ManagementofHypertension

inOlderPersons

IntroductionBy2030,theU.S.populationofpersonswhoolderthan65yrsisexpectedtodoubletomorethan60million.65%ofAmericans60yrsandolderhaveHT.Only27%haveadequateBPcontrolProjectedpopulationoftheUnitedStates,byageandsex:2000to2050.AccessedonlineSeptember29,2004,IntroductionNormotensiveat55agehave90%lifetimeriskfordevelopingHT.HTandothercardiovascularriskfactorsinolderpersons

makehighriskformorbiditymortality.Obesity,LVH,Sedentarylifestyle,Hyperlipidemia,DMBloodPressureMeasurementIsolatedelevatedSBPismoreprevalentinolderpersonsbecauseofincreasedlarge-arterystiffness.JNC7

:-

SBPshouldbetheprimarytargetforthediagnosisandcareofolderpersonswithHT.BloodPressureMeasurementBPshouldbebasedontheaverageof2ormoreproperlymeasuredreadings,inthesittingposition,on2ormoreofficevisits.Age-relateddecreasesinbaroreflexresponsemayleadtoorthostatichypotension,soBPshouldbemonitoredinthesittingandstandingpositions.BloodPressureMeasurementPseudohypertension

-BPcufffailstocompressacalcifiedartery.Pt.withresistantHT(Pt.withinadequateBPcontroldespitetxwithappropriate3drugregimen,Esp.orthrostatichypotension)BloodPressureMeasurementResistanthypertension

-white-coathypertensionambulatorybloodpressuremonitoringmaybeusefulindocumentingwhite-coathypertensionandverifyinghypotensivesymptomsinpatientsreceivingantihypertensiveagents.

BloodPressureGoals

RecommendedbyJNC7

-lessthan140/90mmHg.

-lessthan130/80mmHginpatientswithDMorchronickidneydisease.

-associatedwithadecreaseincardiovasculardiseasecomplications.BloodPressureGoalsJNC7recommendstreatingolderpatientswith

stage1isolatedsystolichypertension(systolicbloodpressure140to159mmHg)

stage2isolatedsystolichypertension(systolicbloodpressurehigherthan160mmHg)equalBloodPressureGoalsSystolicHypertensionintheElderlyProgram(SHEP)

-nodefinitiveevidenceofanincreaseinriskfromaggressiveuseofanti-hypertensivetherapyunlessthediastolicbloodpressurewasloweredtolessthan60mmHg.EvidenceSupportingTreatmentofHypertension

In2000,ameta-analysisofeighttrialswaspublishedthatincluded15,693olderpatientswithisolatedsystolichypertension.

-treatedwithconventionaltherapy(i.e.,thiazidediuretic,betablocker,calciumchannelblocker)orplaceboforfouryears.

Risksofuntreatedandtreatedisolatedsystolichypertensionintheelderly:meta-analysisofoutcometrials[publishederratumappearsinLancet2001;357:724].Lancet2000;355:865-72.EvidenceSupportingTreatmentofHypertension

Activetreatmentwasshowntoreduce

-totalmortality(NNT=59)

-cardiovascularmortality(NNT=79)

-fatalornonfatalcardiovascularevents(NNT=26)

-fatalornonfatalstroke(NNT=48)EvidenceSupportingTreatmentofHypertension

Cochranereviewfoundsimilarresults,concludingthattreatinghealthyolderpersonswithhypertensionishighlyefficacious.Recenttrialshaveevaluatedtheeffectsofdifferentantihypertensiveregimensonthetreatmentofhypertensioninolderpersons.EvidenceSupportingTreatmentofHypertension

Meta-analyseshavedocumented

-reductioninstrokeinpatientsolderthan80years.

-reductionofcardiovasculareventsinpatientsolderthan70years.-Risksofuntreatedandtreatedisolatedsystolichypertensionintheelderly:meta-analysisofoutcometrials[publishederratumappearsinLancet2001;357:724].Lancet2000;355:865-72.-Antihypertensivedrugsinveryoldpeople:asubgroupmeta-analysisofrandomisedcontrolledtrials.Lancet1999;353:793-6.SpecialConsiderationsWhenTreatingHTJNC7recommendationsfortreatinghypertensionaresimilarinthegeneralpopulationandolderpersons.(1)treatisolatedSBP.(2)thiazidediureticsshouldbefirstlinetreatment.(3)second-linetreatmentshouldbebasedoncomorbiditiesandriskfactors.SpecialConsiderations

WhenTreatingHT(4)patientswithSBPhigherthan160mmHgorDBPhigherthan100mmHgusuallywillrequiretwoormoreagentstoreachgoal.(5)treatmentshouldbeinitiatedwithalowdoseofthechosenantihypertensiveagent,andtitratedslowlytominimizesideeffectssuchasorthostatichypotension.SpecialConsiderations

WhenTreatingHT(6)weightlossandsodiumreductionhavebeenshowntobefeasibleandeffectiveinterventionsinolderpatientswithHT.

-recommendedlifestylemodifications.

-JNC7recommendsadoptionoftheDietaryApproachestoStopHypertension(DASH)diet,whichhasbeenshowntoproducebloodpressurereductionssimilartosingle-drugtherapy.-Randomizedcontrolledtrialofnonpharmacologicinterventionsintheelderly(TONE)[publishederratumappearsinJAMA1998;279:1954].JAMA1998;279:839-46.-EffectsonbloodpressureofreduceddietarysodiumandtheDietaryApproachestoStopHypertension(DASH)diet.NEnglJMed2001;344:3-10.SpecialConsiderations

WhenTreatingHT(7)toimproveadherencewithantihypertensiveregimens

-involvepatientsingoalsetting.

