HTN Guidelines For Elderly and whom

with Renal Impairment

ByDr. Mohamed Kharabish

ICU Senior Registrar

Definition of HTN

•Hypertension is defined as a systolic blood pressure (SBP) of 140 mm Hg or more, or a diastolic blood pressure (DBP) of 90 mm Hg or more, or taking antihypertensive medication (Roger et al.,2012).

Classification of Blood pressure

Based on recommendations of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the classification of BP for adults aged 18 years or older has been as follows :

→ Normal: Systolic lower than 120 mmHg, diastolic lower than 80 mmHg

→ Prehypertension: Systolic 120-139 mmHg, diastolic 80-89 mmHg

→ Stage 1: Systolic 140-159 mmHg, diastolic 90-99 mmHg

→ Stage 2: Systolic 160 mm Hg or greater, diastolic 100 mm (Chobanian et al.,2003). Hg or greater

Hints About Mechanism

Aging with decreased compliance in intima and media of large arteries.

Also increased collagen rigidity↑sclerosis and fibrosis of blood vessels.* The renin- aldosterone -angiotensin system becomes ↓↓↓ less responsive with aging, partially as a result of reduced activity of the sympathetic nervous system; plasma renin activity, angiotensin II and aldosterone levels↓↓↓ decrease.

Hints About Mechanism*Geriatric hypertension is generally of a salt-sensitive nature with ↓↓reduced ability to appropriately excrete a salt load.

*Decline in renal function and to a reduced generation of natriuretic substances, such as prostaglandin E2 and dopamine.

*Age-associated declines ↓↓ in the activity of membrane sodium/potassium-adenosine triphosphatase (Na+-K+-ATPase) may also contribute to geriatric hypertension because this results in increased intracellular ↑↑ sodium that may cause reduced sodium-calcium exchange and thereby ↑↑↑↑ increase intracellular calcium and↑↑ vascular resistance.

Summary of causesHypercalcemia

Hyperthyroidism

Hyperaldosteronism

Cushing sx

Obst sleep apnea

Aortic coarctation

Renovascuar

Pheochromocytoma

Geriatric consideration related to HTN

• Is generally of a salt-sensitive nature.

• Aging is often associated with impaired baroreflex function.

• Be careful of white coat HTN (excited with increase of cardiac output with non compliant arteries).

• Measure both sides take average of 3 readings in same visit.

• relative increase in systolic HTN.

• increase in pulse pressure (syst – Diast).

Treatment outlines

systolic and diastolic pulse pressure matter.

Treatment goals.

Non pharmacological therapy.

Pharmacological therapy.

Systolic and Diastolic pulse pressure matter

Specially among older persons, SBP is better predictor of events (coronary heart disease, cardiovascular disease, heart failure, stroke, end-stage renal disease, and all-cause mortality) than is DBP.

The goal of treatment in older patients should be the same as in younger patients (to below 140/90 mmHg if at all possible), although an interim goal of SBP below 160 mmHg may be necessary in those patients with marked systolic hypertension.

If goal blood pressure is not attained with lifestyle modification, antihypertensive therapy should be initiated

Be careful in pharmacological ttt of hypertensive elderly

• start with lower initial dose one half than younger

• lower Bp gradually in absence of emergencies.

• Orthostatic and postprandial hypotension problem>>>>>>>>

How to detect and avoid?????

Pharmacological ttt

Beta blockers — There is evidence that, in the absence of a specific indication for their use (e.g. heart failure, myocardial infarction), beta blockers should not be considered for primary therapy

In general, three classes of drugs are considered first-line therapy for the treatment of hypertension in elderly patients: low-dose thiazide diuretics (eg, 12.5 to 25 mg/day of chlorthalidone), long-acting calcium channel blockers (most often dihydropyridines), and ACE inhibitors or ARBs. A long-acting dihydropyridine or a thiazide diuretic is generally preferred in elderly patients because of increased efficacy in blood pressure lowering

Note that

• Diastolic blood pressure lowering should not be less than 60 mm Hg

Why???

Chronic Kidney Disease (CKD)

Outlines

Definition

Understand

Scheme approac

h

The guidelines define CKD as either

kidney damage or

a decreased glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2 for at least 3 months.

Whatever the underlying etiology, once the loss of nephrons and reduction of functional renal mass reaches a certain point, the remaining nephrons begin a process of irreversible sclerosis that leads to a progressive decline in the GFR.

Definition

UnderstandingRenal mass progressively declines with advancing age, and glomerulosclerosis leads to a decrease ↓ in renal weight. Histologic examination is notable for a decrease in glomerular number of as much as 30-50% by age 70 years.

The GFR peaks during the third decade of life at approximately 120 mL/min/1.73 m2; it then undergoes an annual mean decline of approximately 1 mL/min/y/1.73 m2, reaching a mean value of 70 mL/min/1.73 m2 at age 70 years.

Goal of therapyPatients with nondiabetic and diabetic CKD should have a target BP goal of <130/80 mmHg. Ultimately, the rationale for lowering BP in all patients with CKD is to reduce both renal and

cardiovascular morbidity and mortality. Maintaining BP control and minimizing proteinuria in patients with CKD and HTN is essential for the prevention of the progression of kidney disease and the development or worsening of CVD.

Recent literature suggests that BP targets in diabetic and nondiabetic CKD may need to be individualized based on the presence of proteinuria.

For whom with renal impairment

THANK YOU