Dr. Marcy Tashjian-GibbsInternal Medicine Conference

January 17, 2013

**No financial or other disclosures**

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Know and understand:

• How the diagnosis and treatment of hypertension differ in older adults

• When to recommend lifestyle modification

• How to choose among the various classes of antihypertensive agents

• The principles of adjusting therapy

• Most recent literature

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• Epidemiology And Physiology

• Clinical Evaluation

• Treatment

Lifestyle modification

Pharmacologic treatment

Follow-up visits

• Special Considerations

Hypertensive emergencies and urgencies

Hypertension in the long-term care setting

•RECENT LITERATURE -> changes in management

BP increases with age, especially SBP and pulse pressure (difference between SBP and DBP)

In Americans ≥65 years, the prevalence of hypertension (HTN) is:

• 50% to 70%

• Highest among blacks• Higher in women than men

The proportion of older patients with HTN whose BP is controlled is low.

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Category Systolic

(mm Hg)

Diastolic

(mm Hg)

Normal <120 and <80

Prehypertension 120–39 or 80–89

Hypertension

Stage 1

Stage 2

140–159

>160

or 90–99

>100

• Increased arterial stiffness

• Decline in baroreflex sensitivity

• Increase in sympathetic nervous system activity

• Heightened vasoconstriction

• Alterations in renal function and neurohumoral systems involved in sodium balance sodium-sensitive HTN

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Use the average of several readings taken at each of 3 visits

Consider ambulatory BP monitoring for patients with extreme BP variability or possible “white coat” HTN

Determine SBP by palpation to avoid auscultatory gap

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Exclude secondary forms of HTN

Identify target organ damage

Determine CVD risk factors and identify comorbidities

Inquire about lifestyle (smoking history, dietary intake of sodium and fat, alcohol intake, physical activity)

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Treatment reduces overall mortality, CVD events, heart failure, and stroke

Treatment effect is greatest in men, patients older than 70 years, and patients with greater pulse pressure

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Focus on SBP and pulse pressure• In general:

–SBP 135 to 140 mm Hg–DBP <90 mm Hg

• Type 2 diabetes: SBP <130 mm Hg

If SBP is very high, an intermediate target (eg, 160 mm Hg) may be a better initial goal in the absence of target-organ damage

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6-month trial for nondiabetics with stage 1 HTN

Adjunct to drug therapy for all hypertensive patients

Components:• Weight reduction• Aerobic exercise and strength training• Smoking cessation• Moderation of alcohol intake• Decreased sodium, saturated fat, cholesterol• Maintain adequate intake of potassium,

magnesium and calcium

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Start with a low-dose thiazide-type diuretic

If BP is >20 mm Hg above target, start with diuretic plus ACE inhibitor

Initiate therapy at half the usual dose; increase dose slowly

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Avoid excessively low DBP (<70 mm Hg)

Do not use aggressive therapy if adverse effects (eg, postural hypotension) cannot be avoided

Avoid centrally acting agents and those likely to produce postural hypotension

Continue nonpharmacologic therapies

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Preferred for initial therapy because of:• Relative safety• Once-daily dosing• Low cost• Significant benefits in mortality, stroke and

coronary events Better than other agents at reducing SBP

Potassium replacement is important to prevent arrhythmias, minimize glucose intolerance

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Can be used as initial monotherapy for simple HTN in older patients, especially men

Generally well tolerated (except for cough)

No adverse CNS or metabolic effects

Well suited to patients with diabetes and those with LV systolic dysfunction

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Not well studied in older hypertensive patients

Not an appropriate initial monotherapy

An option for patients with diabetes, heart failure, or chronic kidney disease, especially those unable to tolerate ACE inhibitors

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Reduce peripheral vascular resistance

No adverse CNS or metabolic effects

An option for second-line therapy, generally with a thiazide-type diuretic

Use at low doses (pharmacokinetics change with advancing age)

Do not use short-acting CCAs to treat HTN

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Not recommended for first-line monotherapy

