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Hypertension Management for Elderly Patients Mark A. Supiano, M.D. Professor and Chief, University of Utah Geriatrics Division Director, VA Salt Lake City GRECC Executive Director, University of Utah Center on Aging 1 LEARNING OBJECTIVES Identify the core components of the hypertension syndrome characteristic of older patients. Describe how these core components of the hypertension syndrome contribute to elevated systolic blood pressure and pulse pressure. Specify the current treatment recommendations for geriatric hypertension. GRECC Audioconference January 2007 2 OUTLINE Epidemiology Physiology of BP Regulation Diagnosis and Evaluation Treatment GRECC Audioconference January 2007 3 Hypertension Prevalence by Age and Gender 100 Men Women 75 50 25 0 35-44 45-54 55-64 Age 65-74 >75 NHANES III; 1999-2002; CDC NCHS Data GRECC Audioconference January 2007 4 Residual lifetime risk for developing hypertension Will you live long enough to develop hypertension? Time (years) Women age 55 Women age 65 % (95% confidence interval) % (95% confidence interval) 10 52 (46-58) 64 (60-69) 15 72 (68-76) 81 (77-84) 20 83 (80-86) 89 (86-92) 25 91 (89-93) – Vasan et al.; JAMA 287:1003, 2002 GRECC Audioconference January 2007 5 Aging Sympathetic Nervous System Activation Insulin resistance GRECC Audioconference January 2007 6 Characteristics of Geriatric Hypertension Decreased vascular compliance Decreased baroreceptor sensitivity Salt-sensitivity of blood pressure Increased total and central adiposity Neurohumoral characteristics GRECC Audioconference January 2007 7 Aging: Vascular Changes Increased thickness of intima and media. Matrix collagen deposition increased fibronectin crosslinking (Advanced Glycosylation Endproducts) Net result is increased vascular stiffness. GRECC Audioconference January 2007 8 Consequences of decreased vascular compliance Relative increase in systolic pressure. Increase in pulse pressure (SBP – DBP) Decreased baroreceptor sensitivity? GRECC Audioconference January 2007 9 Consequences of Decreased Baroreceptor Sensitivity Increased BP variability Impaired BP homeostasis Hypertension Postural (orthostatic) hypotension Post-prandial hypotension Increase in sympathetic nervous system activity GRECC Audioconference January 2007 10 Salt Sensitivity of Blood Pressure Definition: Mean arterial blood pressure on high vs. low Na+ diet > 5 mm Hg increase => Sodium Sensitive < 5 mm Hg increase => Sodium Resistant Two thirds of older hypertensives are sodium sensitive. Dengel et al., Am J Physiol 274:E403, 1998 GRECC Audioconference January 2007 11 Obesity (BMI > 30 kg/m2) by age and gender 50 Men Women 40 30 20 10 0 20-34 35-44 45-54 55-64 65-74 >75 Age (years) NHANES III; 1999-2002; CDC NCHS Data GRECC Audioconference January 2007 12 Characteristics of Geriatric Hypertension -2 Neurohumoral Characteristics Metabolic insulin resistance Sympathetic nervous system function GRECC Audioconference January 2007 13 Hypertension and Insulin Resistance S (10 -5/min/pM) I 12 10 r= - 0.487; P=0.004 8 6 4 2 0 60 70 80 90 100 110 Mean Arterial BP (mm Hg) Normotensive n=46 S =16.1 - (0.113)(MABP) I 120 130 Supiano et al., J Gerontol 48: M237, 1993 14 Hypertensive n=14 S =16.0 - (0.113)(MABP) I GRECC Audioconference January 2007 14 Aging and SNS Function Compared with younger people: sympathetic nervous system activity increases. adrenergic receptor responsiveness is reduced. Decreased chronotropic response to b-agonists. Shannon et al., NEJM 342:541, 2000 GRECC Audioconference January 2007 15 Hypertension and SNS Function Compared to normotensive older people, older hypertensives are characterized with: Further increase in SNS activity Relatively greater a-mediated vasoconstriction Supiano et al., Am J Physiol 276:E519, 1999 GRECC Audioconference January 2007 16 Summary: Vascular and Neurohumoral Characteristics Decreased vascular compliance. Decreased baroreceptor sensitivity. Salt-sensitivity of blood pressure. Increased total and central adiposity. Metabolic insulin resistance. Heightened SNS activity. Increased a-adrenergic receptor responsiveness. GRECC Audioconference January 2007 17 OUTLINE Epidemiology Physiology of BP Regulation Diagnosis and Evaluation Measurement issues Secondary causes Classification GRECC Audioconference January 2007 18 Measurement Matters! Auscultatory BP Measurement Method Sitting. Bare arm. Arm supported at heart level (5-6 mmHg increase if arm vertical). Resting for five minutes. Proper cuff size. Use calibrated aneroid manometer. Palpate SBP. Record phase 1 (first sound) and phase 5 (disappearance) Korotkoff sounds as SBP and DBP. Two or more readings taken several minutes apart should be averaged. JNC VI. Arch Int Med 157: 2413, 1997 GRECC Audioconference January 2007 19 Measurement Issues: Posture Blood pressure must be measured in older