Isolated Systolic Hypertension in the elderly Daniel Hayoz Clinique de Médecine Interne HFR-Hôpital Cantonal Fribourg
Case no 1 Man aged 75, from Kosovo, in CH since 1.5 years Former smoker (45 PY) BP: 168/78 mmhg Creat : 121 mmol/l (76 kg/166 cm) Clear: 50ml/min Lipids: LDL 5.6 mmol/l How do you proceed?
Cas no 1 Man aged 75, from Kosovo, in CH since 1.5 years Former smoker (45 PY) BP: 168/78 mmhg: pulse pressure = 90 mmhg Creat : 121 mmol/l (76 kg/166 cm) Lipids: LDL 5.6 mmol/l How do you proceed?
Cas no 1 Man aged 75, from Kosovo, in CH since 1.5 years Former smoker (45 PY) BP: 168/78 mmhg: pulse pressure = 90 mmhg Creat : 121 mmol/l (76 kg/166 cm) Lipids: LDL 5.6 mmol/l AGLA/GSLA: 60%...
Survival Role of initial PP on CV mortality N = 19 083 100 Men; age (> 55 yrs): MAP > 107 mmhg p (Cox)= 0.0043 Corrected for cholesterol and smoking 90 80 1: PP < 45 mmhg 2: PP 45-50 mmhg 3: PP 50-65 mmhg 4: PP > 65 mmhg 1 2 3 4 70 0 2 4 6 8 10 12 14 16 18 20 22 Follow-up (yrs) Benetos A et al. Hypertension. 1997;30:1410-1415.
Prevalence of HTN with age 70 64 65 60 54 % population With HTN 50 40 44 30 21 20 10 4 11 0 18-29 30-39 40-49 50-59 60-69 70-79 80+ Kannel WB. Am J Cardiol. 1996;77(suppl B):6B-11B. Age (years)
Distribution of Hypertension Categories by age 100% 90% 80% 70% 60% 50% 40% 30% HSI Combinée HDI 20% 10% 0% 30-39 40-49 50-59 60-69 70-79 80-89 Sagie et al. NEJM 1993;329:1912-17
Adapté de Franklin SS et al. Circulation 1997;96:308-315
180 160 140 120 100 80 60
Adapté de Franklin SS et al. Circulation 1997;96:308-315
Fibers integrity Aging and large elastic arteries Rupture and degradation of fibers Increased collagen rigidity 1 2 Cardiac cycles (10 9 )
Arterial stiffness and early reflected waves Compliant artery : Normal pulse wave velocity (8 m/sec) Systole Diastole (1) Heart-vessel coupling (2) coronary flow Systole Stiff artery : Elevated pulse wave velocity (12 m/sec) (1) Heart-vessel Mismatch (2) Reflected wave increases systolic central pressure at end of systole Increased afterload with increased risk of LVH Reduced coronary perfusion Increased O2 consumption of myocardium & subendocardial ischemia Increased turbulent flow inducing endothelial dysfunction Increase pulsatile deformation and plaque rupture
Smith a et al. J Am Soc Nephrol 16: 1069-1075, 2005
CHF and pulse pressure CHF Risk of CHF after controlling for age Mean age (78yrs) 55% HT DM 19% CHD 10% Follow up of 3.8 yrs 12% increase in risk/10mmhg SBP Chae CU et al. JAMA 1999;281:634-639
Arterial stiffness Well identified CV risk factors age sex blood pressure (PP>SBP) lipids, smoking, diabetes, Poorly identified CV risk factors Infectioninflammation Low birth weight Genetics... Arterial stiffness = cumulative measure of previous exposure to CV risk factors
Arterial stiffness as a marker of CV risk : Cross-sectional study Risk score (European SCORE, Framingham Risk Score) Arterial stiffness
Case no 1 Man aged 75, from Kosovo, in CH since 1.5 years Former smoker (45 PY) BP: 168/78 mmhg Creat : 121 mmol/l (76 kg/166 cm) Lipids: LDL 5.6 mmol/l How do you proceed?
Case no 2 Woman aged 78 years, in good general condition until 59 ans, when HTN is diagnosed. First treated with b-blocker, then with add. Amlo + HCTZ. Developed a moderate form of Parkinson Disease; and Madopar is introduced when rigidity becomes bothering. For the past 6 mo. several falls without loss of consciousness
What happens? On-off phenomenon due to anti-pd Orthostatic Hypotension Dysautonomia Arrythmia
PD: is a cause of primary dysautonomia HOWEVER: OH is often considered as an exclusion criteria for PD!!! Look for alternative diagnosis
Parkinson disease 20% of patients with PD suffer from OH when tested for orthostatism but it occures quite late..
