1、HYPERTENSION IN ELDERLY,Dr. Kunal KothariEmeritus Professor of Medicine and Clinical Cardiology Director Primary Health Care and Strategic initiative,HYPERTENSION,Sphygmanometer- size of the cuffs Food Exercise Caffeine Smoking,200,140,160,120,180,20,40,60,80,100,0,A softer blowing sound,A sharp thu
2、mp,A softer thump,A blowing or whooshing sound,K1,K2,K3,K4,K5,Benefits of Lowering Blood Pressure,Antihypertensive Therapy has been associated with reductions in:,Stroke Incidence (35-40 %).MI (20-25 %).Heart Failure ( averaging 50 %).,Guidelines,The Seventh Report of the Joint National Committee on
3、 Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults:,135/85 Ambulatory Pressure,140/90,Clinic Pressure,Sustained Hypertension,White Coat Hypertension,True Normotension,Masked Hypertension,Pseudo Hypertension,Recording of high B
4、.P. but do not haveCommon cause of this is brachial artery compression,WHITE COAT HYPERTENSION,BP recording in office or clinic is high while at home is normotensive“white coat“ hypertension appear to have no greater risk than people with normal blood pressure ( Aug. 2, 2005, American college of car
5、diology ),MASKED HYPERTENSION,Proposed the term masked hypertension Pickering et al (Hypertension 2002;102:1139-44)Documented by Ohkubo et al (N Engl J Medicine 2003;348:2407-15),MASKED HYPERTENSION,HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. “UNDETECTED AMBULATORY HYPERTENSION“ UNUSUALLY H
6、IGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION SHOW MORE EXTENSIVE TARGET ORGAN DAMAGE THAN TRUE NORMOTENSIVE SUBJECTS,Blood Pressure in 347,978 men aged 35-57 screened for MRFIT,160,% of Men,Systolic pressure mmHg, ,Lifetime Risk of Developing Hypertension in Middle Ag
7、ed (Vasan et al, JAMA 2002; 287: 1010),Risk for Hypertension in a 55 year oldTime, yr Women Men52% 56%72% 78%83% 88% 25 91% 93%,Diagnostic Evaluation of the Hypertensive Patient- How much is enough?,How high is the blood pressure?Why is it high?What is the risk?,Clinical Manifestations I,Physical ex
8、am:AbdomenFunduscopicVascularCardiacPulmonaryNeurological,Lab tests:UrinalysisBlood ChemistryECGRenal ultrasoundEchocardiogramVascular studies,Differential Diagnosis,Rule out isolated incident of increased blood pressure. Rule out secondary hypertension related to:Renal diseaseCushings diseasePheoch
9、romocytomaHyperthyroidismHyperparathyroidism,Complications,Complications as a result of HTN include:StrokeDementiaMyocardial InfarctionCongestive Heart FailureRetinal VasculopathyAortic DissectionRenal Disease or Failure,Management,MedicationsDiuretics- Thiazides (HCTZ), Loop (Furosemide), Potassium
10、-sparing (Spironolactone)Beta-Blockers- Atenolol, Nadolol, PropranololACE Inhibitors- Benezapril, Captopril, CilizaprilARBs- Losartan, ValsartanCa+ Channel Blockers- Nifedipine, VerapamilAlpha blockers- Prazosin, TerazosinVasodilators- Apresoline,Management,Primary goal is to reduce cardiovascular a
11、nd renal morbidity and mortality. Other keys to management are:PreventionPatient educationLife-style modificationMedication,Hospitalization should be considered if,Very high BPSevere headacheChest pain Neurologic symptomsAltered mental statusAcutely worsening renal failureS & S of hypertensive emerg
12、ency,DOES ELDERLY HYPERTENSION HAVE SPECIFIC CHARACTERISTICS?,CHARACTERISTICS OF HYPERTENSION IN THE ELDERLYIncreasedSystolic blood pressure and pulse pressureLeft ventricular mass and wall thicknessArterial stiffnessCalculated total peripheral resistanceDecreasedCardiac output and heart rateRenal b
13、lood flow, plasma renin activity, and angiotensin II levelsArterial compliance and blood volumeDiastolic blood pressureBlack H. JCH 2003; 5:12,Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359.,Stroke Volume,Aorta,Resistance Arterioles,Pressure (Flow),Young Artery,Systole,Diastole,Elastic Vess
14、el,Arteriosclerotic Artery,Stiff Vessel,Systole,Diastole,Arterial Wall Compliance and Pulse Pressure Wave,Do lifestyle measures really work for elderly hypertension?,Lifestyle Modifications,Bar graph shows change in mean arterial blood pressure used to define salt responsivity as a function of age i
15、n normotensive open bars and hypertensive color bars subjects.,Change in Mean Arterial Blood Pressure,Weinberger M. Hypertens 1991; 18:69,Effect of 30 minute walk 3 days a week Age 70 - 79Systolic Diastolic Exercise Group Baseline 156 10 mm Hg 86 8 mm Hg3 months 151 15 mm Hg 80 6 mm HgControl Group
16、Baseline 153 7 mm Hg 85 8 mm Hg3 months 156 10 mm Hg 85 6 mm HgConone et al. Med Scl in Sports and Exercise. 1991,What is the effect of drug therapy related to age? Are the recommendations different?,Antihypertensive Drugs,AACEI, ARBs BBeta Blocker CCCB DDiuretic,Dlow dose HCTZ A B C,Algorithm for M
