Transcript No Slide Title - GRECC Audio Conferences

Hypertension Management for
Elderly Patients
Mark A. Supiano, M.D.
Professor and Chief,
University of Utah Geriatrics Division
Director, VA Salt Lake City GRECC
Executive Director, University of Utah Center on Aging
1
LEARNING OBJECTIVES
 Identify the core components of the hypertension
syndrome characteristic of older patients.
 Describe how these core components of the
hypertension syndrome contribute to elevated
systolic blood pressure and pulse pressure.
 Specify the current treatment recommendations
for geriatric hypertension.
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OUTLINE




Epidemiology
Physiology of BP Regulation
Diagnosis and Evaluation
Treatment
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Hypertension Prevalence by Age and
Gender
100
Men
Women
75
50
25
0
35-44
45-54
55-64
Age
65-74
>75
NHANES III; 1999-2002; CDC NCHS Data
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Residual lifetime risk for developing hypertension
Will you live long enough to develop hypertension?
Time
(years)
Women age 55
Women age 65
% (95% confidence interval)
% (95% confidence interval)
10
52 (46-58)
64 (60-69)
15
72 (68-76)
81 (77-84)
20
83 (80-86)
89 (86-92)
25
91 (89-93)
–
Vasan et al.; JAMA 287:1003, 2002
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Aging
Sympathetic
Nervous
System Activation
Insulin
resistance
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Characteristics of Geriatric
Hypertension





Decreased vascular compliance
Decreased baroreceptor sensitivity
Salt-sensitivity of blood pressure
Increased total and central adiposity
Neurohumoral characteristics
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Aging: Vascular Changes
 Increased thickness of
intima and media.
 Matrix
 collagen deposition
 increased fibronectin
 crosslinking (Advanced
Glycosylation Endproducts)
Net result is increased vascular stiffness.
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Consequences of decreased vascular
compliance
 Relative increase in systolic pressure.
 Increase in pulse pressure (SBP – DBP)
 Decreased baroreceptor sensitivity?
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Consequences of Decreased
Baroreceptor Sensitivity
 Increased BP variability
 Impaired BP homeostasis
 Hypertension
 Postural (orthostatic) hypotension
 Post-prandial hypotension
 Increase in sympathetic nervous system activity
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Salt Sensitivity of Blood Pressure
 Definition: Mean arterial blood pressure on high
vs. low Na+ diet
 > 5 mm Hg increase => Sodium Sensitive
 < 5 mm Hg increase => Sodium Resistant
 Two thirds of older hypertensives are sodium
sensitive.
Dengel et al., Am J Physiol 274:E403, 1998
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Obesity (BMI > 30 kg/m2) by age
and gender
50
Men
Women
40
30
20
10
0
20-34 35-44 45-54 55-64 65-74 >75
Age (years)
NHANES III; 1999-2002; CDC NCHS Data
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Characteristics of Geriatric
Hypertension -2 Neurohumoral Characteristics
 Metabolic insulin resistance
 Sympathetic nervous system function
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Hypertension and Insulin Resistance
S I (10
-5
/min/pM)
12
10
r= - 0.487; P=0.004
8
6
4
2
0
60
70
80
90
100 110
Mean Arterial BP (mm Hg)
Normotensive n=46
S I=16.1 - (0.113)(MABP)
120
130
Supiano et al., J Gerontol 48: M237, 1993
14
Hypertensive n=14
S I=16.0 - (0.113)(MABP)
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Aging and SNS Function
Compared with younger
people:
 sympathetic nervous
system activity increases.
 adrenergic receptor
responsiveness is
reduced.
 Decreased chronotropic
response to b-agonists.
Shannon et al., NEJM 342:541, 2000
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Hypertension and SNS Function
 Compared to normotensive older people, older
hypertensives are characterized with:
 Further increase in SNS activity
 Relatively greater a-mediated vasoconstriction
Supiano et al., Am J Physiol 276:E519, 1999
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Summary: Vascular and
Neurohumoral Characteristics
 Decreased vascular
compliance.
 Decreased baroreceptor
sensitivity.
 Salt-sensitivity of blood
pressure.
 Increased total and
central adiposity.
 Metabolic insulin
resistance.
 Heightened SNS activity.
 Increased a-adrenergic
receptor responsiveness.
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OUTLINE
 Epidemiology
 Physiology of BP Regulation
 Diagnosis and Evaluation
 Measurement issues
 Secondary causes
 Classification
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Measurement Matters!
Auscultatory BP Measurement Method
 Sitting. Bare arm. Arm supported at heart level (5-6
mmHg increase if arm vertical).
 Resting for five minutes.
 Proper cuff size.
 Use calibrated aneroid manometer.
 Palpate SBP.
 Record phase 1 (first sound) and phase 5
(disappearance) Korotkoff sounds as SBP and DBP.
 Two or more readings taken several minutes apart
should be averaged.
JNC VI. Arch Int Med 157: 2413, 1997
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Measurement Issues: Posture
Blood pressure must be measured in older
persons with special care ...
In addition, older patients are more likely
than younger patients to exhibit an orthostatic
fall in blood pressure and hypotension; thus, in
older patients, blood pressure should always be
measured in the standing as well as seated or
supine positions.
JNC VI. Arch Int Med 157: 2413, 1997
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Measurement Issues: Multiple
Measurements
 Hypertension should not be diagnosed on the
basis of a single measurement.
 BP variability is higher in older hypertensive
individuals.
 Decreased baroreceptor sensitivity.
 Diagnosis of hypertension should be based on:
 Average of readings from three visits.
 Three separate readings recorded at each visit.
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Evaluation of Patient with White-coat Hypertension:
Ambulatory (24 hour) Monitoring
 Advantages:
 BP profile over 24 hour period.
 Nocturnal dipper pattern.
 BP load: correlates with target organ damage.
 Useful to evaluate white coat hypertension, drug
resistance, secondary causes, hypotensive
symptoms.
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Evaluation: Secondary Causes
 Primary hypertension is the most common form
of hypertension in older persons.
 A sudden increase in DBP, malignant HTN or
resistant HTN should prompt an evaluation for
secondary causes.
 Renovascular disease and medication
interactions are most common secondary
causes.
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Blood Pressure Classification
JNC 7
BP Classification
SBP mmHg
Normal
<120
and
<80
Prehypertension
120–139
or
80–89
Stage 1 Hypertension
140–159
or
90–99
Stage 2 Hypertension
>160
or
>100
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DBP mmHg
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Role of SBP in Classification
 In the older hypertensive population, the level of
SBP will correctly classify the stage of
hypertension in 99% of patients.
 Lloyd-Jones Hypertension 34:381, 1999
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Simplified JNC 7 Classification
BP Classification
SBP
Normal
< 120
Pre-hypertension
120-139
Stage 1 Hypertension
140-159
Stage 2 Hypertension
≥ 160
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JNC 7 Report. JAMA. 2003:2560
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OUTLINE
Treatment





