Best Practices in the Management of Hypertension in Older Adults George Dresser, MD, PhD, FRCPC Associate Professor of Medicine Division of Clinical Pharmacology, Western U.
Speaker Disclosure Form George Dresser I have had in the past 2 years, a financial interest, arrangement or affiliation with one or more organizations that could be perceived as a direct/indirect conflict of interest in the content of the subject of this or any other program. 1. Grant / Research Support Abbott, Boehringer Ingelheim, Heart and Stroke Foundation Ontario, Merck 2. Speaker s Honorarium Abbott, Astra, Boehringer Ingelheim, Bristol Myers Squibb, Merck, Novartis, Pfizer, and Servier
Workshop objectives 1. Discuss the rationale for changing blood pressure targets and optimal anti-hypertensive medications 2. Describe an approach to orthostatic hypotension
Proportion of Deaths Attributable to Leading Risk Factors Worldwide (2000) 0 1 2 3 4 5 6 7 8 Attributable Mortality WHO 2000 Report. Lancet. 2002;360:1347-1360.
Annual rate/1000 OXVASC community-based acute stroke and acute MI 45 40 35 30 25 20 15 10 5 0 45-54 55-64 65-74 75-84 85+ CAD CVD Rothwell PM et al. Lancet 2005
Risk factors for stroke Risk vs prevalence Hypertension 35% Hyperlipidaemia 27% Smoking 27% Percentages indicate prevalence Inactivity 27% Obesity 18% Carotid stenosis 4% Atrial fibrillation 2% 0 1 2 3 4 5 6 7 8 9 10 Alberts. Curr Med Res Opin 2003;19:438 441 Relative risk
Impact of Risk factors on Stroke Risk Prevalence % Pop. AR % Relative Risk Factor Hypertension Age 50 y 20 40 4.0 Age 60 y 30 35 3.0 Age 70 y 40 30 2.0 RRR 38% Smoking 25 12 18 1.8 50% Diabetes 7.3 5 27 1.8 6 5% Obesity 17.9 12 20 1.8 2.4 Unknown Goldstein et al. AHA/ASA Guideline: Primary Prevention of Ischemic Stroke. Circulation.2006; 113: e873-e923doi: 10.1161/
Case #1 70 yo male patient new to your practice. Presents because his blood pressure was noted to be 168/80 in the pharmacy His wife just had a stroke and is in Rehab He is asymptomatic He has no history of CV end organ damage Age of onset was likely ~ 50, no obvious secondary causes On no medications Seems motivated
Case #1 BP History Step 1: Is he symptomatic from hypertension? o Confusion o Headache o Dyspnea/CHF o Chest pain Step 2: Does he have secondary hypertension? Step 3: What can he do non-pharmacologically to help control his BP? o Salt reduction strategies o Exercise strategies o Everything else Step 4: Compelling reasons for specific pharmacotherapy
Case #1 BP Physical Step 1: Evaluate BP o In clinic: Both arms, orthostatic, and possibly the legs o Pattern assessment: repeat clinic, versus HBPM, versus ABPM Step 2: Assessment of target organ damage? o Cognitive impairment, PRES, stoke o Retinopathy o Vascular disease o LVH o Endocrine hypertension
Consider aggravating causes 2 Causes Self-inflicted Doctor-inflicted: Fate Salt Wear a white Obstructive coat (or make sleep apnea patients wait) (mimics pheo/1 Aldo biochemically) NSAIDs Not measure Consider BP correctly Hyperaldosteronism (single in those Stimulants (Street drugs/otc) measurements with/without are not low serum [K] Alcohol adequate) Intrinsic kidney disease Withdrawal reactions Give from drugs: (do a urinalysis for both blood and prescription or non-prescription Glucocorticoids drugs protein or microalbumin/cr ratio) Pain Stimulants Consider RAS in those with NSAIDs atherosclerosis Estrogens/Androgens Thyroid/Parathyroid disease Cyclosporine/EPO (measure TSH and a serum [Ca]) Nasal decongestants Consider other endocrine causes (Pheo, Cushings, Acromegaly, etc)
Back to the Case 70 yo male BP 165-170/80-85 repeated measures No postural drop Asymptomatic Borderline LVH on ECG No other comorbidities Appears to be 1 Hypertension Working at salt reduction Exercise 30 min/day Why give him BP drugs? What is your goal? Can you do this safely? What drugs should you use? What is the evidence they work? How many will he need? How should they be followed up?
How I talk to the patient about BP Drugs 70 yo male BP 165-170/80-85 repeated measures No postural drop Asymptomatic Borderline LVH on ECG No other comorbidities Working at salt reduction Exercise 30 min/day If we get you on the right pills, and they successfully lower your BP, we can lower your risk of stroke by half, prevent heart failure, and make your life in the future better. My goal is that you get this benefit while feeling well and experiencing no side effects. I will worry about the side effects, so you don t have too.