Cause of OH in PD Medications Antiparkinson drugs Levodopa and dopaminergic agents splanchnic and renal vasodilatation) Reduce vasopressive effect released from CNS Diuretics Antidepressant drugs (imipramine), much less with SSRI
HYVET Trial: Study Design 3845 patients > 80 years with continual hypertension and systolic blood pressure 160 mm Hg prior to randomization Prospective. Randomized. Double Blind. Placebo-Controlled. Mean follow-up 1.8yrs R Active Treatment 1.5 mg Indapamide (SR) n=1933 Placebo Matching Dose n=1912 2 yrs. follow-up Primary Endpoint: fatal and non-fatal strokes Secondary Endpoints: death from: stroke, cardiovascular causes, cardiac causes and any cause Copyleft Clinical Trial Results. You Must Redistribute Slides N Engl J Med 2008;358/ACC 2008
HYVET Trial: Baseline Characteristics Characteristic Active Treatment (n=1933) Placebo (n=1912) Age (years SD) 83.6 3.2 83.5 3.1 Female (%) 1174 (60.7) 1152 (60.3) Blood Pressure (mm Hg) While sitting Systolic Diastolic While standing Systolic Diastolic 173.0 8.4 90.8 8.5 168.0 11.0 88.7 9.3 173.0 8.6 90.8 8.5 167.9 11.1 88.6 9.3
15 mm Hg 6 mm Hg N ENGL J MED 358;18 www.nejm.org may 1, 2008
All strokes (30% reduction) Placebo P=0.055 Indapamide SR ± perindopril Placebo Indapamide SR ± perindopril
Heart failure (64% reduction) Placebo P<0.0001 Indapamide SR ± perindopril Placebo Indapamide SR ± perindopril
ITT results
% 0 1 2 3 4 Time since randomisation (years) Staessen J et al. Lancet 1997; 350: 757 64
Major Clinical Trials Showing Benefit of Treating Isolated Systolic Hypertension SHEP Syst-Eur Syst-China (n=4736) (n=4695) (n=2394) Baseline 160-219/ 160-219/ 160-219/ SBP/DBP (mm Hg) <90 <95 <95 BP reduction: 27/9 23/7 20/5 SBP/DBP (mm Hg) Drug therapy Chlorthalidone Nitrendipine Nitrendipine Atenolol Enalapril Captopril HCTZ HCTZ Outcomes (%) Stroke 33 42 38 CAD 27 30 27 CHF 55 29 All CVR disease 32 31 25 Journal of Clinical Hypertension Vol II, No. 5, page 336, September/October 2000.
Benefit of the treatment of ISH Fatal and nonfatal coronary events Staessen JA et al. Lancet 2000;355:865
GERD and dependent variables. Friedenberg FK et al. Dig Dis Sci 2010:55; 1911-1917
Algorithm for Management of the Elderly Primarily Systolic Hypertension 1) Lifestyle changes 2) Low dose diuretic (12.5 mg HCTZ) CCB B-Blocker ACE or ARB 3) It takes time do not change dosages to early Let the Baroreceptors reset
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Thank you for your attention
Composantes dynamiques de la pression artérielle systolique Résistance (P = Q. R) Ondes de réflexion Rigidité artérielle (compliance) diastolique
Diminution de la compliance artérielle Découplage coeur-vaisseaux Dommage vasculaire Intima Dysfonction endothéliale) Media (altération de la fonction d amortissement) Accélération athérogenèse Favorise rupture de plaque Augmente vasoconstriction Diminution de la réserve vasodilatation Favorise thrombogenèse Evénements cardiovasculaires Pression Systolique Pulse pressure Pression Diastolique Ischémie Hypertrophie VG Insuffisance cardiaque Impedance
Introduction Elevated risk of CVD together with increased prevalence of hypertension is the leading cause of mortality in the western world An age-related increase in arterial stiffness results in an increase in systolic blood pressure (SBP) and left ventricular hypertrophy. It is also a strong predictor of CVD-associated mortality in patients with hypertension
Very old patients > 80 yrs (primary end point: stroke) Treatment better Control better 0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 SHEP SHEP-Pilot STOP Syst-Eur Double-blind trials COOPE CASTEL Open label trials Total RR=0.64, p=0.01 RR=0.85, p=0.75 RR=0.67, p=0.01 Gueyffier Lancet 1999