persons with special care ... In addition, older patients are more likely than younger patients to exhibit an orthostatic fall in blood pressure and hypotension; thus, in older patients, blood pressure should always be measured in the standing as well as seated or supine positions. JNC VI. Arch Int Med 157: 2413, 1997 GRECC Audioconference January 2007 20 Measurement Issues: Multiple Measurements Hypertension should not be diagnosed on the basis of a single measurement. BP variability is higher in older hypertensive individuals. Decreased baroreceptor sensitivity. Diagnosis of hypertension should be based on: Average of readings from three visits. Three separate readings recorded at each visit. GRECC Audioconference January 2007 21 Evaluation of Patient with White-coat Hypertension: Ambulatory (24 hour) Monitoring Advantages: BP profile over 24 hour period. Nocturnal dipper pattern. BP load: correlates with target organ damage. Useful to evaluate white coat hypertension, drug resistance, secondary causes, hypotensive symptoms. GRECC Audioconference January 2007 22 Evaluation: Secondary Causes Primary hypertension is the most common form of hypertension in older persons. A sudden increase in DBP, malignant HTN or resistant HTN should prompt an evaluation for secondary causes. Renovascular disease and medication interactions are most common secondary causes. GRECC Audioconference January 2007 23 Blood Pressure Classification JNC 7 BP Classification SBP mmHg Normal <120 and <80 Prehypertension 120–139 or 80–89 Stage 1 Hypertension 140–159 or 90–99 Stage 2 Hypertension >160 or >100 GRECC Audioconference January 2007 DBP mmHg 24 Role of SBP in Classification In the older hypertensive population, the level of SBP will correctly classify the stage of hypertension in 99% of patients. Lloyd-Jones Hypertension 34:381, 1999 GRECC Audioconference January 2007 25 Simplified JNC 7 Classification BP Classification SBP Normal < 120 Pre-hypertension 120-139 Stage 1 Hypertension 140-159 Stage 2 Hypertension ≥ 160 GRECC Audioconference January 2007 JNC 7 Report. JAMA. 2003:2560 26 OUTLINE Treatment Efficacy Systolic BP and Pulse Pressure Matter Treatment Goals Non-pharmacological therapy Pharmacological therapy GRECC Audioconference January 2007 27 Treatment of hypertension in older persons has demonstrated major benefits. JNC 7 Report. JAMA. 2003:2560 GRECC Audioconference January 2007 28 35% reduction in stroke rate SHEP Study; JAMA 265:3255; 1991 GRECC Audioconference January 2007 29 Treating hypertension reduces cardiovascular risk and mortality Favors Diuretics Favors Placebo Total Mortality CVD Mortality CVD Events Stroke CHF CHD 0.4 0.6 0.8 1.0 1.2 1.4 Relative Risk Psaty et al.; JAMA 289: 2534, 2003 GRECC Audioconference January 2007 30 Which is the more dangerous BP? SBP/DBP MABP Pulse Pressure Patient 1 140/ 94 109 46 Patient 2 158/84 109 74 GRECC Audioconference January 2007 31 Especially among older persons, SBP is a better predictor of events (coronary heart disease, cardiovascular disease, heart failure, stroke, end-stage renal disease, and all-cause mortality) than is DBP. JNC VI, 1997 GRECC Audioconference January 2007 32 Pulse Pressure as CV Risk Factor Framingham data: in those >50 yrs., CV mortality independently related best to pulse pressure; for given SBP, lower DBP associated with higher mortality. Franklin et al. Circulation 100:354, 1999. SHEP data analysis: stroke and total mortality associated with pulse pressure independent of mean BP. Domanski et al. Hypertension 34:375, 1999. GRECC Audioconference January 2007 33 GRECC Audioconference January 2007 34 The goal of treatment in older patients should be the same as in younger patients (to below140/90 mm Hg if at all possible), although an interim goal of SBP below 160 mm Hg may be necessary in those patients with marked systolic hypertension. JNC VI, 1997 GRECC Audioconference January 2007 35 Treatment Implications Optimal anti-hypertensive therapy will: Lower blood pressure. Improve vascular compliance. Increase baroreceptor sensitivity. Decrease central fat mass. Increase insulin sensitivity. Decrease SNS activity. Decrease RAAS activity. GRECC Audioconference January 2007 36 Non-pharmacological Therapy CHARACTERISTIC Overweight – central adiposity Sedentary Salt-sensitive LIFE STYLE MODIFICATION Weight loss Exercise program Dietary salt restriction GRECC Audioconference January 2007 37 Lifestyle Modification Modification Weight reduction Approximate SBP reduction (range) 5–20 mmHg/10 kg weight loss Adopt DASH eating plan 8–14 mmHg Dietary sodium reduction 2–8 mmHg Physical activity 4–9 mmHg Moderation of alcohol consumption 2–4 mmHg GRECC Audioconference January 2007 JNC 7 Report. JAMA. 2003:2560 38 DASH Fact Sheet GRECC Audioconference January 2007 39 What about exercise? Aerobic Capacity Blood Pressure Insulin Sensitivity Adiposity SNS activity Aging Exercise Training GRECC Audioconference January 2007 40 Classification and Management of BP for adults Initial drug therapy SBP* mmHg DBP* mmHg Lifestyle modification <120 and <80 Encourage Prehypertension 120–139 or 80–89 Yes No antihypertensive drug indicated. Stage 1 Hypertension 140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 Hypertension >160 or >100 Yes BP classification Normal Without compelling indication With compelling indications Drug(s) for compelling indications. ‡ Drug(s) for the compelling indications.