Hypertension in the very old. Objectives: Clinical Perspective

Transcription

1 Harvard Medical School Hypertension in the very old Ihab Hajjar, MD, MS, AGSF Associate Director, CV Research Lab Assistant Professor of Medicine, Harvard Medical School Objectives: Describe the clinical characteristics and evaluation of hypertension in the very elderly patient. Recognize the principles of management of hypertension in the very elderly patient. Clinical Perspective In 2003, there were more than 35 million physician office visits for hypertension In those 80 or older, rate of treatment is lower than those between years. Various concerns have been raised regarding treatment of those 80 years or older: increase mortality Orthostatic hypotension and compromised cerebral perfusion Polypharmacy Worsening cognitive function and quality of life 1

2 National Survey of geriatric MD, DO and NP: 25% considered treating those 80 years or older as having more risk than benefit % Risk>Benefit Risk<Benefit Hajjar I, et al. J Gerontol A Biol Sci Med Sci Aug;57(8):M Blood pressure increases with aging Hajjar I, George V, Grim CE, Kotchen TA. Arch of IM.2001;161: Hypertension prevalence increases with age in all races and both genders ** * prevalence,% or older Age, years *: P<0.01 for the difference between the and surveys. **: P<0.01 for the difference between the three age groups Hajjar I,Kotchen TA. JAMA

3 What constitutes Hypertension: JNC- 7 BP (mm Hg) SBP DBP Normal Prehypertension Hypertension Stage 1 Stage 2 < >160 and or or or < >100 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.jama. 2003;289(19): Special characteristics of hypertension in the elderly patient In the Young Mostly diastolic hypertension Less resistant Hyperactive cardiovascular system Less comorbidities and polypharmacy In the Old Mostly systolic hypertension More resistant (usually requires >1 drug) High vascular resistance and increased stiffness Polypharmacy/ Comorbidities BP measurement in the very old BP in the elderly may not be sustained: Multiple readings are needed including home readings or 24h ambulatory readings [White Coat Phenomenon] Auscultatory Gap: Use Minimum Inflation Pressure Measure orthostatic BP and HR ( 1 or 3 minute standing) Pseudohypertension: ~4% of elderly hypertensives. Osler s Maneuver is suggestive but not diagnostic Suspect Pseudohypertension when Wide pulse pressure High BP with no end organ damage Positive OM Unexpected severe side effects related to hypotension. 3

4 Evaluation of the very old hypertensive patient: more than just a number Risk stratification: diabetes, lipids, anemia, CV disease Functional/prognosis assessment: Robust vs frail Screen for end organ damage: Fundoscopy, proteinuria/ microalbuminuria, LVH, Peripheral vascular diseases When to consider secondary Hypertension (RARE): Finding New-onset HTN with BP>180/90 Syndrome no control despite compliance and 3 drugs Hypokalemia (spontaneous or diuretic induced) Hyperaldosteronism Abdominal Bruit new poorly controlled HTN Renovascular Hypertension Cushingnoid features, Findings DM of secondary Hypercortisolism Hypertension: Headache, palpitation, paroxysmal hypertension Pheocromocytoma Lower extremity edema, allergic rhinitis Drugs: Decongestants, NSAIDS Obesity, snoring, or day somnolence Obstructive Sleep Apnea Case-1 Mr. T is an 85-year old African American man who has recently relocated to Florida. He has been working until last year when he decided to retire. He has been extremely busy and has not been able to see a primary care physician for many years. Since his retirement, his wife has been bugging him about seeing a primary care physician for a physical. Case-1: Blood Pressure Sitting BP=182/74 mm Hg; HR=78 bpm Three-minute standing BP=174/70 mm Hg; HR=80 bpm Repeat BP 20 minutes later BP=164/66 mm Hg; HR= 82 bpm Repeat BP at home and next visit >160/58-76 mm Hg 4

5 Case-2 Your next patient is Mr. M who is an 84-year old African American man transferring his care to you due to retirement of his prior physician. He has congestive heart failure, diabetes mellitus, and severe osteoarthritis of the knees and hip. He has mild cognitive impairment and requires minimal assistance in his daily activities. He has a cardiac murmur but negative exam otherwise. Case-2: Blood Pressure Sitting BP=180/54 mm Hg; HR=58 bpm Three-minute standing BP=164/50 mm Hg; HR=64 bpm Repeat BP 20 minutes later BP=162/52 mm Hg; HR= 62 bpm Repeat BP at home and next visit >160/50-56 mm Hg Case-3 You finished your morning clinic and now plan to do a NH visit to evaluate a new resident. She is an 83 year old Caucasian woman who has advanced dementia, hyperlipidemia, osteoporosis, and severe OA of the knees and hip. She had a stroke 2 years ago and has recently lost 15 lbs/6 months. Her exam shows significant aphasia, stage II sacral ulcer, and muscle wasting. 5

