0
Hypertension in the Elderly: Taking up the Slack Amrit Singh, MD Department of Family Medicine University of North Carolin...
Objectives <ul><li>Understand impact of disease </li></ul><ul><li>Know goals of treatment </li></ul><ul><li>Understand ele...
The Seventh Report of the  Joint National Committee on Prevention, Detection,  Evaluation, and Treatment of High Blood Pre...
Growth of Geriatric Population
 
Demographic Changes
Prevalence of Hypertension
Blood Pressure Regulation
<ul><li>Age 55 and not hypertensive?  </li></ul><ul><ul><li>90% lifetime risk of hypertension </li></ul></ul><ul><ul><li>N...
 
HTN: Undetected vs. Detected
Case <ul><li>JL </li></ul><ul><ul><li>74 yo AAF </li></ul></ul><ul><ul><li>“ no problems … no doctors” </li></ul></ul><ul>...
Hypertension <ul><li>Associated Conditions </li></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>CVA </li></ul></ul><ul><ul>...
HTN & Cardiovascular Disease Risks <ul><li>Relationship of BP to CVD risk: </li></ul><ul><ul><li>continuous, consistent, i...
Blood Pressure Classification <80 and <120 Normal 80–89 or 120–139 Prehypertension 90–99 or 140–159 Stage 1 Hypertension >...
<ul><li>Age 50+ </li></ul><ul><ul><li>SBP more important than DBP as CVD risk factor. </li></ul></ul><ul><ul><li>NHLBI, 20...
Benefits of Lowering BP Average Percent Reduction Stroke incidence  35–40%  Myocardial infarction  20–25%  Heart failure 5...
“ Systolic Hypertension in the Elderly”: Results of  Treatment Morse, M. Hypertension Treatment and the Prevention of Coro...
Benefits of Lowering BP In stage 1 HTN + other CVD risk factors: NNT for preventing 1 death = 11 (sustained 12 mmHg  decli...
Dementia <ul><li>Cognitive impairment more common w/ HTN </li></ul><ul><ul><ul><ul><ul><li>Reduced progression of occurs w...
Accurately Measuring BP <ul><li>·Cuff size </li></ul><ul><li>·Correct inflation </li></ul><ul><li>·Appropriate interval </...
Case <ul><li>JL </li></ul><ul><ul><li>74 yo AAF </li></ul></ul><ul><ul><li>“ no problems … no doctors” </li></ul></ul><ul>...
 
Secondary Hypertension <ul><li>Sleep apnea </li></ul><ul><li>Drug-induced </li></ul><ul><li>Chronic kidney disease </li></...
CVD Risk Factors Hypertension* Obesity* (BMI  > 30 kg/m 2 ) Cigarette smoking  Physical inactivity Dyslipidemia* Diabetes ...
Target Organ Damage   <ul><li>Heart </li></ul><ul><ul><li>LVH </li></ul></ul><ul><ul><li>Angina or prior MI </li></ul></ul...
Left Ventricular Hypertrophy <ul><li>LVH  =  independent risk factor for CVD.  </li></ul><ul><li>Regression of LVH occurs ...
Laboratory Tests <ul><li>Always </li></ul><ul><ul><li>EKG </li></ul></ul><ul><ul><li>UA  </li></ul></ul><ul><ul><li>Chem 7...
Lifestyle Modification Approximate SBP reduction (range) Modification 5–20 mmHg/10 kg weight loss Weight reduction   8–14 ...
Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg)  (<130/80 mmHg for those with diabetes o...
Classification and Management  of BP for adults Two-drug combination for most †  (usually thiazide and ACEI or ARB or BB o...
Case  <ul><li>KH </li></ul><ul><ul><li>84 yo W F </li></ul></ul><ul><ul><ul><li>OA, osteoporosis, urinary incontinence </l...
Ambulatory BP Monitoring <ul><li>Ambulatory BP values are usually lower than clinic readings . </li></ul><ul><li>Hypertens...
Self-Measurement of BP <ul><li>Home measurement of >135/85 mmHg is generally considered  hypertensive. </li></ul>
Pharmacologic Tx
JNC 7: Key Messages <ul><li>Is BP >20/10 mmHg above goal? </li></ul><ul><ul><li>start with two agents  </li></ul></ul><ul>...
Compelling Indications for  Individual Drug Classes Clinical Trial Basis Initial Therapy  Indication   ALLHAT, HOPE, ANBP2...
Compelling Indications for  Individual Drug Classes Recurrent stroke prevention   Chronic renal disease   Diabetes   Clini...
Drugs: Other Considerations <ul><ul><ul><li>Thiazides:  good for osteopenia/osteoporosis. </li></ul></ul></ul><ul><li>BBs:...
Drugs: Other Considerations Relative Contraindications: Thiazides:  gout, hx hyponatremia   BBs:  RAD or 2 nd /3 rd  degre...
Postural Hypotension <ul><li>Drop in standing SBP >10 mmHg ; associated with dizziness/fainting </li></ul><ul><li>Always c...
Hypertensive Urgencies  and Emergencies <ul><li>Emergency:  marked BP elevations AND acute TOD </li></ul><ul><ul><ul><li>e...
<ul><li>Conclusions </li></ul><ul><ul><li>Elderly benefit from aggressive BP control </li></ul></ul><ul><ul><li>Goal: <140...
Upcoming SlideShare
Loading in...5
×

