include patients 85+ years
• The study patients are mainly robust elderly with low
comorbidity
• A high proportion of the 80+ patients are frail and
with a high comorbidity.
• Heterogenity in elderly patients (age, comorbidity,
function)
• Life expectancy is high - and increasing
What we need to know:
• How to assess the patients: measure BP,
other assessment
• BP limits according to risk
• Indications for drug treatment
• What drugs?
• Treatment goals
Sub-group analyses - meta-analyse
• > 80 yrs, N=1670
• RCT
• Gueyffier F. Bulpitt C. et
al, Lancet 1999
• 34 % risk reduction for
stroke
• NNT 1 per 100 patients
treated one year
• 22 % risk reduction for
myocardial infarction
• 39 % risk reduction fro
cardiac failure
• No risk reduction for
cardiovascular death or total
death
Beckett et al. N May 2008
3845 patients from Europe, China, Australasia, and Tunisia who were 80 years of age or older and had a
sustained systolic blood pressure of 160 mm Hg or more to receive either the diuretic indapamide
(sustained release, 1.5 mg) or matching placebo. The angiotensin-converting-enzyme inhibitor perindopril (2
or 4 mg), or matching placebo, was added if necessary to achieve the target blood pressure of 150/80 mm
Hg. The primary end point was fatal or nonfatal stroke.
At 2 years, the mean blood pressure while sitting was 15.0/6.1 mm Hg lower in the active-treatment group
than in the placebo group.
30% reduction in the rate of fatal or nonfatal stroke (95% confidence interval [CI], -1 to 51; P=0.06)
39% reduction in the rate of death from stroke (95% CI, 1 to 62; P=0.05)
21% reduction in the rate of death from any cause (95% CI, 4 to 35; P=0.02)
23% reduction in the rate of death from cardiovascular causes (95% CI, -1 to 40; P=0.06)
64% reduction in the rate of heart failure (95% CI, 42 to 78; P<0.001).
Fewer serious adverse events were reported in the active-treatment group (358, vs. 448 in the placebo group;
P=0.001).
CONCLUSIONS: The results provide evidence that antihypertensive treatment with indapamide (sustained
release), with or without perindopril, in persons 80 years of age or older is beneficial.
“Elderly” is mentioned 12 times
Independent of age
Systolic vs diastolic and pulse
pressure
In the largest meta-analysis of observational data available today (61 studies in
almost 1million subjects without overt cardiovascular disease, 70% europeans
Lancet 2002:
Both systolic and diastolic blood pressures were independently
and similarly predictive of stroke and coronary mortality, and
the contribution of pulse pressure was small, particularly in
individuals aged less than 55 years.
By contrast, in middle aged and elderly hypertensive
patients with cardiovascular risk factors or associated
clinical conditions, pulse pressure showed a strong
predictive value for cardiovascular events.
”All patients should be classified not only in relation to the
grades of hypertension but also in terms of the total
cardiovascular risk resulting from the coexistence of
different risk factors, organ damage and disease.”
(Organ damage)
AGE > 55 years in Men and 65 years in female is a risk factor
Conclusions
Treatment of SH in older patients with
SBP of at least 160 mmHg is
supported by strong evidences. The
evidence
available
to
support
treatment of patients to the level of
140 mmHg or those with baseline
SBP of 140 to 159 mmHg is less
strong; thus, this treatment decisions
should be more sensitive to patient
preferences and tolerance of therapy.
Treatment goals
Blood Pressure and Survival in the Oldest Old
Journal of the American Geriatrics Society 2007, 55 (3), 383–388. Oates DJ et al.
In a cohort of very old (80+yrs), hypertensive veterans, in
subjects with controlled BPs (<140/90), subjects with lower
BP levels had a lower 5-year survival than those with higher
BPs. This suggests that clinicians should use caution in their
approach to BP lowering in this age group.
All patients were controlled to < 140/90 –
but don’t push it too far…..
Diagnostic evaluation
Diagnostic procedures aim at:
1) establishing blood pressure levels
2) identifying secondary causes of hypertension
3) evaluating the overall cardiovascular risk by searching
for other risk factors, target organ damage and
concomitant diseases or accompanying clinical
conditions.
The diagnostic procedures comprise:
• repeated blood pressure measurements
• medical history
• physical examination
• laboratory and instrumental investigations
Premorbid status
Robust
Intermediate
Minor
functional imp.
Substantial
Functional imp.
Dependent
Comorbidity
Life expectancy
illness/risk factor
outcome
HYPERTENSION
When to initiate antihypertensive treatment?
Drug treatment in the elderly
• Guide by comorbidity
– Coronary syndrom: Beta-blocker
– Atrial fibrillation in need of reduction of frequency: Beta-blocker
– Cardiac failure: ACE-inhibitor or/and beta-blocker, event AII
blocker
– COPD: Avoid non-selective beta-blockers
• Start low - go slow
• Rather two or more drugs in combination than one in high
dose
• Remember to check: electrolytes, creatinin when using
ACEI, ARB and diuretics
• OBS drug interactions
• Follow up for antihypertensive drug treatment in
elderly patients is crucial
Treatment goals
To achieve maximum reduction in the long-term total risk of
cardiovascular disease.
•Treatment of the raised BP per se as well as of all
associated reversible risk factors.
•BP should be reduced to at least below 140/90 mmHg.
•Target BP should be at least 130/80 mmHg in diabetics and
in high or very high risk patients.
•Despite use of combination treatment, reducing systolic BP
to 140 mmHg may be difficult. Additional difficulties should
be expected in elderly and diabetic patients, and, in
general, in patients with cardiovascular damage.
•In order to more easily achieve goal BP, antihypertensive
treatment should be initiated before significant cardiovascular
damage develops.
Treatment goals
Blood Pressure and Survival in the Oldest Old
Journal of the American Geriatrics Society 2007, 55 (3), 383–388. Oates DJ et al.
In a cohort of very old (80+yrs), hypertensive veterans, in
subjects with controlled BPs (<140/90), subjects with lower
BP levels had a lower 5-year survival than those with higher
BPs. This suggests that clinicians should use caution in their
approach to BP lowering in this age group.
All patients were controlled to < 140/90 –
but don’t push it too far…..
Conclusions
• Definitions and classification of BP levels are now independent
of age
• Total cardiovascular risk should decide wether treatment should
be given
• BP in supine posistiton after 1 and 5 mins – and 24 hrs BT are
recommended in elderly persons
• Evidence for benefit of antihypertensive treatment in subjects
>80 years with sustained systolic BP >160 mmhg is present!
• The 2007 guidelines focus particularly on elderly - and
correspond better to ”best practice” in geriatric medicine
than previous guidelines