What is the target BP? 70 yo male BP 165-170/80-85 repeated measures No postural drop Asymptomatic Borderline LVH on ECG No other comorbidities Working at salt reduction Exercise 30 min/day Is there an optimal BP? 130/80?? Is there an optimal drop in BP? -20/-10?? Is the BP/Benefit curve J-shaped? Harm at the lowest levels?? Should we target the systolic, or the diastolic BP, or both??
Evidence-based Annual Recommendations The Canadian Hypertension Education Program is central to Hypertension Canada CHEP is known as the most credible source for evidence-based chronic disease management recommendations with annual updates, a well-validated review process and effective dissemination techniques across Canada Canada has the world s highest reported national blood pressure control rates
CHEP 2013 Committee
The HYpertension in the Very Elderly Trial N. Beckett, R. Peters, A. Fletcher, C. Bulpitt on behalf of the HYVET committees and investigators ClinicalTrials.gov: NCT00122811
HYVET Blood pressures BP throughout trial BP target group Active Placebo SBP (mm Hg) Baseline 173 173 Achieved 143 158 Difference 30 15 DBP (mm Hg) Baseline 91 91 Achieved 78 84 Difference 13 7 Lancet. 2009 May 30; 373(9678): 1849 1860.
Blood Pressure (mmhg) Blood pressure separation 180 170 15 mmhg 160 150 140 130 120 110 100 90 80 70 Median follow-up I 1.8 years 0 1 2 3 4 5 Follow-up (years) 6 mmhg Placebo Indapamide SR +/- perindopril
All stroke (30% reduction) No. at Risk Placebo 1912 1484 807 374 194 IndapamideSR perindopril 1933 1557 873 417 229
Total Mortality (21% reduction) No. at Risk Placebo 1912 1492 814 379 202 IndapamideSR perindopril 1933 1565 877 420 231
Heart Failure (64% reduction) No. at Risk Placebo 1912 1480 794 367 188 IndapamideSR perindopril 1933 1559 872 416 228
HYVET Conclusions In a group of patients with an initial mean age of 84 and BP of 173/91, targeting an SBP < 150, and achieving a BP of 143/78, resulted in substantially better outcomes than if achieved BP is 158/84 Addition of a simple diuretic/acei combination drug to Very Elderly patients prevented problems they care about: o Heart Failure: You will end up spending hours in ER with puffy legs and the oxygen hose in your nose o Stroke o Death
Japanese Trial to Assess Optimal Systolic Blood pressure in Elderly Designed to compare target SBP < 140 to a target of 140-160 4418 Japanese patients with 1 HTN and age 65-85 enrolled in PROBE design Mean baseline blood pressure 172/89 Mean age 74 Average follow up 2 years Hypertens Res 2008; 374: 525 33
JATOS Primary outcome Hypertens Res 2008; 374: 525 33
JATOS conclusions Patients aged 65-85 (mean 74) with a baseline BP of 172/89 down to did equally well if their BP was lowered to 146/78 or 136/75 Patients under the age of 75 seemed to be better if assigned to strict control, and those over the age of 75 seemed better if assigned to mild (Hyvet style) treatment Rates of 1 Outcome Hypertens Res 2008; 374: 525 33
BP treatment in the elderly Rule out significant orthostatic BP drop If patient is over age 80, target SBP<150 If patient is under age 75, target SBP<140
CHEP Recommendation: the very elderly III. Choice of Therapy for Adults With Hypertension without Compelling Indications for Specific Agents B) Recommendations for Individuals with Isolated Systolic Hypertension New Recommendation for 2013 ADD: In the very elderly (age 80 years and older), the target for systolic BP should be < 150 mmhg (Grade C).
Back to the Case 70 yo male BP 165-170/80-85 repeated measures No postural drop Asymptomatic Borderline LVH on ECG No other comorbidities Working at salt reduction Exercise 30 min/day Why give him BP drugs? What is your goal? Can you do this safely? What drugs should you use? What is the evidence they work? How many will he need? How should they be followed up?