HTNintheElderly_000.ppt

826

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
826
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
52
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Lowest rates of BP control
  • Transcript of "HTNintheElderly_000.ppt"

    1. 1. Hypertension in the Elderly: Taking up the Slack Amrit Singh, MD Department of Family Medicine University of North Carolina June 25, 2003
    2. 2. Objectives <ul><li>Understand impact of disease </li></ul><ul><li>Know goals of treatment </li></ul><ul><li>Understand elements of care </li></ul><ul><li>Be familiar with JNC 7 guidelines </li></ul>
    3. 3. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) National Heart, Lung, and Blood Institute National High Blood Pressure Education Program U.S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute
    4. 4. Growth of Geriatric Population
    5. 6. Demographic Changes
    6. 7. Prevalence of Hypertension
    7. 8. Blood Pressure Regulation
    8. 9. <ul><li>Age 55 and not hypertensive? </li></ul><ul><ul><li>90% lifetime risk of hypertension </li></ul></ul><ul><ul><li>NHLBI, 2003 </li></ul></ul>JNC 7
    9. 11. HTN: Undetected vs. Detected
    10. 12. Case <ul><li>JL </li></ul><ul><ul><li>74 yo AAF </li></ul></ul><ul><ul><li>“ no problems … no doctors” </li></ul></ul><ul><ul><li>bothered by uterine prolapse </li></ul></ul><ul><ul><li>BP = 145/80 </li></ul></ul><ul><ul><li>Is this a problem? </li></ul></ul>
    11. 13. Hypertension <ul><li>Associated Conditions </li></ul><ul><ul><li>MI </li></ul></ul><ul><ul><li>CVA </li></ul></ul><ul><ul><li>PVD </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Renal failure </li></ul></ul>
    12. 14. HTN & Cardiovascular Disease Risks <ul><li>Relationship of BP to CVD risk: </li></ul><ul><ul><li>continuous, consistent, independent of other risks </li></ul></ul><ul><ul><li>115/75: </li></ul></ul><ul><ul><ul><li>Each 20/10 mmHg rise doubles risk of CVD </li></ul></ul></ul><ul><li>Adapted from JNC 7 guidelines, NHLBI website, 2003 </li></ul>
    13. 15. Blood Pressure Classification <80 and <120 Normal 80–89 or 120–139 Prehypertension 90–99 or 140–159 Stage 1 Hypertension > 100 or > 160 Stage 2 Hypertension DBP mmHg SBP mmHg BP Classification
    14. 16. <ul><li>Age 50+ </li></ul><ul><ul><li>SBP more important than DBP as CVD risk factor. </li></ul></ul><ul><ul><li>NHLBI, 2003 </li></ul></ul>JNC 7: New Messages
    15. 17. Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%
    16. 18. “ Systolic Hypertension in the Elderly”: Results of Treatment Morse, M. Hypertension Treatment and the Prevention of Coronary Heart Disease in the Elderly. AFP ; March 1, 1999.
    17. 19. Benefits of Lowering BP In stage 1 HTN + other CVD risk factors: NNT for preventing 1 death = 11 (sustained 12 mmHg decline in SBP over 10 years)
    18. 20. Dementia <ul><li>Cognitive impairment more common w/ HTN </li></ul><ul><ul><ul><ul><ul><li>Reduced progression of occurs with effective antihypertensive therapy. </li></ul></ul></ul></ul></ul>
    19. 21. Accurately Measuring BP <ul><li>·Cuff size </li></ul><ul><li>·Correct inflation </li></ul><ul><li>·Appropriate interval </li></ul><ul><li>·Several readings </li></ul>
    20. 22. Case <ul><li>JL </li></ul><ul><ul><li>74 yo AAF </li></ul></ul><ul><ul><li>“ no problems … no doctors” </li></ul></ul><ul><ul><li>BP = 145/80 </li></ul></ul><ul><ul><li>__________________________ </li></ul></ul><ul><ul><li>Recheck= 140/70 </li></ul></ul><ul><ul><li>Next steps? </li></ul></ul>
