Transcript Bynum-HTN-in-the-elderly

Flying Blind Without Instruments
Treating Hypertension in the Elderly
Will Bynum, MD
Attending Faculty, NCC Family Medicine Residency
Fort Belvoir, VA
Outline
Overall Goal: to increase awareness of the
complexities of treating hypertension in the
highly heterogenous elderly population
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Limitations of JNC-8 guidelines
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Practical approach to avoiding adverse events
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Brief overview of recommended medications
Case
Mrs. S is a 92 year old who you are seeing in the nursing
home. No complaints today.
PMHx: HTN, HLP, CAD s/p stent in 1997, severe OA
Meds: ASA 81 mg, lipitor 20 mg, Vit D 1000 IU
Today’s Vital Signs
Recent Vital Signs
P 73 RR 18 BP 166/70
T 98.4
P 75
P 68
BP 164/72
BP 162/71
P 80
BP 157/68
*Remainder of physical exam unremarkable
*Recent labs normal
In addition to advising lifestyle
change, would you start a
medication?
Treating Blood Pressure in
Elderly Patients
Part I: The (mis)guidelines
What does JNC-8 say?
• In adults > 60 yo, initiate pharmacologic therapy
for BP >150/90
• Treat to a goal of <150/90
• If patient is already on anti-hypertensive and SBP is
less than 140, no need to stop medication if the
patient is tolerating it well
JAMA. Feb 5 2014;311(5):507-520
What does “general population” mean?
What about the diastolic blood pressure?
What do these studies show and in whom?
The Data
Randomized Controlled Trials
Study
Age of Participants
Mean BP of
Participants
Study Population
Characteristics
Primary Finding
SHEP
> 60
170/76
Community Dwelling
36% reduction in stroke
94% had no impairment
in ADLs
13% reduction in allcause mortality
Mean: 71 (SD 6.7)
14% were >80 yo
0.4% had e/o cog.
impairment
Syst-Eur
> 60
174/85
Community dwelling
Mean: 73 yo (SD 6.7)
MRC
> 60
31% reduction in nonfatal CV events
180s/90s
Community dwelling
Mean: 70.4
Meta-Analysis
(8 studies)
> 60
42% reduction in stroke
25% reduction in stroke
17% reduction in all CV
events
174/83
Community dwelling
Active treatment…
13% reduction all-cause
18% reduction CV deaths
30% reduction stroke
23% reduction coronary
What about patients >80 years old?
HYVET Trial
HYVET Trial
The HYVET Trial – Results
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30% reduction in non-fatal stroke
39% reduction in stroke-related mortality
21% reduction in all-cause mortality
29% reduction in CV-related mortality
64% reduction in CHF incidence
• Fewer adverse effects in the treatment
group (358) than the placebo group (448)
NEJM 2008;358(18)1887-98
HYVET – a deeper look
Inclusion Criteria - AGE
Who was actually enrolled?
Age >80
80 – 84 yo: 74%
85 – 89 yo: 22.4%
>90 yo: 4.6%
Inclusion Criteria - BP
Who was actually enrolled?
Exclusion Criteria
SBP > 160, DBP < 110
Mean BP: 173/90
Secondary HTN, hemorrhagic stroke in
last 6 months, heart failure requiring an
anti-HTN med, Cr >1.7, diagnosis of
clinical dementia, and a requirement of
nursing care
This study best applies to a patient…
• in his/her early 80’s
• who is functional
• who does not have dementia
• who does not have a borderline DBP
The (mis)guidelines
Re-cap
• HTN studies in the elderly only represent
a healthy subset of the population
• Guidelines do not take heterogeneity into
account
• Thus, the guidelines may not apply to the
patient in front of you
Treating Blood Pressure in
Elderly Patients
Part II: First do no harm?
