Managing HTN in the Elderly: How Low to Go

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1 Managing HTN in the Elderly: How Low to Go Laxmi S. Mehta, MD, FACC The Ohio State University Medical Center Assistant Professor of Clinical Internal Medicine Clinical Director of the Women s Cardiovascular Health Program Associate Program Director of Education, Center for Women s Health Orlando, Florida October 7-9, 2011

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3 ( Prevalence of High Blood Pressure in Adults by Age and Sex (NHANES 3 Aronow, W. S. et al. J Am Coll Cardiol 2011;57: Copyright 2011 American College of Cardiology Foundation. Restrictions may apply.

4 Age Changes in Systolic and Diastolic BP 4 Source: J Gerontol Med Sci 1997;52:M177-83

5 Decades Past Rise in BP with age: support organ perfusion Empiric formula for BP age FHS: SBP strong independent risk factor for CV events in all decades of life Follow up studies: treatment of SBP reduces events JNC V: shift to control on SBP

6 Nomenclature Elderly > 65 years Young old: Older old: Oldest old: > 85 JNC VII: SBP > 140 and/or DBP > 90 Usual definitions and target BP may not be applicable to elderly patients. Category Systolic Diastolic Normal <120 and <80 Pre-hypertension or Stage 1 hypertension or Stage 2 hypertension >160 or >100

7 Trials Examining Treatment of Hypertension in the Elderly EWPHE MRC-Elderly SHEP STOP-H Syst-China Syst-Eur (N = 840) (N = 4396) (N = 4736) (N = 1627) (N = 2394) (N = 4695) Stroke reduction, % CAD change, % CHF reduction, % -22 Not stated % of Patients receiving (b-blocker) combination drug therapy 38 (diuretic) Prisant, Moser M. Arch Int Med 2000; 160:284

8 The Trial: International, multi-centre, randomised double-blind placebo controlled Inclusion Criteria: Exclusion Criteria: Aged 80 or more, Standing SBP < 140mmHg Systolic BP; mmHg Stroke in last 6 months + diastolic BP; <110 mmhg, Dementia Informed consent Need daily nursing care Primary Endpoint: All strokes (fatal and non-fatal) + Perindopril 4 mg + Perindopril 2 mg Indapamide SR 1.5 mg Placebo Placebo Target blood pressure 150/80 mmhg + Placebo + Placebo M-2 M-1 M0 M3 M6 M9 M12 M18 M24 M60 8

9 Baseline data Placebo (n= 1912) Active (n= 1933) Age (years) Female 60.3% 60.7% Blood Pressure: Sitting SBP (mmhg) Sitting DBP (mmhg) Orthostatic Hypotension 8.8% 7.9% Isolated Systolic Hypertension 32.6% 32.3% 9 Fall in SBP 20mmHg and/or fall in DBP 10mmHg

10 Baseline Data (Previous Cardiovascular History) Placebo (%) Active (%) Cardiovascular disease Known Hypertension Anti-hypertensive treatment Stroke Myocardial Infarction Heart Failure

11 Blood pressure separation mmhg Blood Pressure (mmhg) Median follow-up I 1.8 years Placebo Indapamide SR +/- perindopril mmhg Follow-up (years) 11

12 All stroke (30% reduction) Fatal Stroke (39% reduction) 12

13 Total Mortality (21% reduction) Heart Failure (64% reduction) 13

14 Cautions Subjects recruited generally healthier than those within a general population Large and significant benefit in reduction of heart failure events and for combined endpoint of cardiovascular events Benefits seen early Target blood pressure was 150/80 mmhg Benefit from lower targets still needs to be established 14

15 Treatment Recommendations for the Elderly in JNC 7 Recommendations are no different according to age for: BP classification BP goals Lifestyle interventions Selection of medications

16 Recommendations for Prevention and Management of IHD: BP Targets Patient Type Goal BP (mm Hg) Left ventricular dysfunction <120/80 Diabetes mellitus <130/80 Chronic renal disease <130/80 Coronary artery disease <130/80 Carotid artery disease <130/80 Peripheral artery disease <130/80 Abdominal aortic aneurysm <130/80 High risk (10-y FRS >10%) <130/80 Uncomplicated hypertension <140/90

17 How far should BP be lowered in the elderly? Trial Starting BP Final BP HOT EWPHE SHEP Syst-Eur Conclude: No evidence to support lowering BP to<140 mmhg Goal to achieve a target BP of <140/ 90 mm Hg.

18 Exceptions to the Goal SBP< SBP < 150 with 1-2 drugs, further intensification to lower SBP <140 could be considered 2. SBP > 150 Despite taking a regimen of 4 medications Unacceptable side effects, in particular postural changes DBP < Under these circumstances, lowest safely achieved SBP > 150 is acceptable. Aronow. Guidelines for HTN in the Elderly JACC 2011:

19 If the standing blood pressure is consistently much lower than the sitting blood pressure, the standing blood pressure should be used to titrate drug dosages during treatment. National High Blood Pressure Education Program Working Group Report on Hypertension in the Elderly.

20 20 Copyright 2011 American College Aronow, of Cardiology W. S. Foundation. et al. J Restrictions Am Coll may Cardiol apply. 2011;57:

21 Conclusions Evidence supports benefit of BP control in elderly patients with significant decreases in total mortality, stroke, CV events. Lifestyle interventions need to be instated. Target BP of <140/ 90 mm Hg, <145 if 80 yrs Future Research Working definition of elderly Establish BP values: diagnosis and treatment targets Which drugs most effective for reduction of CV events

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