    21. 24. Secondary Hypertension <ul><li>Sleep apnea </li></ul><ul><li>Drug-induced </li></ul><ul><li>Chronic kidney disease </li></ul><ul><li>Primary aldosteronism </li></ul><ul><li>Renovascular disease </li></ul><ul><li>Chronic steroid therapy or Cushing’s syndrome </li></ul><ul><li>Pheochromocytoma </li></ul><ul><li>Coarctation of the aorta </li></ul><ul><li>Thyroid or parathyroid disease </li></ul>
    22. 25. CVD Risk Factors Hypertension* Obesity* (BMI > 30 kg/m 2 ) Cigarette smoking Physical inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min Age ( 55+ for men, 65+ for women) Family history of premature CVD (men < 55 or women < 65) *Components of the metabolic syndrome.
    23. 26. Target Organ Damage <ul><li>Heart </li></ul><ul><ul><li>LVH </li></ul></ul><ul><ul><li>Angina or prior MI </li></ul></ul><ul><ul><li>Prior coronary revascularization </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><li>Cerebrovascular disease (CVA/TIA) </li></ul><ul><li>Renal disease </li></ul><ul><li>Peripheral arterial disease </li></ul><ul><li>Retinopathy </li></ul>
    24. 27. Left Ventricular Hypertrophy <ul><li>LVH = independent risk factor for CVD. </li></ul><ul><li>Regression of LVH occurs with aggressive BP management: </li></ul><ul><ul><ul><li>weight loss, sodium restriction, and treatment with all classes of drugs except the direct vasodilators hydralazine and minoxidil. </li></ul></ul></ul>
    25. 28. Laboratory Tests <ul><li>Always </li></ul><ul><ul><li>EKG </li></ul></ul><ul><ul><li>UA </li></ul></ul><ul><ul><li>Chem 7 </li></ul></ul><ul><ul><li>Fasting lipid panel </li></ul></ul><ul><ul><li>Ca, Hct, TSH* </li></ul></ul><ul><li>Optional tests </li></ul><ul><ul><li>Microalbumin </li></ul></ul>
    26. 29. Lifestyle Modification Approximate SBP reduction (range) Modification 5–20 mmHg/10 kg weight loss Weight reduction 8–14 mmHg Adopt DASH eating plan 2–8 mmHg Dietary sodium reduction 4–9 mmHg Physical activity 2–4 mmHg Moderation of alcohol consumption
    27. 30. Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Lifestyle Modifications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Stage 2 Hypertension (SBP > 160 or DBP > 100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
    28. 31. Classification and Management of BP for adults Two-drug combination for most † (usually thiazide and ACEI or ARB or BB or CCB). Yes or > 100 > 160 Stage 2 Hypertension Drug(s) Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Thiazides for most. May consider ACEI, ARB, BB, CCB, or combination. Yes or 90–99 140–159 Stage 1 Hypertension Drug(s) ‡ No drug indicated. Yes or 80–89 120–139 Prehypertension Encourage and <80 <120 Normal With compelling indications Without compelling indication Initial drug therapy Lifestyle modification DBP* mmHg SBP* mmHg BP classification
    29. 32. Case <ul><li>KH </li></ul><ul><ul><li>84 yo W F </li></ul></ul><ul><ul><ul><li>OA, osteoporosis, urinary incontinence </li></ul></ul></ul><ul><ul><li>Urogyn clinic: BP=190/100 </li></ul></ul><ul><ul><ul><li>Asymptomatic </li></ul></ul></ul><ul><ul><ul><li>BP history: 130/80 – 160/90, no consistency </li></ul></ul></ul><ul><ul><ul><li>No meds </li></ul></ul></ul>
