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Hypertension
In elderly population
JNC VII
BP
Classification
Normal
SBP mmHg
<120
DBP mmHg
<80
Prehypertension 120–139
80–89
Stage 1
Hypertension
140–159
90–99
Stage 2
Hypertension
>160
>100
Relook at hypertension
Hypertension is a major cardiovascular risk
factor, but knowledge about the real magnitude of
the problem and its determinants is lacking.
Hypertension is poorly controlled in most
patients with a high risk of cardiovascular
disease.
Uncontrolled hypertension is frequently
associated with poor control of other risk factors.
Swedish trial
Screened: 27,936 subjects (10,953 men and 16,983
women), 45 to 73 years old
16 648 subjects (60%) had hypertension
23 % received
77 % untreated
treatment
88.2% had BP levels > or =140/90 mm Hg
49.5% had BP levels >or =160/100 mm Hg
Li C et al, Stroke. 2005 Apr;36(4):725-30. Epub 2005 Mar 3
US study
According to the third National Health and Nutrition
Examination Survey (NHANES III), approximately 60% of
the 50 million Americans with hypertension are at
increased risk for cardiovascular disease resulting from
uncontrolled hypertension.
This is because only 53% of hypertensive patients are
being treated and only 24% have their hypertension under
control.
Dosh SA et al, J Fam Pract. 2002 Jan;51(1):74-80
Patient awareness- US
study
91% reported that a health care
provider had told them that they have
hypertension or high BP
41% of patients did not know their BP
level, while 28% of all patients correctly
identified the meaning of HTN as "high
blood pressure."
34% of patients correctly identified SBP
as the "top" number of their reading;
32% correctly identified diastolic blood
pressure (DBP) as the "bottom“
Oliveria SA et al, J Gen Intern Med. 2005 Mar;20(3):219-25
Impact of uncontrolled
hypertension
Coronary
artery disease
(CAD)
Congestive
heart failure
(CHF)
Stroke
Hypertension
is dreadful.
Peripheral
vascular
diseases
Renal
failure
LVH
Sudden death
Risk of complications
For individuals aged 40 to 70 years, each
increment of 20 mm Hg in systolic BP or 10 mm Hg
in diastolic BP doubles the risk of CVD across the
entire BP range from 115/75 to 185/115 mm Hg.
JNC VII
Higher incidence of stroke
800
700
600
Per
100 000
personyear
2.5 times
higher
500
400
Crude inidence
of stroke
300
200
100
0
Controlled
hypertensives
Uncontrolled
hypertensive
Li C et al, Stroke. 2005 Apr;36(4):725-30. Epub 2005 Mar 3
Elderly hypertensives
Framingham Heart Study suggest that individuals
who are normotensive at 55 years of age have a
90% lifetime risk for developing hypertension.
Hypertension and the presence of other
cardiovascular risk factors in older persons (i.e.,
obesity, left ventricular hypertrophy, sedentary
lifestyle, hyperlipidemia, and diabetes) make this
population at high risk for morbidity and
mortality.
Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76
Isolated systolic hypertension
Multiple studies have demonstrated that isolated
elevated systolic blood pressure is more
prevalent in older persons because of increased
large-artery stiffness.
Recommendations from the JNC state that
systolic blood pressure should be the primary
target for the diagnosis and care of older persons
with hypertension.
What
is the
goal BP?
Goals
of Therapy
Treating systolic BP and diastolic BP to targets
that are less than 140/90 mm Hg is associated
with a decrease in CVD complications.
In patients with hypertension with diabetes or
renal disease, the BP goal is less than 130/80
mm Hg.
JNC VII
What is the goal BP?
Although most data support the treatment of older
patients with stage 2 isolated systolic hypertension
(systolic blood pressure higher than 160 mm Hg), JNC
7 recommends treating older patients with stage 1
isolated systolic hypertension (systolic blood pressure
140 to 159 mm Hg) equally aggressively.
Benefits of Lowering BP
In clinical trials, antihypertensive therapy has
been associated with 35% to 40% mean
reductions in stroke incidence; 20% to 25% in
myocardial infarction; and more than 50% in HF.
It is estimated that in patients with stage 1
hypertension and additional cardiovascular risk
factors, achieving a sustained 12-mm Hg
decrease in systolic BP for 10 years will prevent 1
death for every 11 patients treated.
JNC VII
Evidence based
medicine
STOP-2
Swedish Trial in Old Patients with Hypertension-2 study
Mean
age in
years
Mean
follow
up in
years
Initial
blood
pressure
(mm of
Hg)
Blood
Regimens
pressure
after
treatment
(mm of
Hg)
76
5
194/98
~158/80
in both
groups
Beta blocker or
thiazide (older drugs)
vs. ACE inhibitor or
calcium channel
blocker (newer
drugs)
Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76
STOP-2
Regimens did not differ in rates of stroke,
cardiovascular events, or mortality.
ACE inhibitor better than calcium channel
blocker for myocardial infarction (NNT =
26) and congestive heart failure (NNT =
28).