First Do No Harm
The Mortality
Curve
Mortality & MI
The Lancet. 1987;329(8533):581-584
Mortality & MI
Data from the
INVEST trial
Annals of Internal Medicine. 2006;144(12):884-893
Mortality & MI
Low diastolic blood pressure is associated with
increased risk of mortality and MI
There is no evidence that sets a safe minimum DBP
Expert Opinion:
In the elderly treat to a minimum DBP of…
• 60 in patients without CAD
• 65 in patients with CAD
Gait Speed & Mortality
Gait speed is a “strong and consistent predictor of
adverse outcomes” in community-dwelling older
people”
Slowed gait speed is a predictor of functional
disability
Also a marker for falls and increased mortality
The Journal of Nutrition, Health & Aging. Dec 2009;13(10):881-
2,340 patients >65 years old
Fast Walkers
<4 seconds to walk 10 feet
Slow Walkers
>4 seconds to walk 10 feet
No Walkers
Unable to participate in test
Archives Intern Med. 2012;172(15):1162-1168
Gait Speed & Mortality
Fast Walkers: Elevated SBP (>140) associated with
increased mortality risk (OR 1.35)
Slow Walkers: no association between elevated BP
and mortality
No Walkers: Elevated SBP (>140) and DBP (>90)
associated with decreased mortality risk
(HR 0.38 and 0.10)
Archives Intern Med. 2012;172(15):1162-1168
Gait Speed & Mortality
BP >140/90 appears to be most protective in
patients with significantly lower functional ability
Use gait speed to help determine if your patient is a
good candidate for anti-hypertensive therapy
• Consider therapy in fast walkers
• Use extreme caution in non-walkers
Orthostasis
Orthostasis is associated with increased risk of…
• Falls
• Future CV events
• Congestive heart failure
• Incidental atrial fibrillation
Hypertension. 2010;56(1):56
Hypertension. 2012;59(5):913-8
J Intern Med. 2010;268(4):383-9
J Am Geriatr Soc. 2011;59(3):383-9
Am J Med. 2000;108(2):106-111
Incidence of orthostasis in 21% (Syst-Eur) and
17% (SHEP) of patients after starting treatment
The Lancet. 1997;350(9080):757-764
JAMA. 1991;265(24):3255-3264
Orthostasis
Screen for orthostatic hypotension…
• BEFORE starting anti-hypertensives in the
elderly
• In patients already on anti-hypertensives who
have borderline blood pressure
Falls & Hip Fractures
Being on an anti-hypertensive is a known risk factor for
falls (OR 1.2 – 1.4 if no prior fall, 2.1 – 2.3 if prior fall)
Arch Intern Med. 2009;169(21):1952
JAMA Int Med 2014;174(4):588-95
Falls are strongly associated with hip fractures
• 90% of hip fractures in the elderly occur following
a simple fall
Baumgaertner MR, Higgins TF. Femoral neck fractures.
Falls & Hip Fractures
• Case series that evaluated association between initiation
of an anti-hypertensive in the elderly and risk of
immediate hip fracture after initiation
• Average age of patients = 81 yo. All were community
dwelling
Arch Intern Med. 2012;172(22):1739-1744
Falls & Hip Fractures
Falls & Hip Fractures
Increased risk of hip fracture in the 45 days following
initiation of therapy (OR 1.45 for all classes)
Beta blockers (OR 1.58)
Consider
the patient’s
risk when making
ACEI/ARBs
(ORfall
1.53)
the decision to start an anti-hypertensive
Thiazides (OR 1.33)
Mitigate
other
risk factors, especially in the
CCB’s
(ORfalls
1.30)
first 45 days after initiation of therapy
Re-Cap
Use caution in starting/continuing anti-hypertensive
therapy in the following:
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Borderline diastolic BP (60-65)
Low functional status
Increased falls risk
Underlying orthostatic hypotension
Non-community dwelling
Old old (>85 yo)
Permissive systolic hypertension appears to be protective
Treating Blood Pressure in
Elderly Patients
Part III: The meds
Medications
Initial Monotherapy
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Thiazides: appear to be the best overall 1st line choice
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CCB’s: 1st line but may have increased risk of heart failure
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ACEI/ARBs: acceptable but best used as 2nd/3rd line
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Avoid Beta Blockers & Vasodilators as 1st line treatment
JAMA 2002;288(23):2981-2997
Medications
Combination Therapy
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ACCOMPLISH trial (mean age 68, mean BP 145/80)
showed…ACEI + CCB >> ACEI + Thiazide
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ESH/ESC & JNC-8 recommend any combination of
ACEI, CCB, and thiazide
NEJM. 2008;359(23):2417
Putting it All Together
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The decision to treat, not treat, or continue treatment in
elderly patients is very complex
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The guidelines are based on studies of communitydwellers who were more or less healthy, young-old, and
with mean SBP 170-180
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The benefits of treating SBP >160 are tremendous in
relatively healthy, community-dwelling, young-old patients
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However, hypertension may be protective, especially in
patients with lower functional ability
Putting it All Together
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The data shows a consistent association between low
DBP and mortality. Remember 65 & 60
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Other risks include MI, falls (especially 1st 45 days), and
orthostasis
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Start treatment with a thiazide in most patients.
Calcium channel blockers are also first line option
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Any combination of thiazides, CCBs, and ACE/ARB
is acceptable
Questions?