    30. 33. Ambulatory BP Monitoring <ul><li>Ambulatory BP values are usually lower than clinic readings . </li></ul><ul><li>Hypertensive individuals: </li></ul><ul><ul><ul><li>ave awake BP > 135/85 </li></ul></ul></ul><ul><ul><ul><li>ave sleep BP >120/75 mmHg. </li></ul></ul></ul><ul><li>Lack of BP drop of 10 to 20% during night? </li></ul><ul><ul><li>possible increased risk for cardiovascular events. </li></ul></ul>
    31. 34. Self-Measurement of BP <ul><li>Home measurement of >135/85 mmHg is generally considered hypertensive. </li></ul>
    32. 35. Pharmacologic Tx
    33. 36. JNC 7: Key Messages <ul><li>Is BP >20/10 mmHg above goal? </li></ul><ul><ul><li>start with two agents </li></ul></ul><ul><ul><li>one usually should be a thiazide-type diuretic. </li></ul></ul><ul><li>Most will require >1 drug to achieve goal BP. </li></ul><ul><li>NHLBI, 2003 </li></ul>
    34. 37. Compelling Indications for Individual Drug Classes Clinical Trial Basis Initial Therapy Indication ALLHAT, HOPE, ANBP2, LIFE, CONVINCE ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES THIAZ, BB, ACE, CCB BB, ACEI, ALDO ANT THIAZ, BB, ACEI, ARB, ALDO ANT High CAD risk S/P MI Heart failure
    35. 38. Compelling Indications for Individual Drug Classes Recurrent stroke prevention Chronic renal disease Diabetes Clinical Trial Basis Initial Therapy Options Indication PROGRESS NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK NKF-ADA Guideline, UKPDS, ALLHAT THIAZ, ACEI ACEI, ARB THIAZ, BB, ACE, ARB, CCB
    36. 39. Drugs: Other Considerations <ul><ul><ul><li>Thiazides: good for osteopenia/osteoporosis. </li></ul></ul></ul><ul><li>BBs: atrial tachycardias, migraine, thyrotoxicosis, </li></ul><ul><ul><ul><ul><ul><li>essential tremor, perioperative period </li></ul></ul></ul></ul></ul><ul><li>CCBs: useful in Raynaud’s syndrome </li></ul><ul><li>Alpha-blockers: useful in BPH </li></ul>
    37. 40. Drugs: Other Considerations Relative Contraindications: Thiazides: gout, hx hyponatremia BBs: RAD or 2 nd /3 rd degree heart block ACEI/ARBs: risk of pregnancy Aldosterone antags / K-sparing diuretics: hyperkalemia
    38. 41. Postural Hypotension <ul><li>Drop in standing SBP >10 mmHg ; associated with dizziness/fainting </li></ul><ul><li>Always check orthostatics when adjusting meds </li></ul><ul><li>Avoid volume depletion and excessively rapid titration </li></ul>
    39. 42. Hypertensive Urgencies and Emergencies <ul><li>Emergency: marked BP elevations AND acute TOD </li></ul><ul><ul><ul><li>encephalopathy, TIA/CVA, papilledema, MI or unstable angina, pulmonary edema, life-threatening arterial bleeding or aortic dissection, renal failure </li></ul></ul></ul><ul><ul><ul><li>requires hospitalization and parenteral drug therapy. </li></ul></ul></ul><ul><li>Urgency: marked BP elevation but NO acute TOD </li></ul><ul><ul><li>usually does not require hospitalization </li></ul></ul><ul><ul><li>does require immediate combination oral antihypertensive therapy. </li></ul></ul>
    40. 43. <ul><li>Conclusions </li></ul><ul><ul><li>Elderly benefit from aggressive BP control </li></ul></ul><ul><ul><li>Goal: <140/90 </li></ul></ul><ul><ul><li>Evaluate for: </li></ul></ul><ul><ul><ul><li>Target organ damage </li></ul></ul></ul><ul><ul><ul><li>Other cardiovascular risk factors </li></ul></ul></ul>www.nhlbi.nih.gov /
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×