HYPERTENSION IN ELDERLYHYPERTENSION IN ELDERLY

Dr. Kunal KothariDr. Kunal Kothari Emeritus Professor of Medicine and Clinical Cardiology Emeritus Professor of Medicine and Clinical Cardiology

Director Primary Health Care and Strategic Director Primary Health Care and Strategic initiativeinitiative

HYPERTENSION

K I L L E R

I

S

E

N

T

L O W

Sphygmanometer- Sphygmanometer- size of the cuffssize of the cuffs

Food Food ExerciseExercise CaffeineCaffeine Smoking Smoking

200

140

160

120

180

20

40

60

80

100

0

A softer blowing sound

A sharp thump

A softer thump

A blowing or whooshing sound

K1

K2

K3

K4

K5

Benefits of Lowering Blood Benefits of Lowering Blood PressurePressure

Antihypertensive Therapy has been Antihypertensive Therapy has been associated with reductions in:associated with reductions in:

Stroke Incidence (35-40 %).

MI (20-25 %).

Heart Failure ( averaging > 50 %).

GuidelinesGuidelines

The Seventh Report of the Joint National Committee The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults:guidelines to define HTN in adults:

CategoryCategory SystolicSystolic DiastolicDiastolic

NormalNormal <120<120 andand <80<80Pre-hypertensionPre-hypertension 120-139120-139 oror 85-8985-89

Stage 1 Stage 1 hypertensionhypertension

140-159140-159 oror 90-9990-99

Stage 2 Stage 2 hypertensionhypertension

>>160160 oror >>100100

135/85 Ambulatory Pressure

140/90

Clinic Pressure Sustained

HypertensionWhite Coat Hypertension

True Normotension

Masked Hypertension

Pseudo HypertensionPseudo Hypertension

Recording of high B.P. but do not Recording of high B.P. but do not havehave

Common cause of this is brachial Common cause of this is brachial artery compression artery compression

WHITE COAT WHITE COAT HYPERTENSIONHYPERTENSION

BP recording in office or clinic is BP recording in office or clinic is high while at home is normotensivehigh while at home is normotensive

"white coat" hypertension appear "white coat" hypertension appear to have no greater risk than people to have no greater risk than people with normal blood pressure with normal blood pressure ( Aug. 2, ( Aug. 2, 2005, American college of cardiology )2005, American college of cardiology )

MASKED HYPERTENSIONMASKED HYPERTENSION

Proposed the term masked hypertensionProposed the term masked hypertension

Pickering et al (Hypertension Pickering et al (Hypertension 2002;102:1139-44)2002;102:1139-44)

Documented by Ohkubo et al Documented by Ohkubo et al (N Engl J (N Engl J Medicine 2003;348:2407-15)Medicine 2003;348:2407-15)

MASKED HYPERTENSIONMASKED HYPERTENSION

HYPERTENSION IS NOT DETECTED BY THE HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. "UNDETECTED AMBULATORY ROUTINE METHODS. "UNDETECTED AMBULATORY HYPERTENSION" HYPERTENSION"

UNUSUALLY HIGH AMBULATORY PRESSURE OR A UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION OCCASION

SHOW MORE EXTENSIVE TARGET ORGAN SHOW MORE EXTENSIVE TARGET ORGAN

DAMAGE THAN TRUE NORMOTENSIVE SUBJECTSDAMAGE THAN TRUE NORMOTENSIVE SUBJECTS

Blood Pressure in 347,978 men Blood Pressure in 347,978 men aged 35-57 screened for MRFITaged 35-57 screened for MRFIT

6.5

19

28

23

13

75

0

5

10

15

20

25

30

35

<110 110-119 120-129 130-139 140-149 150-159 >160

% of Men

Systolic pressure mmHg

¼ ½ ¼

Lifetime Risk of Developing Lifetime Risk of Developing Hypertension in Middle Aged Hypertension in Middle Aged

(Vasan et al, JAMA 2002; 287: 1010(Vasan et al, JAMA 2002; 287: 1010))

Risk for Hypertension in a 55 year oldRisk for Hypertension in a 55 year old

Time, yrTime, yr WomenWomen MenMen

1010 52%52% 56% 56%

1515 72%72% 78% 78%

2020 83% 88%83% 88%

25 91% 93% 25 91% 93%

Diagnostic Evaluation of the Hypertensive Diagnostic Evaluation of the Hypertensive

Patient- Patient- How much is enough?How much is enough?

How high is the blood pressure?How high is the blood pressure?

Why is it high?Why is it high?

What is the risk?What is the risk?