Less effective than diuretics in reducing BP and preventing CVD events, stroke, and death

Consider for patients with symptomatic CAD, those with a history of MI, and certain patients with heart failure

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High risk of postural hypotension in older patients

When used as monotherapy, associated with a high rate of CVD events (new-onset heart failure) in a large-scale clinical trial

May be considered, usually in combination with another drug, for older men with prostatism

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Assess adherence to therapy

Monitor for adverse effects, especially postural hypotension

Measure supine and standing BP

Adjust dosage cautiously – “start low and go slow”

In general, allow 1 to 2 months between visits

Except in hypertensive emergencies, rapid reduction of BP is unnecessary and likely deleterious

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DefinitionVascular compromise of vital organs due to extreme BP elevation (eg, hypertensive encephalopathy, pulmonary edema, aortic dissection, unstable angina)

Management

In hospital with continuous BP monitoring

Parenteral administration of antihypertensive

Do not initially target a normal BP level

Try to achieve 160/100 mm Hg gradually over first 6 hours

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Defined as cases in which BP should be lowered within 24 hours to prevent target-organ damage

Most can be managed with oral antihypertensive medications

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HTN affects about 33% to 66% of residents of long-term care (LTC) facilities

Postprandial hypotension• Affects about 33% of residents• Independent risk factor for falls, syncope,

stroke, mortality

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No well-designed trials have studied antihypertensive treatment in the LTC setting

Risk-benefit ratio of treatment is unclear in:

• Patients older than 80 years

• Patients with multiple comorbidities, taking multiple medications

Antihypertensive medications are a risk factor for falls, so assess postural and postprandial BP

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2 recent studies that have specifically explored hypertension in the elderly

JATOS STUDY – 2 subgroup studies Association of Blood Pressure Control and

Metabolic Syndrome With Cardiovascular Risk in Elderly Japanese

Comparison of Strict and mild blood pressure control in elderly hypertensive patients: a per-protocol analysis of JATOS

HYVET STUDY Blood Pressure control in the Hypertension in the

Very Elderly Trial

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Blood Pressure Control in the Hypertension in the Very Elderly Trial

Main Objective: To identify any reduction in stroke events,

and relate this change and any change in total mortality, cardiac mortality and cardiovascular events to the difference in blood pressure between the groups

To look specifically at patients over the age of 80

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After giving consent, patients were given a placebo

Seen again in 1 and 2 months Sitting blood pressure after 1 and 2

months measured twice after a rest of 5 minutes giving 4 readings of sitting blood pressure

Eligible for randomization: Average of systolic readings 160-199

and Average of diastolic readings 90-109 Slide 27

Eventually requirement for both systolic and diastolic were dropped Patients randomized with a diastolic pressure <110 if systolic was 160-199

2 groups (SDH and ISH) Standing systolic pressure measured at 2

months and patients excluded if standing BP <140 due to risk of postural hypotension

Participants followed at 3, 6, 9 and 12 months, and 6 months thereafter

KEY: BP GOAL 150/80Slide 28

12% of SDH controlled on placebo at 2 years SDH with active treatment

5.7% controlled on monotherapy 33% controlled after full titration 39% controlled at 2 years, 75% had systolic

controlled at 2 years ISH with active treatment

Full control achieved in 62% of all ISH patients

Systolic control in 73% and diastolic control in 77%

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Reduction in stroke – 30% Reduction in Total Mortality – 21% Reduction in Heart Failure – 64%

REMINDER: Goal BP in study was 150/80 Question becomes should this be the

goal BP for treatment of HTN in the elderly?

