Workshop hypertension: approach in the elderly patient Johan Rosman Renal Physician and Specialist in Hypertension North Shore Hospital and the Apollo Health Centre North Shore Auckland

Case Conny is a 72 year old active widow She stopped smoking 5 years ago and uses NSAIDs for osteoarthritis She has a strong family history of hypertension Recently her BP increased, you measure 174/98. She would like to know if it is really worth treating this

Questions What are the risks and benefits of treating her BP ? Which agents are most appropriate ? Does her age put her at any particular risk apart from medication ?

Facts Syst BP rises with age, diast only till age 60, after which it tends to decrease. So syst HT is very common in the elderly, this is caused by decreased compliance of the vascular bed The elderly have significant alterations in salt sensitivity, enhanced sympathetic nervous system activity and baroreceptor responsiveness (orthostatic hypotension, especially when overtreated !) HT is the singlemost important modifiable risk factor for vascular disease in the elderly Up to 90% of the elderly people are hypertensive (is this a physiological response ?) 25% of the elderly found with hypertension actually have ‘office-white coat’ hypertension (overtreatment risk !) Elderly are more prone and at risk to suffer from side effects (e.g. falls)

Benefits ? Decrease of heart failure with 50% Decrease of stroke with 35% Decrease of Myocardial infarcts with 25% Slower progression of cognitive decline BUT: Balance that with the life expectancy and the risk of side effects !!!

Causes of secondary HT in the Elderly Obstructive Sleep Apnoea Renovascular disease or chronic kidney disease High alcohol intake Concomitant medications (NSAIDs, decongestants, etc) Endocrine: Mineralocorticoid excess Thyroid disease Hyperparathyroidism Steroid use or Cushing’s syndrome

Diagnostic steps, global views ECG, chest X-ray Plasma levels of B-type natriuretic peptide (BNP) or NT-proBNP (I have my doubts here, would rather go with clinical impression) Renal function/proteinuria Carotis artery intima thickness excellent surrogate marker for developing atherosclerosis Fundi !!

Drug use – evidence based For all drugs: start on a low dose and titrate up, Elderly patients ‘good old – old fashioned drugs best’ If our aim is 140/90: start on thiazide (problems: diabetes, gout, hyperkalaemia). Chlortalidone in the elderly to be excluded as more neagtive metabolic impact. Dihydropyridine CCB’s are as effective but have more side effects ACE/ARB in the elderly were always used if there is a second reason to use them, e.g. heart failure, proteinuria, diabetes, post MI. Recent trials suggest a more prominet place in the elderly for ACE/ARB as they are well tolerated and have few side effects. Beta blockers not attractive unless other indications as angina at the same time

Diagram treatment options Sec causes CV risk assessment Target organ damage Special group: Alpha blockers in elderly men with BPH Alpha methyldopamin

My personal view ? We OVERTREAT our elderly with antihypertensives as well as with lipid lowering agents. We contribute with that to falls, stroke and side effects impacting quality of life After discharge from a hospital a careful review of medication changes that took place is warranted, a cut back is likely !!

New Case Jessica is a 82 year old woman, managing well at home and taking care of her husband Stroke 2 years ago, remains with mild residual left sided weakness, mobile with stick Med: thiazide, inhalers for COPD, and aspirin 100 mg OD She is a non-smoker, no overweight eGFR is 48 ml/min, electrolytes normal You find her to have persistenly a systolic BP of 160/74

Questions Is it beneficial to treat this level of BP at her age ? Are there any risks from drug treatment to lower her BP ? Which agents are most useful in this age group ?

Facts Most hypertension trials have excluded the elderly and those with significant co –morbidities Those that were done until recently only with diuretics There is good evidence for a relationship between the BP and survival in the elderly But; low BP, especially diastolic is associated with lower survival, so small bandwidth to operate in Most clinical trial have confirmed this, with reduction of stroke and heart failure with 30-40% and MI with 25% but the treatment itself increased mortality The treshold for treatment is higher than in younger people The aim should be: consider treatment if syst BP is over 160, but do not work towards a syst BP lower than 140 !

Benefits-studies (1) ANBP Study (Oz) recruited 6083 pat aged 64-84. Randomised to enalapril or HCT follow up for median time of 4.1 years Compared to HCT, the hazard ratio for any CV event was 0.89 in the ACE group But: the protection of the ACE inhibitor was only significant in men !

Benefits-studies (2) SCOPE trial (Study of COgnition and Prognosis in the Elderly) had 5000 pat aged 70-89 years with SBP 160-180 or DBP 90-99 Randomised to candesartan or diuretic In candesartan group reduction of MAP of 22 mmHg against 18 in diuretics Marked reduction in stroke in candesartan but no decrease in overall CV event rate Cognitive functional decline similar in both groups over the 3.7 years of follow up

Benefits-studies (3) HYVET (HYpertension in the Very Elderly Trial) very recently finished 4000 Patients over 80 with SBP > 160 Randomised to indapamide 1.5 mg or placebo If needed perindopril was added in treatment group 21% reductions of death from any cause, CV deaths reduced by 23%, Stroke by 30%, Heart failure by 64% over 2 years with a MAP reduction of 15 mmHg In a 5 year follow up the advantages of treatment are less obvious

SBP > 160 BALANCE: Est. longevity Risk of CV event In next 2-5 yrs Quality of Life End organ damage Target SBP>140

Target SBP > 140 Treatment Preference Monitor U/E Diuretics Less metabolic risk Indapamide ACE / ARB LVH, CCF, CKD If dementia risk CCB Angina or MI Beta Blockers Caution if DBP<80