Clinical Manifestations IClinical Manifestations I

Physical exam:Physical exam:AbdomenAbdomenFunduscopicFunduscopicVascularVascularCardiacCardiacPulmonaryPulmonaryNeurologicalNeurological

Lab tests:Lab tests:UrinalysisUrinalysisBlood ChemistryBlood ChemistryECGECGRenal ultrasoundRenal ultrasoundEchocardiogramEchocardiogramVascular studiesVascular studies

Differential DiagnosisDifferential Diagnosis

1.1. Rule out isolated incident of increased Rule out isolated incident of increased blood pressure.blood pressure.

2.2. Rule out secondary hypertension related Rule out secondary hypertension related to:to:

Renal diseaseRenal disease

Cushing's diseaseCushing's disease

PheochromocytomaPheochromocytoma

HyperthyroidismHyperthyroidism

HyperparathyroidismHyperparathyroidism

ComplicationsComplicationsComplications as a result of HTN Complications as a result of HTN

include:include:

StrokeStroke

DementiaDementia

Myocardial InfarctionMyocardial Infarction

Congestive Heart FailureCongestive Heart Failure

Retinal VasculopathyRetinal Vasculopathy

Aortic DissectionAortic Dissection

Renal Disease or FailureRenal Disease or Failure

ManagementManagementMedicationsMedications

DiureticsDiuretics- Thiazides (HCTZ), Loop (Furosemide), - Thiazides (HCTZ), Loop (Furosemide), Potassium-sparing (Spironolactone)Potassium-sparing (Spironolactone)

Beta-BlockersBeta-Blockers- Atenolol, Nadolol, Propranolol- Atenolol, Nadolol, Propranolol

ACEACE InhibitorsInhibitors-- Benezapril, Captopril, Cilizapril Benezapril, Captopril, Cilizapril

ARBsARBs-- Losartan, ValsartanLosartan, Valsartan

Ca+ Channel BlockersCa+ Channel Blockers-- Nifedipine, Verapamil Nifedipine, Verapamil

Alpha blockers-Alpha blockers- Prazosin, Terazosin Prazosin, Terazosin

VasodilatorsVasodilators-- Apresoline Apresoline

ManagementManagementPrimary goalPrimary goal is to reduce is to reduce

cardiovascular and renal morbidity cardiovascular and renal morbidity and mortality.and mortality.

Other keysOther keys to management are: to management are:

PreventionPrevention

Patient educationPatient education

Life-style modificationLife-style modification

MedicationMedication

Hospitalization should be Hospitalization should be considered ifconsidered if

Very high BPVery high BP

Severe headacheSevere headache

Chest pain Chest pain

Neurologic symptomsNeurologic symptoms

Altered mental statusAltered mental status

Acutely worsening renal failureAcutely worsening renal failure

S & S of hypertensive emergencyS & S of hypertensive emergency

DOES ELDERLY DOES ELDERLY HYPERTENSION HAVE HYPERTENSION HAVE

SPECIFIC SPECIFIC CHARACTERISTICS?CHARACTERISTICS?

CHARACTERISTICS OF HYPERTENSION IN THE ELDERLY

Increased

Systolic blood pressure and pulse pressure

Left ventricular mass and wall thickness

Arterial stiffness

Calculated total peripheral resistance

Decreased

Cardiac output and heart rate

Renal blood flow, plasma renin activity, and angiotensin II levels

Arterial compliance and blood volume

Diastolic blood pressure

Black H. JCH 2003; 5:12

Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.

Stroke Volume

Aorta

Resistance Arterioles

Pressure (Flow)

Young Artery

Systole Diastole

Elastic Vessel

Arteriosclerotic Artery

Stiff Vessel

Systole Diastole

Arterial Wall Compliance and Pulse Pressure Wave

Do lifestyle measures Do lifestyle measures really work for elderly really work for elderly

hypertension?hypertension?

ModificationModificationApproximate SBP Approximate SBP

ReductionReduction(range)(range)

Weight ReductionWeight Reduction 5-10 5-10 mmHg/10kgmmHg/10kg

Adopt DASH eating planAdopt DASH eating plan 8-14 mmHg8-14 mmHg

Dietary sodium reductionDietary sodium reduction 2-8 mmHg2-8 mmHg

Physical activityPhysical activity 4-9 mmHg4-9 mmHg

Moderation of alcohol Moderation of alcohol consumptionconsumption

2–4 mmHg2–4 mmHg

Lifestyle ModificationsLifestyle Modifications

Bar graph shows change in mean arterial blood pressure used to define salt responsivity as a function of age in normotensive [open bars] and hypertensive [color bars] subjects.

