Hypertension Management for Elderly Patients

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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

GRECC AudioconferenceJanuary 2007

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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

35-44 45-54 55-64 65-74 >750

25

50

75

100Men

Women

Age

NHANES III; 1999-2002; CDC NCHS Data


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Residual lifetime risk for developing hypertensionWill you live long enough to develop hypertension?

Time (years)

Women age 55% (95% confidence interval)

Women age 65% (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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AgingAging

InsulinInsulinresistanceresistance

Sympathetic Sympathetic Nervous Nervous

System ActivationSystem Activation


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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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Dengel et al., Am J Physiol 274:E403, 1998

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.


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Obesity (BMI > 30 kg/m2) by age and gender

20-34 35-44 45-54 55-64 65-74 >750

10

20

30

40

50Men

Women

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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0

2

4

6

8

10

12

14

60 70 80 90 100 110 120 130

Normotensive n=46 Hypertensive n=14

SI

(10

-5

/min/pM)

Mean Arterial BP (mm Hg)

SI=16.1 - (0.113)(MABP) S

I=16.0 - (0.113)(MABP)

r= - 0.487; P=0.004

Su

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et

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l 48

: M

237,

199

3

Hypertension and Insulin Resistance


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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 -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 -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 -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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JNC VI. Arch Int Med 157: 2413, 1997

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.


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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

Measurement Issues: Posture


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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 ClassificationJNC 7

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension 140–159 or 90–99

Stage 2 Hypertension >160 or >100

BP Classification SBP mmHg 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

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.



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SHEP Study; JAMA 265:3255; 1991

35% reduction in stroke rate


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Treating hypertension reduces cardiovascular risk and mortality

0.4 0.6 0.8 1.0 1.2 1.4

Total Mortality

CVD MortalityCVD Events

Stroke

CHF

CHD

Favors Diuretics Favors Placebo

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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Modification Approximate SBP reduction(range)

Weight reduction 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

Lifestyle Modification



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DASH Fact Sheet


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What about exercise?

Aging Exercise Training

Aerobic Capacity Blood Pressure Insulin Sensitivity Adiposity SNS activity Í


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Classification and Management of BP for adults

BP classification SBP*

mmHg DBP*

mmHg Lifestyle

modification

Initial drug therapy

Without compelling indication With compelling indications

Normal <120 and <80 Encourage

Prehypertension 120–139 or 80–89 Yes No antihypertensive drug indicated. Drug(s) for compelling indications. ‡

Stage 1 Hypertension 140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

Drug(s) for the compelling indications.‡

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

Stage 2 Hypertension >160 or >100 Yes Two-drug combination for most† (usually thiazide-type diuretic and ACEI 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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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

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed.

With Compelling Indications

Lifestyle Modifications

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.



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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 RatesTrends in awareness, treatment, and control of high

blood pressure in adults ages 18–74

National Health and Nutrition Examination Survey, Percent

II1976–80

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 34Sources: 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...About our logo...

The bristlecone pine tree (Pinus longaeva) - the earth’s oldest inhabitant with a life span of 4,000 years - is found only in Utah and five other western states. Its extraordinary longevity and ability to adapt and survive in extremely harsh environmental conditions above 10,000 feet embodies the investigative spirit and mission of the Utah Center on Aging.


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References 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 angiotensin-converting-enzyme inhibitors and diuretics for hypertension in the elderly. NEJM. 2003;348:583-592.

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Hypertension Management for Elderly Patients