LIFE
Losartan Intervention For Endpoint reduction in hypertension study
Mean
age in
years
Mean
follow
up in
years
Initial
blood
pressure
(mm of
Hg)
Blood
Regimens
pressure
after
treatment
(mm of
Hg)
70
4
174/98
~145/81
in both
groups
ARB (losartan) vs.
beta blocker
(atenolol)
Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76
LIFE
ARB better than beta blocker for stroke
and combined end point of cardiovascular
mortality, stroke, and myocardial
infarction.
Regimens did not differ in rates of total
mortality.
ALLHAT
Antihypertensive and Lipid-Lowering Treatment to prevent Heart Attack Trial
Mean
age in
years
Mean
follow
up in
years
Initial
blood
pressure
(mm of
Hg)
Blood
Regimens
pressure
after
treatment
(mm of
Hg)
67
5
146/84
~134/85
in all
groups
Thiazide
(chlorthalidone) vs.
ACE inhibitor
(lisinopril) vs.
calcium channel
blocker (amlodipine)
Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76
ALLHAT
Regimens did not differ in combined end point of
fatal coronary heart disease or nonfatal myocardial
infarction.
Thiazide better than calcium channel blocker for
congestive heart failure and angina.
Thiazide better than ACE inhibitor for stroke,
cardiovascular disease, congestive heart failure, or
revascularization.
Regimens did not differ in rates of total mortality.
INVEST
International Verapamil-Trandolapril study
Mean
age in
years
Mean
follow
up in
years
Initial
blood
pressure
(mm of
Hg)
Blood
pressure
after
treatment
(mm of Hg)
Regimens
66
2
150/87
~131/77 in
both
groups
Calcium channel
blocker (verapamil) plus
ACE inhibitor
(trandolapril) vs. beta
blocker (atenolol) plus
thiazide
(hydrochlorothiazide)
Regimens did not differ in rates of
cardiovascular outcomes or total mortality.
ANBP-2
Second Australian National Blood Pressure study
Mean
age in
years
Mean
follow
up in
years
Initial
blood
pressure
(mm of
Hg)
Blood
Regimens
pressure
after
treatment
(mm of
Hg)
72
4
168/91
~142/79
in both
groups
ACE inhibitor
(enalapril) vs thiazide
(hydrochlorthiazide)
Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76
ANBP-2
ACE inhibitor better than thiazide for
primary end point of all cardiovascular
events or total mortality (NNT = 72) and for
myocardial infarction (NNT = 125).
Regimens did not differ in rates of total
mortality.
Management of
hypertension in elderly
Thiazide-type diuretics
Thiazide-type diuretics should be used as initial
therapy for most patients with hypertension, either
alone or in combination with 1 of the other classes
(ACE inhibitors, ARBs, Beta-blockers, CCBs)
demonstrated to be beneficial in randomized
controlled outcome trials.
JNC VII
Thiazide-type diuretics
Thiazide-type diuretics have been the basis of
antihypertensive therapy in most outcome trials.
In these trials, including the recently published
Antihypertensive and Lipid-Lowering Treatment to
Prevent Heart Attack Trial, diuretics have been
virtually unsurpassed in preventing the
cardiovascular complications of hypertension.
Diuretics enhance the antihypertensive efficacy of
multidrug regimens, can be useful in achieving BP
control, and are more affordable than other
antihypertensive agents.
JNC VII
Compelling indications
Indications
Antihypertensives as initial therapy
Heart failure
Diuretic, Beta blocker, ACE inhibitor,
ARB, Aldosterone antagonist
Post MI
Beta blocker, ACE inhibitor,
Aldosterone antagonist
High coronary Diuretic, Beta blocker, ACE inhibitor,
disease risk
CCB
JNC VII
Compelling indications
Indications
Diabetes
Antihypertensives as initial therapy
Diuretic, Beta blocker, ACE inhibitor,
ARB, CCB
Chronic
ACE inhibitor, ARB
kidney disease
Recurrent
stroke
prevention
Diuretic, ACE inhibitors
JNC VII
JNC VII - Tips
Treat isolated systolic blood pressure
Thiazide diuretics should be first-line
treatment
Second-line treatment should be
based on comorbidities and risk
factors
JNC VII - Tips
Patients with systolic blood pressure higher
than 160 mm Hg or diastolic blood pressure
higher than 100 mm Hg usually will require
two or more agents to reach goal
Treatment should be initiated with a low
dose of the chosen antihypertensive agent,
and titrated slowly to minimize side effects
such as orthostatic hypotension
JNC VII - Tips
Weight loss and sodium reduction have been
shown to be feasible and effective interventions
in older patients with hypertension.
To improve adherence with antihypertensive
regimens, involve patients in goal setting, and
ensure that the patient's cultural beliefs and
previous experiences are incorporated in a
treatment plan.
Simplify the medication regimen, keeping in mind
how much it costs.
Need of an hour
Implementation of guidelines
Closing the gap between experts’
recommendations
and poor blood pressure control
in medical practice.
+
Patient behavior change: Motivation
improves when patients have positive
experiences with and trust in their
JNC VII
clinicians.
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