THIS BRINGS US TO JATOS!!! Slide 30

Elderly patients 65-85 years old Randomly assigned to strict SBP <140 or

mild SBP 140-159 Patients followed for 2 years Treated with efonidipine based regimen Metabolic syndrome defined according to

the National Cholesterol Education Program Adult Treatment Panel III criteria, with exception for use of BMI instead of waist circumference

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Prospective, randomized, open-label study with blinded assessment of endpoints

Designed to compare the effects of 2 years of strict antihypertensive treatment to maintain SBP <140 with those of mild treatment to maintain SBP 140-159

Baseline drug: efonidipine; other classes added if target BP not reached

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Primary endpoint was the combined incidence of cerebrovascular disease, cardiac and vascular disease, and renal failure Cerebral hemorrhage, cerebral infarction, TIA,

subarachnoid hemorrhage MI, angina requiring hospitalization, heart

failure, sudden death, dissecting aneurysms of the aorta, occlusive arterial disease

Doubling of the serum creatinine concentration with the reached level of creatinine >1.5

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At start of study patients evaluated for Cardiovascular risk factors History of cerebrovascular disease Enlarged heart/cardiomegaly

Defined as cardiothoracic ratio of >50% on chest x ray film; LV hypertrophy diagnosed to Sokolow-Lyon criteria on EKG

History of cardiac or vascular diseases Renal damage

Diagnosis of Metabolic Syndrome (MS) National Cholesterol Education Program Adult

Treatment Panel III CriteriaSlide 34

The impact of metabolic syndrome on cardiovascular events differs between

patients with and without strictly controlled BP and also between early

elderly (65-74 yrs old) and late elderly (>75 yrs old).

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BP decreased in both treatment groups and average BP was controlled at the target levels

In patients with and without MS SBP was significantly lower in the strict group

Additional antihypertensive drugs used more frequently in the strict group

Number of drugs not significantly different in MS and non MS groups

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Cardiovascular risk associated with MS was evident in elderly patient with hypertension aged <75 years old but not in those >75 years old

The increased risk associated with MS (<75 yrs old) was apparent when SBP was controlled mildly but not under strict BP control

Strict control of SBP appears to be desirable for elderly hypertensive patients with MS if < 75 years old

Benefit of aggressive antihypertensive therapy is not obvious for patients >75 years old even if they have MS

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In this study, the incidences of the primary endpoint in patients who failed to achieve the treatment goal were analyzed

Percentage of patients who achieved goal in the strict treatment group: 53.8%

Percentage of patients who achieved goal in the mild group: 69.4%

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1191 in strict group 67 protocol violation, 138 discontinued study,

52 incomplete BP data (257 total) 764 uncontrolled within the strict BP goal

1531 in mild group 59 protocol violation, 153 discontinued study,

39 incomplete BP data (251 total) 424 uncontrolled within goal

103 with systolic >160 321 with systolic < 140

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In the target achieved groups (strict and mild) the cumulative incidence rates of primary end points showed no difference between strict target achieved and mild target achieved groups (Conclusion from JATOS)

Can be suggested that once BP is reduced to 147 systolic the clinical benefit of lowering to lower than 140 systolic is of little significance

Next Step: Compare the target achieved to the target unachieved groups

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Primary events in target unachieved patients were significantly higher than in those in the target achieved patients in both strict and mild groups

Target unachieved patients had higher baseline incidence of elevated systolic BP, higher prevalence of dyslipidemia, current smoking, DM, and renal disease

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No significant difference in outcomes between the strict and mild treatment despite the significant difference in final BP in the target achieved groups

High incidence of cardiovascular events in patients who did not achieve the target BP in both strict and mild treatment groups Have to consider that the target unachieved

patients had higher incidence of risk factors This tells us patients should be treated more

aggressively if unable to reach their goal

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BP should be controlled to between 132 (achieved in the strict group) and 147 systolic (achieved in the mild group).

Patients who have difficulties in achieving treatment goals should be treated as a high risk population and should be given more

aggressive treatment

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Treatment of HTN reduces the risk of CVD events and mortality in older adults

A trial of lifestyle modification is recommended for nondiabetic patients with stage 1 HTN

A low-dose thiazide-type diuretic is the preferred first-line drug therapy

“Start low and go slow”—monitor for falls, postural hypotension, and other adverse events

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The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) recommends which of the following for initial treatment of hypertension in older adults?