Efficacy
Systolic BP and Pulse Pressure Matter
Treatment Goals
Non-pharmacological therapy
Pharmacological therapy
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Treatment of hypertension in
older persons has
demonstrated major
benefits.
JNC 7 Report. JAMA. 2003:2560
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35% reduction in stroke rate
SHEP Study; JAMA 265:3255; 1991
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Treating hypertension reduces
cardiovascular risk and mortality
Favors Diuretics
Favors Placebo
Total Mortality
CVD Mortality
CVD Events
Stroke
CHF
CHD
0.4
0.6
0.8
1.0
1.2
1.4
Relative Risk
Psaty et al.; JAMA 289: 2534, 2003
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Which is the more dangerous BP?
SBP/DBP MABP
Pulse Pressure
Patient 1
140/ 94
109
46
Patient 2
158/84
109
74
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Especially among older persons,
SBP is a better predictor of events
(coronary heart disease,
cardiovascular disease, heart failure,
stroke, end-stage renal disease, and
all-cause mortality) than is DBP.
JNC VI, 1997
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Pulse Pressure as CV Risk Factor
 Framingham data: in those >50 yrs., CV mortality
independently related best to pulse pressure; for
given SBP, lower DBP associated with higher
mortality.
 Franklin et al. Circulation 100:354, 1999.
 SHEP data analysis: stroke and total mortality
associated with pulse pressure independent of
mean BP.
 Domanski et al. Hypertension 34:375, 1999.
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The goal of treatment in older patients
should be the same as in younger patients (to
below140/90 mm Hg if at all possible),
although an interim goal of SBP below 160
mm Hg may be necessary in those patients
with marked systolic hypertension.
JNC VI, 1997
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Treatment Implications
 Optimal anti-hypertensive therapy will:







Lower blood pressure.
Improve vascular compliance.
Increase baroreceptor sensitivity.
Decrease central fat mass.
Increase insulin sensitivity.
Decrease SNS activity.
Decrease RAAS activity.
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Non-pharmacological Therapy
CHARACTERISTIC
 Overweight – central
adiposity
 Sedentary
 Salt-sensitive
LIFE STYLE MODIFICATION
 Weight loss
 Exercise program
 Dietary salt restriction
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Lifestyle Modification
Modification
Weight reduction
Approximate SBP reduction
(range)
5–20 mmHg/10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol
consumption
2–4 mmHg
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JNC 7 Report. JAMA. 2003:2560
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DASH Fact Sheet
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What about exercise?
Aerobic Capacity
Blood Pressure
Insulin Sensitivity
Adiposity
SNS activity
Aging Exercise
Training

