HYPERTENSION IN ELDERLY HYPERTENSION IN ELDERLY Dr. Kunal Dr. Kunal Kothari Kothari Emeritus Professor of Medicine and Clinical Emeritus Professor of Medicine and Clinical Cardiology Cardiology Director Primary Health Care and Strategic initiative Director Primary Health Care and Strategic initiative
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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
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:
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
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
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
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.
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