‡ Other antihypertensive drugs Two-drug combination for most† (diuretics, ACEI, ARB, BB, (usually thiazide-type diuretic and ACEI CCB) as needed. or ARB or BB or CCB). *Treatment determined by highest BP category. †Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. GRECC Audioconference January 2007 JNC 7 Report. JAMA. 2003:2560 41 Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Without Compelling Indications With Compelling Indications Stage 1 Hypertension Stage 2 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. GRECC Audioconference January 2007 JNC 7 Report. JAMA. 2003:2560 42 Adverse Effects Common to Antihypertensive Drugs Orthostatic hypotension postural dizziness or lightheadedness risk factor for falls Many produce metabolic and/or electrolyte changes Interactions with other medications GRECC Audioconference January 2007 43 Overview of Pharmacologic Treatment All antihypertensive drug classes are effective in older hypertensives. Thiazide-type diuretics recommended by JNC-7. Avoid direct vasodilators and central adrenergic drugs. Drug selection should be an individualized decision. Start low; go slow! GRECC Audioconference January 2007 44 General Treatment Recommendations for Stage 1, Simple Hypertension Begin with nonpharmacological approach – weight loss, exercise, salt restriction. Consider low dose diuretic as initial drug selection; an ACE inhibitor is an alternative. Base alternative drug selection or combination therapies on individual patient characteristics. When initiating drug therapy, begin at half of the usual dose, increase dose slowly, and continue non-pharmacological therapies. GRECC Audioconference January 2007 45 General Treatment Recommendations for Stage 1, Simple Hypertension -2 Focus treatment goal on systolic blood pressure reduction to 135-140 mm Hg. Avoid excessive reduction in diastolic blood pressure (below 70 mm Hg). Aggressive therapy is not appropriate if adverse side effects (e.g., postural hypotension) cannot be avoided. GRECC Audioconference January 2007 46 BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 National Health and Nutrition Examination Survey, Percent II 1976–80 II (Phase 1) 1988–91 II (Phase 2) 1991–94 1999–2000 Awareness 51 73 68 70 Treatment 31 55 54 59 Control 10 29 27 34 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6. GRECC Audioconference January 2007 47 SUMMARY Hypertension is a common condition among the elderly. Treating high blood pressure lowers the risks of heart attack, heart failure and stroke. Systolic BP and pulse pressure matter. Optimal blood pressure control should be achieved using the treatment which is least likely to produce side effects. GRECC Audioconference January 2007 48 Unanswered Questions Treatment goals in very old. Conflicts between practice guidelines and treatment related risks. How to further improve blood pressure control rate. GRECC Audioconference January 2007 49 Questions... About our logo... The bristlecone pine tree (Pinus longaeva) - the earth’s oldest inhabitant with a life span of 4,000 years - is found only in Utah and five other western states. Its extraordinary longevity and ability to adapt and survive in extremely harsh environmental conditions above 10,000 feet embodies the investigative spirit and mission of the Utah Center on Aging. GRECC Audioconference January 2007 50 References Chobanian, A.V., Bakris, G.L., Black, H.R., et al. The Seventh Report of The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; The JNC 7 Report. JAMA. 2003;289(19): 2560-2572. Domanski MJ, Davis BR, Pfeffer MA, et al. Isolated systolic hypertension: prognostic information provided by pulse pressure. Hypertension. 1999;34:375–380. Psaty, B.M., Lumley, T., Furberg, C.D., et al. Health outcomes associated with various antihypertensive therapies used as first-line agents. A network meta-analysis. JAMA. 2003;289:2534-2544. The ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuretic. JAMA. 2002;288:2918-2997. Vasan R.S., Beiser A, Seshadri, S., et al. Residual lifetime risk for developing hypertension in middle-aged women and men. JAMA. 2002;287:1003-1010. Wing, L.M.H., Reid, C.M., Ryan, P. et al. A comparison of outcomes with angiotensinconverting-enzyme inhibitors and diuretics for hypertension in the elderly. NEJM. 2003;348:583-592. GRECC Audioconference January 2007 51