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  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> /