Dr. Marcy Tashjian-Gibbs
Internal Medicine Conference
January 17, 2013
**No financial or other disclosures**
Slide 1
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
Slide 2
• 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
Slide 3

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.
Slide 4
Category
Normal
Systolic
(mm Hg)
Diastolic
(mm Hg)
<120
and
<80
Prehypertension
120–39
or
80–89
Hypertension
Stage 1
Stage 2
140–159
>160
or
90–99
>100
Slide 5
•
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  sodiumsensitive HTN
Slide 6

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
Slide 7

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)
Slide 8

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
Slide 9

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
Slide 10

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
Slide 11

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
Slide 12

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
Slide 13



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
Slide 14

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
Slide 15

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
Slide 16

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
Slide 17

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
Slide 18

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
Slide 19
 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
Slide 20
Definition
Vascular 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
Slide 21

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
Slide 22

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
Slide 23

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
Slide 24
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
Slide 25


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

Slide 26




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 150/80
Slide 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%
Slide 29




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
Slide 31



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
Slide 32

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
Slide 33

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 Criteria
Slide 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).
Slide 35




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
Slide 36




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
Slide 37



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%
Slide 38

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
Slide 39



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
Slide 40


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
Slide 41


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
Slide 42
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
Slide 43

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
Slide 44
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
Slide 45
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
Slide 46
•
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.
Slide 47
•
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.
Slide 48

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.
Slide 49

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.
Slide 50

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.
Slide 51
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.
Slide 52
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.
Slide 53



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.
Slide 54
Editor:

Annette Medina-Walpole,
MD

GRS7 Chapter Author:

GRS7 Question Writer:
Mark A. Supiano, MD
Rebecca Boxer,
MD

Pharmacotherapy Editor:

Medical Writers:
Judith L. Beizer, PharmD
Beverly A.
Caley
Faith Reidenbach

Managing Editor:

Andrea N.
Sherman, MS

Copyright © 2010 American Geriatrics Society
Slide 55