6 Case-3: Blood Pressure Supine BP=166/54 mm Hg; HR=58 bpm Three-minute standing (with 2 point support) BP=138/48 mm Hg; HR=64 bpm Repeat supine BP 20 minutes later BP=162/48 mm Hg; HR= 52 bpm Repeat BP 2 weeks later >160/48-56 Three Contrasting Cases:Points Heterogeneity of the clinical population: Age alone is not a very informative factor. The functional/comorbid Continuum: Robust Comorbidities NH resident Case 1 Case 2 Case 3 Who should be treated and, how and how low should we treat the 3 cases? Who should we treat of the very old? Age>80 was an exclusion in many HTN studies prior to HYVET. To date, only one study specifically included very old hypertensives: Hypertension in the very elderly trial or HYVET External validity and generalizability: How applicable are the results to my patient. Becket NS et al. NEJM. 2008;358:EPUB 6

7 Generalizability Age, years % Non-Caucasians Stroke DM CHF Smokers 84± % 6.4% 84±0.3 11% 6% 11.6% BMI, Kg/m Dementia 0 31% % on 2 antihypertensives HYVET* 6.7% 6.8% 73.4% Primary care geriatric practice (USA) (N=993)** 6.5% 15% 33% *: Becket NS. NEJM. 2008;358:EPUB **: Hajjar I. J Gerontol A Biol Sci Med Sci Jan;60(1):67-73 Who should we treat? If life expectancy >1-2 years ie robust, then benefit may be accrued from treatment. If life expectancy is less, evidence is lacking and would be very careful! Becket NS et al. NEJM. 2008;358:EPUB How should we treat the very old hypertensive? Based on HYVET and JNC 7, Diuretic± ACEI are first line and are likely to be safe. Safety: No change in serum K, glucose or creatinine,? Cough (no information)in the very old. ARB are well tolerated as well and may have pleiotropic effect: Cognition and physical function. Lifestyle modification is effective and feasible in the very old (? Robust) 7

8 What about Beta Blockers? In a metanalysis, in those 60 years or older use of beta blockers was associated with worse outcome including death compared to other antihypertensives (RR=1.06 (95% CI ) In the ASCOT trial, Atenolol based regimen increased risk of poor outcome compared to CCB and ACEI. In those with CAD and CHF, BB have an important role and are clearly indicated for management. Therefore, BB, especially Atenolol, maybe associated with poor outcome. In older hypertensives without CAD and CHF or other clear indications for BB, would use other alternative drugs Khan, N. et al. CMAJ 2006;174: Dahlof, B. Lancet Sep 10-16;366(9489): How low should we treat the very old hypertensive patient? HYVET Target 150/80 mm Hg vs JNC-7 140/90 mm Hg (130 in those with DM and other comorbid illnesses) Even in a research setting such as HYVET, only 48% of the treatment group were below 150/80mm Hg at 2 years (BP in the very old is hard to control) Lower BP to either 150/90 mm Hg in the very old if is tolerable. Consider lower target in high risk groups such as diabetics HYVET: Back to our cases? Case 1: Target 150/80 mm Hg (Robust). Case 2: Target 150/80 mm Hg (?lower). JNC-VII: Diabetics target below 130 mm Hg. DM were included in HYVET. Case 3: Significantly different than HYVET participant (standing pressure <140, NH resident, poor function/ prognosis) Unclear evidence for or against currently. Individualize, Consider if LE>1-2 years 8

9 Back to our cases HYVET Case 1 Case 2 Case 3 Start Diuretic RX? (if LE>1-2 years) <150/90 <150/90?? Summary Clinical characteristics and evaluation: Risk stratify by function and comorbidity Measure BP accurately both sit and stand Management: Who: those with expected survival >1 year and have good functional status. Others Be Careful! How: Diuretic±ACEI. ARB and CCB alternatives. Avoid BB unless clearly indicated (eg CAD, MI etc..) How low: overall 150/90 mm Hg. Less if Diabetic or other comorbidities. Monitor for low blood pressure symptoms. Funding and Acknowledgement Dr. Hajjar receives funding from the National Institute of Health/ NIA (1K23AG030057). 9