-ensurethepatient’sculturalbeliefsandpreviousexperiencesareincorporatedinatreatmentplan.

-simplifythemedicationregimen.

-keepinginmindhowmuchitcosts.SpecificAgents:THIAZIDEDIURETICS

Olderpatientsaremorepronetothiazide-induceddehydrationandorthostaticchanges.

-checkfororthostatichypotensionforpreventingfalls.

-serumelectrolytelevelsshouldbemonitoredfrequently.-hypokalemia

shouldbetreatedwithpotassiumadministration,theadditionofapotassium-sparingdiuretic.SpecificAgents:THIAZIDEDIURETICSSHEPtrial,olderpatientswithpotassiumlevelslessthan3.5mgperdL(0.9mmolperL)lostthecardiovascularprotectivebenefitfromthethiazide.Uricacidandthiazidescompeteforexcretionattheleveloftherenaltubule,socautionisnecessaryinpatientswithahistoryofgout.-HypokalemiaassociatedwithdiureticuseincardiovasculareventsintheSystolicHypertensionintheElderlyProgram.Hypertension2000;35:1025-30.SpecificAgents:THIAZIDEDIURETICSThiazidediureticmaybeatincreasedriskofdigoxintoxicity.NSAIDsmayreducediureticandanti-hypertensiveeffectsofthiazides.ACEinhibitororARBtoexistingdiuretictherapy,thereisapossibilityoffirst-dosehypotensionandtheriskofacuterenalinsufficiency.SpecificAgents:BETABLOCKERS

Reducemortalityandmorbidityinolderpatientswithhypertension.Inolderpersonsthathighriskforcoronarydiseaseandpreventionofasecondmyocardialinfarctionandheartfailure.Atenolol,bisoprolol,andmetoprololarecardioselectivebetablockerswithlowlipidsolubility,andhaveapreferablesideeffectprofileinolderpersons.SpecificAgents:BETABLOCKERSBetablockersthatarelipophilice.g.,propranololcrosstheblood-brainbarrier,possiblycausingmoresedation,depression,andsexualdysfunctioninolderpatients.Causebradycardia,conductionabnormalities,anddevelopmentofheartfailureifstartedtooaggressivelyinpatientswithpreexistingleftventriculardysfunction.SpecificAgents:BETABLOCKERSShouldbeusedwithcautionincombinationwithothernegativechronotropes,suchasdiltiazem,verapamil,ordigoxin.Contraindicatedinpatientswithseverereactiveairwaydisease,especiallythenonselectiveagents.SpecificAgents:ACEINHIBITORS

ANDARBSIndicationsforuseinheartfailure,diabetesmellitus,chronickidneydisease,aftermyocardialinfarction,highriskforcoronarydisease,andforrecurrentstrokeprevention.Incidenceofsideeffectsislow.-angioedema:frequentinblacks.

-cough:occursinupto25%SpecificAgents:ACEINHIBITORS

ANDARBSARBs(i.e.,candesartan,irbesartan,losartan,valsartanarereasonablealternativesforthosewithACEinhibitor–associatedcough.First-dosehypotensionisaconcernindehydrated,decompensatedpatientswithheartfailure,andthosewithbilateralrenalarterystenosis.SpecificAgents:ACEINHIBITORS

ANDARBSInolderpatients,hypotensionandrenalfunctionshouldbemonitoredcloselyuponinitiation.Acuteelevationinserumcreatinineabove30percentwarrantsatemporarydiscontinuationorloweringofthedose.ACEinhibitorsalsomaycausehyperkalemia,serumelectrolytesandcreatinineshouldbemonitored.SpecificAgents:CALCIUMCHANNEL BLOCKERSDihydropyridinesandnondihydropyridinesareeffectivetreatmentsforhypertensioninolderpatients.Indicationsforuseinpatientsathighriskforcoronarydiseaseandthosewithdiabetesmellitus.Short-actingagentsarenotrecommendedinclinicalpractice.SpecificAgents:CALCIUMCHANNEL BLOCKERSNondihydropyridines(e.g.,diltiazem,verapamil)exhibitnegativeinotropicandchronotropiceffects:inatrialfibrillationandsupraventriculartachyarrythmias.Dihydropyridines(i.e.,amlodipine,felodipine)aresafeforuseinpatientswithheartfailure,hypertension,orchronicstableangina.SpecificAgents:CALCIUMCHANNEL BLOCKERSSystematicreviewsgenerallyhavefoundcalciumchannelblockerstobeequivalentorinferiortootherantihypertensiveagents.AntihypertensiveandLipid-LoweringTreatmenttoPreventHeartAttackTrial(ALLHAT),amlodipinewasfoundtobeinferiortochlorthalidoneinpreventingheartfailure–relatedevents.-Healthoutcomesassociatedwithvariousantihypertensivetherapiesusedasfirst-lineagents:anetworkmeta-analysis.JAMA2003;289:2534-44.-

Majoroutcomesinhigh-riskhypertensivepatientsrandomizedtoangiotensin-convertingenzymeinhibitororcalciumchannelblockervsdiuretic:theAntihypertensiveandLipid-LoweringTreatmenttoPreventHeartAttackTrial(ALLHAT)JAMA2002;288:2981-97.

SpecificAgents:CALC