1、Management of Hypertension in Older Persons,Introduction,By 2030, the U.S. population of persons who older than 65 yrs is expected to double to more than 60 million. 65% of Americans 60 yrs and older have HT.,Only 27% have adequate BP control,Projected population of the United States, by age and sex
2、: 2000 to 2050. Accessed online September 29, 2004,Introduction,Normotensive at 55 age have 90% lifetime risk for developing HT. HT and other cardiovascular risk factors in older personsmake high risk for morbiditymortality.,Obesity, LVH, Sedentary lifestyle, Hyperlipidemia, DM,Blood Pressure Measur
3、ement,Isolated elevated SBP is more prevalent in older persons because of increased large-artery stiffness.JNC 7 :- SBP should be the primary target for the diagnosis and care of older persons with HT.,Blood Pressure Measurement,BP should be based on the average of 2 or more properly measured readin
4、gs, in the sitting position, on 2 or more office visits.Age-related decreases in baroreflex response may lead to orthostatic hypotension, so BP should be monitored in the sitting and standing positions.,Blood Pressure Measurement,Pseudohypertension- BP cuff fails to compress a calcified artery.,Pt.
5、with resistant HT (Pt. with inadequate BP control despite tx with appropriate 3 drug regimen, Esp. orthrostatic hypotension),Blood Pressure Measurement,Resistant hypertension- white-coat hypertension ambulatory blood pressure monitoring may be useful in documenting white-coat hypertension and verify
6、ing hypotensive symptoms in patients receiving antihypertensive agents.,Blood Pressure Goals,Recommended by JNC 7 - less than 140/90 mm Hg. - less than 130/80 mm Hg in patients with DM or chronic kidney disease.- associated with a decrease in cardiovascular disease complications.,Blood Pressure Goal
7、s,JNC 7 recommends treating older patients with stage 1 isolated systolic hypertension (systolic blood pressure 140 to 159 mm Hg) stage 2 isolated systolic hypertension (systolic blood pressure higher than 160 mm Hg),equal,Blood Pressure Goals,Systolic Hypertension in the Elderly Program (SHEP)- no
8、definitive evidence of an increase in risk from aggressive use of anti-hypertensive therapy unless the diastolic blood pressure was lowered to less than 60 mm Hg.,Evidence Supporting Treatment of Hypertension,In 2000, a meta-analysis of eight trials was published that included 15,693 older patients
9、with isolated systolic hypertension.- treated with conventional therapy (i.e., thiazide diuretic, beta blocker, calcium channel blocker) or placebo for four years.,Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials published erratum appears
10、in Lancet 2001;357:724. Lancet 2000;355:865-72.,Evidence Supporting Treatment of Hypertension,Active treatment was shown to reduce - total mortality (NNT= 59)- cardiovascular mortality (NNT = 79)- fatal or nonfatal cardiovascular events (NNT = 26)- fatal or nonfatal stroke (NNT = 48),Evidence Suppor
11、ting Treatment of Hypertension,Cochrane review found similar results, concluding that treating healthy older persons with hypertension is highly efficacious. Recent trials have evaluated the effects of different antihypertensive regimens on the treatment of hypertension in older persons.,Evidence Su
12、pporting Treatment of Hypertension,Meta-analyses have documented - reduction in stroke in patients older than 80 years.- reduction of cardiovascular events in patients older than 70 years.,- Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials
13、 published erratum appears in Lancet 2001;357:724. Lancet 2000;355:865-72. - Antihypertensive drugs in very old people: a subgroup meta-analysis of randomised controlled trials. Lancet 1999;353:793-6.,Special Considerations When Treating HT,JNC 7 recommendations for treating hypertension are similar
14、 in the general population and older persons.(1) treat isolated SBP.(2) thiazide diuretics should be first line treatment.(3) second-line treatment should be based on comorbidities and risk factors.,Special Considerations When Treating HT,(4) patients with SBP higher than 160 mm Hg or DBP higher tha
15、n 100 mm Hg usually will require two or more agents to reach goal. (5) treatment should be initiated with a low dose of the chosen antihypertensive agent, and titrated slowly to minimize side effects such as orthostatic hypotension.,Special Considerations When Treating HT,(6) weight loss and sodium
16、reduction have been shown to be feasible and effective interventions in older patients with HT.- recommended lifestyle modifications.- JNC 7 recommends adoption of the Dietary Approaches to Stop Hypertension (DASH) diet, which has been shown to produce blood pressure reductions similar to single-dru
17、g therapy.,- Randomized controlled trial of nonpharmacologic interventions in the elderly (TONE) published erratum appears in JAMA 1998;279:1954. JAMA 1998;279:839-46. - Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med 2001
18、;344:3-10.,Special Considerations When Treating HT,(7) to improve adherence with antihypertensive regimens- involve patients in goal setting.- ensure the patients cultural beliefs and previous experiences are incorporated in a treatment plan. - simplify the medication regimen.- keeping in mind how m
19、uch it costs.,Specific Agents : THIAZIDE DIURETICS,Older patients are more prone to thiazide-induced dehydration and orthostatic changes.- check for orthostatic hypotension for preventing falls.- serum electrolyte levels should be monitored frequently.- hypokalemia should be treated with potassium a
