Transcript Geriatric Hypertension

Geriatric Hypertension
Lindsay Yorns D.O. PGY-2
Disclosure Statement of Financial Interest
• I, Lindsay Yorns,
DO NOT have a financial
interest/arrangement or affiliation with
one or more organizations that could be
perceived as a real or apparent conflict of
interest in the context of the subject of
this presentation.
Objectives
• Discover when to treat geriatric hypertension
• Determine when an elderly patient is at
maximal treatment
• Recognize precautions prior to starting elderly
on ant-hypertensive treatment
HYPERTENSION
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Affects ~ 1 billion people worldwide
1 in 3 adults in US (68 million)
Only 1 in 2 adults have it under control
Most common modifiable risk factor
In 2010: HTN cost the US $93.5 billion in
health care service, medications, and missed
days of work
Population
• ~ 34 million Americans
are ≥ 65 y/o
– Expected to be 75
million by 2040
• People > 85 y/o are the
largest growing subset
in the US
Age
Men
(%)
Women
(%)
20-34
11.1
6.8
35-44
25.1
19.0
45-54
37.1
35.2
55-64
54.0
53.3
65-74
64.0
69.3
75 and
older
66.7
78.5
All
34.1
32.7
What gives…?
• More likely to be aware of their HTN
• More likely to be treated for their HTN
• Less likely to achieve control of BP
• More likely to have organ damage
Risk factors
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Family Hx
Dyslipidemia
DM
Obesity
Arthritis
Pathophysiology
• Large arteries become less distensible
– Collagen deposition, fatigue fracture of elastin,
calcification
– Increase in vessel diameter & wall thickness
– Stiffening increases pulse wave velocity
• Lower plasma Renin levels
• Lower plasma Aldosterone levels
• Salt sensitivity
Arterial Wall Compliance and Pulse Pressure Wave
Elastic Vessel
Systole Diastole
Stiff Vessel
Systole Diastole
Stroke Volume
Aorta
Resistance
Arterioles
Pressure (Flow)
Young Artery
Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.
Arteriosclerotic Artery
Complications
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Ischemic Stroke
Cerebral hemorrhage
Coronary Artery Disease
Sudden cardiac death
CHF
LVH
Atrial Fibrillation
PAD
Complications
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10-Year CVD Risk Score
Age
Gender
Total Cholesterol
HDL Cholesterol
Smoker
SBP
Currently on meds to Tx
HTN
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Reynolds Risk Score
Age
Gender
Total Cholesterol
HDL Cholesterol
Smoker
High Sensitivity CRP
Did Mother or Father have
MI before age 60
Diagnosis
• SBP ≥ 140
• DBP ≥ 90
• At least 3 different measurements taken on 2
or more office visits
• Should be sitting for at least 5 minutes
Size Matters!
• Bladder encircles 80% of upper arm
circumference
Recommended Levels
• < 120/80
– Systolic CHF
• < 130/80
– DM, CKD, CAD, PAD, AAA
• < 140/90
– Uncomplicated HTN
Pseudo-Hypertension
• False high BP reading
• Sclerotic arteries that do not collapse during
inflation of the BP cuff
• 1.7 – 70% of the elderly
Pseudo-Hypertension
• Osler Maneuver:
– Palpable radial artery pulse after the cuff is
inflated above systolic pressure
– Questionable accuracy and usefulness
• Suspect if elderly pt has refractory HTN, no
organ damage &/or signs of overmedication
White-Coat Hypertension
• BP is persistently high in office but normal at
home (> 140/90)
– Plus normal ambulatory
daytime BP
• Seen in 15 – 25% of elderly
Masked Hypertension
• Elevated home BP w/ normal office BP
• Increased risk of vascular events
• More extensive target organ damage
• More commonly seen in normotensive pts w/
comorbidities
• Home BP monitoring
Orthostatic HTN
• Rise in BP after assuming
an upright position
• SBP increases by at least
20 mmHg on standing
• No significant change in
DBP
• Increased incidence of
silent CVA
Isolated Systolic HTN
• SBP > 140 & DBP ≤ 80
• 60 – 80% of cases of HTN
• SBP rises & DPB falls after age 60
• Diminished arterial compliance
• Increase in cardiac output
Lifestyle Modifications
• Smoking cessation
• Weight management/ Exercise
• Modified salt and alcohol intake
• Mild hypertension
• Only provided in 26-35% of visits
TONE
Trial of Non-Pharmacologic Interventions in the Elderly
Pharmacological Treatment Initiation
• Start at the lowest dose
• Gradually increase to the maximum dose
tolerated
• If diuretic is not the initial drug, it should be the
second one added
• When BP is >20/10 mmHg above goal, start with
2 drugs
– One should be a thiazide
Uncomplicated HTN
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Thiazide diuretics
Calcium Antagonists
ACE-I
ARB’s
Beta-Blockers
Complication HTN
• Start 2 drugs when there are other comorbidities
• Benzapril-Amlodipine
– At risk for CV events
• Otherwise based on disease complication
ACCOMPLISH
Avoiding Cardiovascular Events through Combination Therapy in
Patients Living with Systolic Hypertension
• Determine if ACE-I + Amlodipine had better CV
outcomes vs ACE-I + Thiazide
HTN & CAD
• Initial mono-therapy
– Beta Blocker
• No BP improvement or continued Angina
– Dihydropyridine Calcium Antagonist
ALLHAT
The Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial
• Determine whether a CCB or ACE-I lowers incidence
of CVD better than a Diuretic
• Large percent of pts were ≥ 65
INVEST
Level (mmHg)
Level (mmHg)
Calcium Antagonist Strategy (CAS)
Non-Calcium Antagonist Strategy (NCAS)
Systolic Blood Pressure
170
150
130
110
Diastolic Blood Pressure
100
90
80
70
60
No. of Pts.