Studies of BP Drugs in the Elderly Drug Class Thiazide diuretics CCB-DHP ARB ACE-I Study SHEP, HYVET Syst-Eur MOSES, LIFE HYVET, ANBP
Case Conclusion 70 yo male BP 165-170/80-85 repeated measures No postural drop Asymptomatic Borderline LVH on ECG No other comorbidities Working at salt reduction Exercise 30 min/day Given that BP is > 20 mm Hg above target, he will require 2 or 3 medications My option A (No concerns about CHF or leg edema): o Start with ARB/DHP combination, half dose o If necessary add half dose diuretic My option B: o Start with ARB/ACEi in combination with diuretic o Add DHP if necessary
Case 2 80 yo male Coming home from hospital after 3 rd bad fall this year broken pelvic bone Note from medical student at hospital: He had hypertension throughout hospitalization which was attributed to pain please reassess in clinic His clinic BP s recorded 3 times over last year 135/68, 146/72, 138/70 Today it is 138/68 Two years ago another doctor tried him on amlodipine 5 mg daily he felt rotten and stopped it. He describes excessive nocturia
Case 2 80 yo male 3 rd bad fall this year Hypertension in hospital Clinic BPs 135-146/68-72 Has DM2 with mild neuropathy Taking amitriptyline 10 mg qhs and terazosin for urination Has excessive nocturia What should you do: 1. Consult psychogeriatrics 2. Consult geriatrics 3. Refer to Dr. Dresser 4. Move your office so it is up one flight of stairs 5. Cancel the rest of your clinic and do a proper assessment of postural BPs
80 yo male 3 rd bad fall this year Hypertension in hospital Clinic BPs 135-146/68-72 Has DM2 with mild neuropathy Taking amitriptyline 10 mg qhs and terazosin for urination (both started recently in hospital) Patient describes excessive nocturia Case 2 After lying supine for 5 minutes, blood pressure is recorded at 184/80 After sitting for 1 minute, BP is 138/68 After standing 1 minute, BP is 104/60 After standing 3 minutes, patient collapses with BP recorded at 94/58
ASH Position Paper: Evaluation and Treatment of Orthostatic Hypotension The Journal of Clinical Hypertension Volume 15, Issue 3, pages 147-153, 14 JAN 2013 DOI: 10.1111/jch.12062 http://onlinelibrary.wiley.com/doi/10.1111/jch.12062/full#jch12062-fig-0001
The American Journal of Medicine, Vol 120, No 10, October 2007, pp 841-847
Case 2 80 yo male 3 rd bad fall this year Supine Hypertension Standing Hypotension DM2 with neuropathy amitriptyline 10 mg qhs for neuropathy terazosin for urination Excessive nocturia What are the goals of treatment in this man? What causes him to have nocturia? What are you more afraid of?: o Supine Grade III HTN o Standing hypotension Is it possible treat both the hypertension and the hypotension simultaneously?
Non-Drug Management Orthostatic Hypotension Withdraw offending medication (either substitution or discontinuation) Rise slowly from supine to sitting to standing position Avoid straining, coughing, and prolonged standing in hot weather Cross legs while standing Squat, stooping forward Raise head of bed 10 to 20 degrees Small meals and coffee in the morning Elastic waist high stocking Increase salt and water intake Exercise, eg, swimming, recumbent biking, and rowing The American Journal of Medicine, Vol 120, No 10, October 2007, pp 841-847
Management of Supine Hypertension/Nocturesis Raise head of bed 10 to 20 degrees Short acting antihypertensive at bed-time o Clonidine o Captopril Commode at bedside to avoid upright posture when lights are turned down/off
Drugs for Orthostatic Hypotension Drug Dose Contraindication Common Side Effects Fludrocortisone Midodrine Initial: 0.1 mg daily Max.: 1 mg daily Initial: 2.5 mg tid Max.: 10 mg tid Hypersensitivity IHD, CHF, urinary retention, thyrotoxicosis, acute renal failure Ibuprofen 400-800 mg tid Hypersensitivity to NSAIDs, active bleeding, impaired renal function Supine hypertension, hypokalemia, HF, headache Supine hypertension, piloerection, pruritus, paresthesia GI intolerance, bleeding, headache, dizziness, renal insufficiency Caffeine 100-250 mg daily Hypersensitivity GI irritation, I nsomnia, agitation,nervousness Erythropoietin 25-75 U/Kg tiw Uncontrolled hypertension Stroke, myocardial infarction, hypertension
Back to Case 2 80 yo male 3 rd bad fall this year Supine Hypertension Standing Hypotension DM2 with neuropathy amitriptyline 10 mg qhs for neuropathy terazosin for urination Excessive nocturia Goal: Improve Function! Step 1: Stop amitriptyline Step 2: Stop terazosin Step 3: Head of bed under 1 or 2 bricks Step 4: Compression stockings thigh/waist high Step 5: Clinically reassess +/- ABPM
Back to Case 2 80 yo male 3 rd bad fall this year Supine Hypertension Standing Hypotension DM2 with neuropathy amitriptyline 10 mg qhs for neuropathy terazosin for urination Excessive nocturia Goal: Improve Function! Step 6: If volume status low, fludrocortisone or water/salt Step 7: If volume up, Caffeine, then midodrine q4h prn while planning to be up must not take within 4 hours of being upright
Back to Case 2 80 yo male 3 rd bad fall this year Supine Hypertension Standing Hypotension DM2 with neuropathy amitriptyline 10 mg qhs for neuropathy terazosin for urination Excessive nocturia Goal: Improve Function! If omidodrine 10 mg TID Then ocall CMPA Midodrine should not be prescribed without careful instructions about how to use safely
80 yo male 3 rd bad fall this year Supine Hypertension Standing Hypotension DM2 with neuropathy amitriptyline 10 mg qhs for neuropathy terazosin for urination Excessive nocturia Back to Case 2 Goal: Improve Function! If ABPM shows significant supine hypertension Then start clonidine 0.1 to 0.4mg qhs o Monitor nocturia o Alternate: Captopril 6.25 25 mg qhs All antihypertensives should be given at bed time!!
Workshop objectives 1. Discuss the rationale for changing blood pressure targets and optimal anti-hypertensive medications 2. Describe an approach to orthostatic hypotension