20、dministration, the addition of a potassium-sparing diuretic.,Specific Agents : THIAZIDE DIURETICS,SHEP trial, older patients with potassium levels less than 3.5 mg per dL (0.9 mmol per L) lost the cardiovascular protective benefit from the thiazide. Uric acid and thiazides compete for excretion at t
21、he level of the renal tubule, so caution is necessary in patients with a history of gout.,- Hypokalemia associated with diuretic use in cardiovascular events in the Systolic Hypertension in the Elderly Program. Hypertension 2000;35:1025-30.,Specific Agents : THIAZIDE DIURETICS,Thiazide diuretic may
22、be at increased risk of digoxin toxicity. NSAIDs may reduce diuretic and anti- hypertensive effects of thiazides. ACE inhibitor or ARB to existing diuretic therapy, there is a possibility of first-dose hypotension and the risk of acute renal insufficiency.,Specific Agents : BETA BLOCKERS,Reduce mort
23、ality and morbidity in older patients with hypertension. In older persons that high risk for coronary disease and prevention of a second myocardial infarction and heart failure. Atenolol, bisoprolol, and metoprolol are cardioselective beta blockers with low lipid solubility, and have a preferable si
24、de effect profile in older persons.,Specific Agents : BETA BLOCKERS,Beta blockers that are lipophilic e.g., propranolol cross the blood-brain barrier, possibly causing more sedation, depression, and sexual dysfunction in older patients. Cause bradycardia, conduction abnormalities, and development of
25、 heart failure if started too aggressively in patients with preexisting left ventricular dysfunction.,Specific Agents : BETA BLOCKERS,Should be used with caution in combination with other negative chronotropes, such as diltiazem, verapamil, or digoxin. Contraindicated in patients with severe reactiv
26、e airway disease, especially the nonselective agents.,Specific Agents : ACE INHIBITORS AND ARBS,Indications for use in heart failure, diabetes mellitus, chronic kidney disease, after myocardial infarction, high risk for coronary disease, and for recurrent stroke prevention. Incidence of side effects
27、 is low.- angioedema : frequent in blacks.- cough : occurs in up to 25 %,Specific Agents : ACE INHIBITORS AND ARBS,ARBs (i.e., candesartan, irbesartan, losartan, valsartan are reasonable alternatives for those with ACE inhibitorassociated cough. First-dose hypotension is a concern in dehydrated, dec
28、ompensated patients with heart failure, and those with bilateral renal artery stenosis.,Specific Agents : ACE INHIBITORS AND ARBS,In older patients, hypotension and renal function should be monitored closely upon initiation. Acute elevation in serum creatinine above 30 percent warrants a temporary d
29、iscontinuation or lowering of the dose. ACE inhibitors also may cause hyperkalemia, serum electrolytes and creatinine should be monitored.,Specific Agents : CALCIUM CHANNEL BLOCKERS,Dihydropyridines and nondihydropyridines are effective treatments for hypertension in older patients. Indications for
30、use in patients at high risk for coronary disease and those with diabetes mellitus. Short-acting agents are not recommended in clinical practice.,Specific Agents : CALCIUM CHANNEL BLOCKERS,Nondihydropyridines (e.g., diltiazem, verapamil) exhibit negative inotropic and chronotropic effects : in atria
31、l fibrillation and supraventricular tachyarrythmias. Dihydropyridines (i.e., amlodipine, felodipine) are safe for use in patients with heart failure, hypertension, or chronic stable angina.,Specific Agents : CALCIUM CHANNEL BLOCKERS,Systematic reviews generally have found calcium channel blockers to
32、 be equivalent or inferior to other antihypertensive agents. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), amlodipine was found to be inferior to chlorthalidone in preventing heart failurerelated events.,- Health outcomes associated with various antihypertensi
33、ve therapies used as first-line agents: a network meta-analysis. JAMA 2003;289:2534-44. - Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart
34、 Attack Trial (ALLHAT) JAMA 2002;288:2981-97.,Specific Agents : CALCIUM CHANNEL BLOCKERS,Effective in salt sensitive hypertensive patients, such as blacks and older persons. Dihydropyridines, especially nifedipine, can cause orthostatic hypotension, peripheral edema, and gingival hyperplasia. Verapa
35、mil often is a cause of constipation in older persons.,MISCELLANEOUS - ANTIHYPERTENSIVE AGENTS,Peripheral alpha blockers, centrally acting agents, and vasodilators have limited use in older persons because of significant side effect profiles. Have not been associated with reductions in morbidity and
36、 mortality in patients with hypertension.,MISCELLANEOUS - ANTIHYPERTENSIVE AGENTS,Central alpha agonists (include clonidine, guanfacine, methyldopa, and reserpine) act centrally and may cause significant sedation, dry mouth, and depression. Many patients experience hypotension in addition to sodium
37、and water retention.,MISCELLANEOUS - ANTIHYPERTENSIVE AGENTS,Abrupt cessation of high doses of (e.g., greater than 1.2 mg daily of clonidine) may cause rebound hypertension. Vasodilators hydralazine and minoxidil cause sodium and water retention and reflex tachycardia, so they are not useful as monotherapy.,