17、anagement of the Elderly -Primarily Systolic Hypertension1) Lifestyle changesLow dose diuretic (12.5 mg HCTZ)CCB B-Blocker ACE or ARB3) Stop, Look & Listen before dosagesLet the Baroreceptors reset4) Rx until goal achieved,+,+,+,+,+,ALLHAT,The Antihypertensive and Lipid Lowering Treatment to Prevent
18、 Heart Attack Trial (ALLHAT) suggests that low dose thiazide diuretics have a better cardiovascular protective effect,Result Highlights,21% reduction in relative risk death from any cause64% reduction relative risk heart failure39% reduction relative risk of death from stroke,Syst-Eur,A study called
19、 the Systolic-Hypertension Trial in Europe (Syst-Eur) showed that aggressive treatment of hypertension reduces the risk of stroke by 42% and dementia is prevented.,Trials Examining Treatment of Hypertension in the ElderlyEWPHE MRC-Elderly SHEP STOP-H Syst-China Syst-Eur(N = 840) (N = 4396) (N = 4736
20、) (N = 1627) (N = 2394) (N = 4695) Stroke reduction, % -36 -25 -33 -47 -38 -42 CAD change, % -20 -19 -27 -13 +6 -26 CHF reduction, % -22 Not stated -55 -51 -58 -27 % of Patients receiving 35 52 (b-blocker) 44 67 11-26 26-36 combination drug therapy 38 (diuretic)Prisant, Moser M. Arch Int Med 2000; 1
21、60:284,Major Clinical Trials Showing Benefit of Treating Isolated Systolic HypertensionSHEP Syst-Eur Syst-China(n=4736) (n=4695) (n=2394)Baseline 160-219/ 160-219/ 160-219/ SBP/DBP (mm Hg) 90 95 95 BP reduction: 27/9 23/7 20/5 SBP/DBP (mm Hg)Drug therapy Chlorthalidone Nitrendipine NitrendipineAteno
22、lol Enalapril CaptoprilHCTZ HCTZOutcomes (%)Stroke 33 42 38 CAD 27 30 27 CHF 55 29 All CVR disease 32 31 25Journal of Clinical Hypertension Vol II, No. 5, page 336, September/October 2000.,Independent Predictors of Using Antihypertensives Medications in 2000Variable Adjusted OR (95% CI) of Using Ant
23、ihypertensivesComorbid conditions Asthma/COPD 0.43 (0.40-0.47)Depression 0.50 (0.45-0.55)GI disorders 0.59 (0.54-0.64)Osteoarthritis 0.63 (0.59-0.67)Cardiovascular conditionsCoronary artery disease 1.31 (1.23-1.40)Cerebrovascular disease 1.03 (.97-1.10)Congestive heart failure 1.05 (0.99-1.11)Diabet
24、es 1.16 (1.10-1.22)Wang PS et al. Hypertension 2005; 46:273-279,Barriers to Optimal Control of HypertensionInaccurate measurement of blood pressure (BP) Focusing on diastolic BP rather than systolic BP goal Failure to consider absolute global risk Failure to advocate lifestyle modifications Failure
25、to use polypharmacy Failure to use effective drug combinations Failure to titrate doses upward Fear of reaching excessively low diastolic BP The patient with truly resistant hypertension Behavioral barriersFranklin S. JCH 2006; 8:524,What is the systolic blood pressure goal?,Blood Pressure in SHEP a
26、nd Syst-Eur (mm Hg)SHEP Syst-Eur Entry 160-219/90 160-219/95 Goal (SBP) 160 + 20 150 + 20 Baseline 170/77 174/86 Achieved: Rx 143/68 151/79 Achieved: Placebo 155/72 161/84 Difference: Rx-Placebo 12/4 10/5Journal of Clinical Hypertension, Vol II, No. 5, page 336. March/April 2000.,REDUCTION OF STROKE
27、S WITH BP LOWERING - SHEP TRIAL,No. of Patients: 4736,Follow-up: 4.5 years,37% in ischemic strokes47% in lacunar infarcts54% in hemorrhagic strokes,Lower BPs - fewer strokes,Am J Hypertension 2000;13:724-733,Hypertension in the Very Elderly Trial NEJM 2008;358(18):1887-1898,Double blind, placebo-con
28、trolled International, multicenter 3845 patients Mean age 83.6 yrs BP range 160-219/90-109 Mean BP 173.0/90.8,f/u median of 1.8 yrs Primary endpoints fatal or non fatal stroke Indapamide 1.5mg Perindopril prn (2mg or 4mg) Mean BP fall 15.0/6.1 at 2 yrs,Result Highlights,21% reduction in relative ris
29、k death from any cause 64% reduction relative risk heart failure 39% reduction relative risk of death from stroke,GOALS OF TREATMENT,To achieve a target BP of 140/ 90 mm Hg.In patients with Hypertension & Diabetes or Renal disease, BP Goal is 130/80 mm Hg.To reduce cardiovascular morbidity & mortali
30、ty.,Thiazide Myths,Sulfa cross reactivityGoutRenal stones,Thiazide Related Gout,Thiazide related hyperuricemia is dose related HDFP Trial: 15 episodes of gout over 5 years in 3693 patients treated with chlorthalidone 25-100mg (equivalent to 50-200 mg HCTZ) Low dose thiazide (HCTZ 12.5-25 mg) is not
31、contraindicated in gout,Treatment Recommendations for the Elderly in JNC 7,Recommendations are no different according to age for: BP classification BP goals Lifestyle interventions Selection of medications,For persons over age 50, SBP is a more important than DBP as CVD risk factor.Starting at 115/7
32、5 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 120139 mmHg or DBP 8089 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.,JNC 7: New Features and Key Messages,Thank YouDr. Kunal Kothari Emeritus Professor of medicine and Clinical Cardiology Director Primary Health care and Strategic initiative,