42

0

-2-4

-6

-8-10

-12

-14

-16-18

-20 20-30 31-40 41-50

AGE [yrs]

Weinberger M. Hypertens 1991; 18:69

51-60 >60

Cha

nge

in M

ean

Art

eria

l Blo

od P

ress

ure

Weinberger M. Hypertens 1991; 18:69

Effect of 30 minute walk 3 days a weekAge 70 - 79

Systolic Diastolic

Exercise Group

Baseline 156 ± 10 mm Hg 86 ± 8 mm Hg

3 months 151 ± 15 mm Hg 80 ± 6 mm Hg

Control Group

Baseline 153 ± 7 mm Hg 85 ± 8 mm Hg

3 months 156 ± 10 mm Hg 85 ± 6 mm Hg

Conone et al. Med Scl in Sports and Exercise. 1991

What is the effect of drug What is the effect of drug therapy related to age? Are therapy related to age? Are

the recommendations the recommendations different?different?

Antihypertensive DrugsAntihypertensive Drugs

AAACEI, ARBsACEI, ARBs

BBBeta BlockerBeta Blocker

CCCCBCCB

DDDiuretic Diuretic

DDlow dose HCTZlow dose HCTZ

AABBCC

Algorithm for Management of the Elderly - Primarily Systolic Hypertension

1) Lifestyle changes

2) Low dose diuretic (12.5 mg HCTZ)

CCB B-Blocker ACE or ARB

3) Stop, Look & Listen before dosages

Let the Baroreceptors reset

4) Rx until goal achieved

++

+

+ +

ALLHATALLHAT

The Antihypertensive and Lipid The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) suggests that Attack Trial (ALLHAT) suggests that low dose thiazide diuretics have a low dose thiazide diuretics have a better cardiovascular protective better cardiovascular protective effecteffect

Result HighlightsResult Highlights

21% reduction in relative risk death 21% reduction in relative risk death from any causefrom any cause

64% reduction relative risk heart 64% reduction relative risk heart failurefailure

39% reduction relative risk of death 39% reduction relative risk of death from strokefrom stroke

Syst-EurSyst-Eur

A study called the Systolic-A study called the Systolic-Hypertension Trial in Europe (Syst-Hypertension Trial in Europe (Syst-Eur) showed that aggressive Eur) showed that aggressive treatment of hypertension reduces treatment of hypertension reduces the risk of stroke by 42% and the risk of stroke by 42% and dementia is prevented. dementia is prevented.

Trials Examining Treatment of Hypertension in the Elderly

EWPHE MRC-Elderly SHEP STOP-H Syst-China Syst-Eur

(N = 840) (N = 4396) (N = 4736) (N = 1627) (N = 2394) (N = 4695)

Stroke reduction, % -36 -25 -33 -47 -38 -42

CAD change, % -20 -19 -27 -13 +6 -26

CHF reduction, % -22 Not stated -55 -51 -58 -27

% of Patients receiving 35 52 (b-blocker) 44 67 11-26 26-36 combination drug therapy 38 (diuretic)

Prisant, Moser M. Arch Int Med 2000; 160:284

Major Clinical Trials Showing Benefit of Treating Isolated Systolic Hypertension

SHEP Syst-Eur Syst-China(n=4736) (n=4695) (n=2394)

Baseline 160-219/ 160-219/ 160-219/

SBP/DBP (mm Hg) <90 <95 <95

BP reduction: 27/9 23/7 20/5

SBP/DBP (mm Hg)

Drug therapy Chlorthalidone Nitrendipine NitrendipineAtenolol Enalapril Captopril

HCTZ HCTZ

Outcomes (%)

Stroke 33 42 38

CAD 27 30 27

CHF 55 29 —

All CVR disease 32 31 25

Journal of Clinical Hypertension Vol II, No. 5, page 336, September/October 2000.

Independent Predictors of Using Antihypertensives Medications in 2000

Variable Adjusted OR (95% CI) of Using Antihypertensives

Comorbid conditions

Asthma/COPD 0.43 (0.40-0.47)

Depression 0.50 (0.45-0.55)

GI disorders 0.59 (0.54-0.64)

Osteoarthritis 0.63 (0.59-0.67)

Cardiovascular conditions

Coronary artery disease 1.31 (1.23-1.40)

Cerebrovascular disease 1.03 (.97-1.10)

Congestive heart failure 1.05 (0.99-1.11)

Diabetes 1.16 (1.10-1.22)

Wang PS et al. Hypertension 2005; 46:273-279

Barriers to Optimal Control of Hypertension

Inaccurate measurement of blood pressure (BP)

Focusing on diastolic BP rather than systolic BP goal

Failure to consider absolute global risk

Failure to advocate lifestyle modifications

Failure to use polypharmacy

Failure to use effective drug combinations

Failure to titrate doses upward

Fear of reaching excessively low diastolic BP

The patient with truly resistant hypertension

Behavioral barriers

Franklin S. JCH 2006; 8:524

What is the systolic What is the systolic blood pressure goal?blood pressure goal?