0
CAS 11267
NCAS 11309
6
12
18
8558
8573
8639
8694
7758
7710
24
30
Time, mo
7842
7850
5721
5834
36
42
48
3659
3679
1458
1473
796
817
INVEST
RR
(95% CI)
Favors
CAS
First event*
0.98 (0.90 – 1.06)
Death
0.98 (0.90 – 1.07)
Nonfatal MI
0.99 (0.79 – 1.24)
Nonfatal stroke
0.89 (0.70 – 1.12)
Cardiovascular death
1.00 (0.88 – 1.14)
Cardiovascular hospitalization
1.03 (0.93 – 1.14)
CAS = Calcium Antagonist Strategy
NCAS = Non-Calcium Antagonist Strategy
Favors
NCAS
0.6 0.8 1.0 1.2 1.4
RR (95% CI)
* Primary Outcome = first occurrence of death, nonfatal MI, or nonfatal stroke
HTN & CHF
• Beta-Blocker + ACE-I
• Systolic HF
– Diuretic, Beta blocker, ACE-I/ ARB, & Aldosterone
antagonist
• Diastolic HF
– Diuretics
• Elderly African-American pts
– Isosorbide dinitrate + Hydrlazine
HTN & CVD
• Diuretic + ACE-I
• Overall, CVD reduction is more associated w/
decrease in BP than type of agent used
HTN & Aortic Dz &/or PAD
• ACE-I/ ARB + Beta Blocker
• Anti-Platelet therapy
HTN & DM
• ACE-I/ ARB
• Co-morbidity based Tx
• Thiazide diuretis increase hyperglycemia
Chronic Kidney Disease & Renal Artery
Stenosis
• ACE-I
• Revascularization
HOPE
Heart Outcomes Prevention Evaluation
• ACE-I vs Placebo in high risk pts w/out LV
dysfunction or HF
• Ages 59 – 73
HYVET
Hypertension in the Very Elderly Trial
• Compare Tx of HTN w/ Indapamide compared
to Placebo in pts > 80 y/o
Compliance
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Asymptomatic State
Cost of medications
Side Effects/ QoL
Number of medications & Dosing complexity
Number of doses a day
Orthostatic Hypotension
• Common complication of HTN treatment in
elderly
• Within two to five minutes of quiet standing,
one or more of the following is present:
– At least a 20 mmHg fall in systolic blood pressure
– At least a 10 mmHg fall in diastolic blood pressure
– Symptoms of cerebral hypoperfusion, such as
dizziness
Agents that interfere with BP
Medications that increase BP
• NSAIDs
• Corticosteroids
• Erythropoietin
• Amphetamines
• Ergotamine
• Anabolic Steroids
Agents that increase
Antihypertensive effect of BB & CA
• Cimetidine
• Antifungal Azolides
• Grapefruit juice
References
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Beckett, Nigel S., Peters, Ruth., Fletcher, Astrid E., et al. Treatment of Hypertension in Patients 80
Years of Age or Older. N Engl J Med. 2008; 358:1887-1898
Jamerson, Kenneth., Weber, Michael., Bakris, George., et al. Benzapril plus Amlodipine or
Hydrochlorothiazide for Hypertension in High Risk Patients. N Engl J Med. 2008; 359:2417-2428
ALLHAT Authors. Major Outcomes in High-Risk Hypertensive Patients Randomized to AngiotensinConverting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic (ALLHAT). J Amer Med
Association. 2002;288(23):2981-2997
Yusuf, Salim., Phil, D., Sleigh, Peter., et al. Effects of an Angiotensin-Converting-Enzyme Inhibitor,
Ramipril, on Carviovascular events in High Risk Patients (Heart Outcomes Prevention Evaluation
Study). N Engl J Med. 2000; 342(3): 145-153
Cacciolati C, Hanon O, Alperovitch A, Dufouil C, Tzourio C. Masked hypertension in the elderly: Cross
sectional analysis of a population-based sample. Am J Hypertens. 2011; 24(6):674-80
Fessel, Joshua & Robertson, David. Orthostatic Hypertension: when pressor reflexes
overcompensate. Nature Clinical Practice Nephrology (2006) 2, 424-431
Kario, Kazuomi., Eguchi, Kazu., Nakagawa, Yukinori., Motai, Keiji., & Shimada, Kazuyuki. Relationship
Between Extreme Dippers and Orthostatic Hypertension in Elderly Hypertensive Patients.
Hypertension. 1998; 31: 77-82
Egan, Brent. 2012. Uptodate. Treatment of hypertension in the elderly patient, particularly isolated
systolic hypertension. http://www.uptodate.com/contents/treatment-of-hypertension-in-theelderly-patient-particularly-isolated-systolichypertension?source=search_result&search=geriatric+hypertension&selectedTitle=1%7E150#H2
Thank You!!