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Classification and Management
of BP for adults
Initial drug therapy
SBP*
mmHg
DBP*
mmHg
Lifestyle
modification
<120
and <80
Encourage
Prehypertension
120–139
or 80–89
Yes
No antihypertensive drug indicated.
Stage 1 Hypertension
140–159
or 90–99
Yes
Thiazide-type diuretics for most. May
consider ACEI, ARB, BB, CCB, or
combination.
Stage 2 Hypertension
>160
or >100
Yes
BP classification
Normal
Without compelling indication
With compelling indications
Drug(s) for compelling
indications. ‡
Drug(s) for the compelling
indications.‡
Other antihypertensive drugs
Two-drug combination for most†
(diuretics, ACEI, ARB, BB,
(usually thiazide-type diuretic and ACEI CCB) as needed.
or ARB or BB or CCB).
*Treatment determined by highest BP category.
†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
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JNC 7 Report. JAMA. 2003:2560
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Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling
Indications
With Compelling
Indications
Stage 1 Hypertension
Stage 2 Hypertension
(SBP 140–159 or DBP 90–99 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
(SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually
thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Drug(s) for the compelling
indications
Other antihypertensive drugs (diuretics,
ACEI, ARB, BB, CCB)
as needed.
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation
with hypertension specialist.
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January 2007
JNC 7 Report. JAMA. 2003:2560
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Adverse Effects Common to
Antihypertensive Drugs
 Orthostatic hypotension
 postural dizziness or lightheadedness
 risk factor for falls
 Many produce metabolic and/or electrolyte
changes
 Interactions with other medications
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Overview of Pharmacologic Treatment
 All antihypertensive drug classes are effective in
older hypertensives.
 Thiazide-type diuretics recommended by JNC-7.
 Avoid direct vasodilators and central adrenergic
drugs.
 Drug selection should be an individualized
decision.
 Start low; go slow!
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General Treatment Recommendations
for Stage 1, Simple Hypertension
 Begin with nonpharmacological approach –
weight loss, exercise, salt restriction.
 Consider low dose diuretic as initial drug
selection; an ACE inhibitor is an alternative.
 Base alternative drug selection or combination
therapies on individual patient characteristics.
 When initiating drug therapy, begin at half of the
usual dose, increase dose slowly, and continue
non-pharmacological therapies.
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General Treatment Recommendations
for Stage 1, Simple Hypertension -2 Focus treatment goal on systolic blood pressure
reduction to 135-140 mm Hg.
 Avoid excessive reduction in diastolic blood
pressure (below 70 mm Hg).
 Aggressive therapy is not appropriate if adverse
side effects (e.g., postural hypotension) cannot
be avoided.
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BP Control Rates
Trends in awareness, treatment, and control of high
blood pressure in adults ages 18–74
National Health and Nutrition Examination Survey, Percent
II
1976–80
II
(Phase 1)
1988–91
II
(Phase 2)
1991–94
1999–2000
Awareness
51
73
68
70
Treatment
31
55
54
59
Control
10
29
27
34
Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC
6.
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SUMMARY
 Hypertension is a common condition among the
elderly.
 Treating high blood pressure lowers the risks of
heart attack, heart failure and stroke.
 Systolic BP and pulse pressure matter.
 Optimal blood pressure control should be
achieved using the treatment which is least likely
to produce side effects.
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Unanswered Questions
 Treatment goals in very old.
 Conflicts between practice guidelines and
treatment related risks.
 How to further improve blood pressure control
rate.
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Questions...
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References
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Chobanian, A.V., Bakris, G.L., Black, H.R., et al. The Seventh Report of The Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure;
The JNC 7 Report. JAMA. 2003;289(19): 2560-2572.
Domanski MJ, Davis BR, Pfeffer MA, et al. Isolated systolic hypertension: prognostic
information provided by pulse pressure. Hypertension. 1999;34:375–380.
Psaty, B.M., Lumley, T., Furberg, C.D., et al. Health outcomes associated with various
antihypertensive therapies used as first-line agents. A network meta-analysis. JAMA.
2003;289:2534-2544.
The ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive
patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker
vs. diuretic. JAMA. 2002;288:2918-2997.
Vasan R.S., Beiser A, Seshadri, S., et al. Residual lifetime risk for developing hypertension in
middle-aged women and men. JAMA. 2002;287:1003-1010.
Wing, L.M.H., Reid, C.M., Ryan, P. et al. A comparison of outcomes with angiotensinconverting-enzyme inhibitors and diuretics for hypertension in the elderly. NEJM.
2003;348:583-592.
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