Blood Pressure in SHEP and Syst-Eur (mm Hg)

SHEP Syst-Eur

Entry 160-219/<90 160-219/<95

Goal (SBP) <160 + ≥20 <150 + ≥20

Baseline 170/77 174/86

Achieved: Rx 143/68 151/79

Achieved: Placebo 155/72 161/84

Difference: Rx-Placebo 12/4 10/5

Journal of Clinical Hypertension, Vol II, No. 5, page 336. March/April 2000.

REDUCTION OF STROKES WITH BP LOWERING - SHEP TRIAL

No. of Patients: 4736

Follow-up: 4.5 years

37% in ischemic strokes

47% in lacunar infarcts

54% in hemorrhagic strokes

Lower BPs - fewer strokes

Am J Hypertension 2000;13:724-733

Hypertension in the Very Elderly TrialHypertension in the Very Elderly TrialNEJM 2008;358(18):1887-1898NEJM 2008;358(18):1887-1898

Double blind, Double blind, placebo-controlledplacebo-controlled

International, International, multicentermulticenter

3845 patients3845 patients Mean age 83.6 yrsMean age 83.6 yrs BP range 160-BP range 160-

219/90-109219/90-109 Mean BP 173.0/90.8Mean BP 173.0/90.8

f/u median of 1.8 yrsf/u median of 1.8 yrs Primary endpoints – Primary endpoints –

fatal or non fatal fatal or non fatal strokestroke

Indapamide 1.5mgIndapamide 1.5mg Perindopril prn (2mg Perindopril prn (2mg

or 4mg)or 4mg) Mean BP fall Mean BP fall

15.0/6.1 at 2 yrs15.0/6.1 at 2 yrs

Result HighlightsResult Highlights

21% reduction in relative risk death 21% reduction in relative risk death from any causefrom any cause

64% reduction relative risk heart 64% reduction relative risk heart failurefailure

39% reduction relative risk of death 39% reduction relative risk of death from strokefrom stroke

GOALS OF TREATMENTGOALS OF TREATMENT

To achieve a target BP of <140/ 90 mm Hg.To achieve a target BP of <140/ 90 mm Hg.

In patients with Hypertension & Diabetes or In patients with Hypertension & Diabetes or Renal disease, BP Goal is < 130/80 mm Hg.Renal disease, BP Goal is < 130/80 mm Hg.

To reduce cardiovascular morbidity & mortality.To reduce cardiovascular morbidity & mortality.

Thiazide MythsThiazide Myths

Sulfa cross Sulfa cross reactivityreactivity

GoutGout

Renal stonesRenal stones

Thiazide Related GoutThiazide Related Gout

Thiazide related hyperuricemia is Thiazide related hyperuricemia is dose relateddose related

HDFP Trial: 15 episodes of gout over HDFP Trial: 15 episodes of gout over 5 years in 3693 patients treated with 5 years in 3693 patients treated with chlorthalidone 25-100mg (equivalent chlorthalidone 25-100mg (equivalent to 50-200 mg HCTZ)to 50-200 mg HCTZ)

Low dose thiazide (HCTZ 12.5-25 mg) Low dose thiazide (HCTZ 12.5-25 mg) is not contraindicated in goutis not contraindicated in gout

Treatment Treatment Recommendations for the Recommendations for the

Elderly in JNC 7Elderly in JNC 7Recommendations are no different Recommendations are no different

according to age for:according to age for: BP classificationBP classification BP goalsBP goals Lifestyle interventionsLifestyle interventions Selection of medicationsSelection of medications

For persons over age 50, SBP is a more important than DBP as CVD risk factor.

Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range.

Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN.

Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.

JNC 7: New Features and Key Messages

Thank YouThank You

Dr. Kunal KothariDr. Kunal KothariEmeritus Professor of medicine and Clinical Emeritus Professor of medicine and Clinical

Cardiology Cardiology Director Primary Health care and Strategic initiativeDirector Primary Health care and Strategic initiative