(A) ACE inhibitor

(B) Thiazide diuretic

(C) Calcium channel blocker

(D) ß-Blocker

(E) Angiotensin-receptor blocker

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The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) recommends which of the following for initial treatment of hypertension in older adults?

(A) ACE inhibitor

(B) Thiazide diuretic

(C) Calcium channel blocker

(D) ß-Blocker

(E) Angiotensin-receptor blocker

• A 70-year-old man comes to the office to establish care. He is generally healthy and has always had normal blood pressure.

• His family history includes diabetes mellitus and hypertension; his father died of a stroke and his mother of cancer. He eats a low-sodium, low-fat diet.

• On examination, blood pressure is 150/90 mmHg without postural change.

• Cardiac examination is normal, and there is no evidence of hypertensive retinopathy or peripheral vascular disease.

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• Laboratory studies (including creatinine concentration of 0.8 mg/dL) and electrocardiography are normal.

• At a repeat check 1 month later, blood pressure is 154/92 mmHg without postural change.

• The patient reports that a reading taken with a friend’s blood pressure cuff was 134/80 mmHg.

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Which of the following is the most appropriate next step in managing this patient’s increased blood pressure?

(A) Repeat blood pressure measurement in 1 mo.

(B) Obtain 24-hour ambulatory blood pressure record.

(C) Refer to a dietitian for dietary counseling.

(D) Recommend a regular exercise regimen.

(E) Begin hydrochlorothiazide.

Which of the following is the most appropriate next step in managing this patient’s increased blood pressure?

(A) Repeat blood pressure measurement in 1 mo.

(B) Obtain 24-hour ambulatory blood pressure record.

(C) Refer to a dietitian for dietary counseling.

(D) Recommend a regular exercise regimen.

(E) Begin hydrochlorothiazide.

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An 80-year-old man comes to the office for routine evaluation.

He has a history of osteoarthritis, major depressive disorder, and well-controlled hypertension.

Medications include hydrochlorothiazide 12.5 mg/d, escitalopram 20 mg/d, ibuprofen 400 mg q8h, and valsartan 80 mg/d.

The patient’s blood pressure readings at home average 160/80 mmHg.

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Which of the following is the next best step to take in managing this patient’s hypertension?

(A) Increase hydrochlorothiazide.

(B) Stop escitalopram.

(C) Stop ibuprofen.

(D) Increase valsartan.

(E) Add amlodipine.

Which of the following is the next best step to take in managing this patient’s hypertension?

(A) Increase hydrochlorothiazide.

(B) Stop escitalopram.

(C) Stop ibuprofen.

(D) Increase valsartan.

(E) Add amlodipine.

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CJ Bulpitt, NS Beckett, R Peters, G Leonetti, V Gergova, R Fagard, LA Burch, W Banya, AE Fletcher. Blood pressure control in the Hypertension in the very Elderly Trial (HYVET). Journal of Human Hypertension. 2011: 1-7

Yuhei Kawano, Toshio Ogihara, Takao Saruta, Yoshio Goto, Masao Ishii. Association of Blood Pressure Control and Metabolic Syndrome With Cardiovascular Risk in Elderly Japanese: JATOS Study. American Journal of Hypertension. 2011; 24: 1250-1256

Hiromi Rakugi, Toshio Ogihara, Yoshio Goto, Masao Ishii. Comparison of strict- and mild-blood pressure control in the elderly hypertensive patients: a per protocol analysis of JATOS. Hypertension Research. 2010; 33: 1124-1128.

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Editor: Annette

Medina-Walpole, MD

GRS7 Chapter Author: Mark A. Supiano,

MD

GRS7 Question Writer: Rebecca Boxer, MD

Pharmacotherapy Editor: Judith L. Beizer, PharmD

Medical Writers: Beverly A.

Caley

Faith

Reidenbach

Managing Editor: Andrea N.

Sherman, MS

Copyright © 2010 American Geriatrics SocietySlide 55