1. Are the European Practice Guidelines for the Management of Arterial Hypertension (2007) adapted to the old and the frail? Anette Hylen Ranhoffahranhoff@yahoo.no MD PhD, Medical Department, Diakonhjemmets Hospital, Oslo Kavli’s Research Centre for Ageing and Dementia, Bergen GerIT 19.08.2008

2. Hypertension – mainly a risk factor, not responsible for symptoms When should it be treated and how – in the old and the frail ? Risk factor for:  Stroke (1 SD SBP: RR 1.59) Rotterdam studien, Mattace-Raso FU, JAGS 2004  Myocardial Infarction (1 SD SBP: RR 1.24) Rotterdam studien, JAGS 2004.  Cardiac failure (LVH and post infraction)  Renal failure (hypertensive renal disease)  Dementia (Vascular and Alzheimer) – but when dementia is progressing BP is falling Skoog I 2001

3. Hypertension in the old and the frail: Still few studies which include patients 85+ years The study patients are mainly robust elderly with low comorbidity A high proportion of the 80+ patients are frail and with a high comorbidity. Heterogenity in elderly patients (age, comorbidity, function) Life expectancy is high - and increasing

4. What we need to know: How to assess the patients: measure BP, other assessment BP limits according to risk Indications for drug treatment What drugs? Treatment goals

5. Sub-group analyses - meta-analyse > 80 yrs, N=1670 RCT Gueyffier F. Bulpitt C. et al, Lancet 1999 34 % risk reduction for stroke NNT 1 per 100 patients treated one year 22 % risk reduction for myocardial infarction 39 % risk reduction fro cardiac failure No risk reduction for cardiovascular death or total death

6. 3845 patients from Europe, China, Australasia, and Tunisia who were 80 years of age or older and had a sustained systolic blood pressure of 160 mm Hg or more to receive either the diuretic indapamide (sustained release, 1.5 mg) or matching placebo. The angiotensin-converting-enzyme inhibitor perindopril (2 or 4 mg), or matching placebo, was added if necessary to achieve the target blood pressure of 150/80 mm Hg. The primary end point was fatal or nonfatal stroke. At 2 years, the mean blood pressure while sitting was 15.0/6.1 mm Hg lower in the active-treatment group than in the placebo group. 30% reduction in the rate of fatal or nonfatal stroke (95% confidence interval [CI], -1 to 51; P=0.06) 39% reduction in the rate of death from stroke (95% CI, 1 to 62; P=0.05) 21% reduction in the rate of death from any cause (95% CI, 4 to 35; P=0.02) 23% reduction in the rate of death from cardiovascular causes (95% CI, -1 to 40; P=0.06) 64% reduction in the rate of heart failure (95% CI, 42 to 78; P<0.001). Fewer serious adverse events were reported in the active-treatment group (358, vs. 448 in the placebo group; P=0.001). CONCLUSIONS: The results provide evidence that antihypertensive treatment with indapamide (sustained release), with or without perindopril, in persons 80 years of age or older is beneficial. Beckett et al. N May 2008

7. “Elderly” is mentioned 12 times

8. Independent of age

9. In the largest meta-analysis of observational data available today (61 studies in almost 1million subjects without overt cardiovascular disease, 70% europeans Lancet 2002 : Both systolic and diastolic blood pressures were independently and similarly predictive of stroke and coronary mortality, and the contribution of pulse pressure was small, particularly in individuals aged less than 55 years. By contrast, in middle aged and elderly hypertensive patients with cardiovascular risk factors or associated clinical conditions, pulse pressure showed a strong predictive value for cardiovascular events. Systolic vs diastolic and pulse pressure

10. ”All patients should be classified not only in relation to the grades of hypertension but also in terms of the total cardiovascular risk resulting from the coexistence of different risk factors, organ damage and disease.”

11. AGE > 55 years in Men and 65 years in female is a risk factor (Organ damage)

12. Conclusions Treatment of SH in older patients with SBP of at least 160 mmHg is supported by strong evidences. The evidence available to support treatment of patients to the level of 140 mmHg or those with baseline SBP of 140 to 159 mmHg is less strong; thus, this treatment decisions should be more sensitive to patient preferences and tolerance of therapy.

13. Blood Pressure and Survival in the Oldest Old Journal of the American Geriatrics Society 2007, 55 (3), 383–388. Oates DJ et al. In a cohort of very old (80+yrs), hypertensive veterans, in subjects with controlled BPs (<140/90), subjects with lower BP levels had a lower 5-year survival than those with higher BPs. This suggests that clinicians should use caution in their approach to BP lowering in this age group. All patients were controlled to < 140/90 – but don’t push it too far….. Treatment goals

14. Diagnostic procedures aim at: 1)establishing blood pressure levels 2)identifying secondary causes of hypertension 3)evaluating the overall cardiovascular risk by searching for other risk factors, target organ damage and concomitant diseases or accompanying clinical conditions. The diagnostic procedures comprise: repeated blood pressure measurements medical history physical examination laboratory and instrumental investigations Diagnostic evaluation

17. Premorbid status RobustIntermediate Minor functional imp. Substantial Functional imp. Dependent Comorbidity Life expectancy illness/risk factor outcome HYPERTENSION

18. When to initiate antihypertensive treatment?

19. Drug treatment in the elderly Guide by comorbidity –Coronary syndrom: Beta-blocker –Atrial fibrillation in need of reduction of frequency: Beta-blocker –Cardiac failure: ACE-inhibitor or/and beta-blocker, event AII blocker –COPD: Avoid non-selective beta-blockers Start low - go slow Rather two or more drugs in combination than one in high dose Remember to check: electrolytes, creatinin when using ACEI, ARB and diuretics OBS drug interactions Follow up for antihypertensive drug treatment in elderly patients is crucial

20. To achieve maximum reduction in the long-term total risk of cardiovascular disease. Treatment of the raised BP per se as well as of all associated reversible risk factors. BP should be reduced to at least below 140/90 mmHg. Target BP should be at least 130/80 mmHg in diabetics and in high or very high risk patients. Despite use of combination treatment, reducing systolic BP to 140 mmHg may be difficult. Additional difficulties should be expected in elderly and diabetic patients, and, in general, in patients with cardiovascular damage. In order to more easily achieve goal BP, antihypertensive treatment should be initiated before significant cardiovascular damage develops. Treatment goals

21. Blood Pressure and Survival in the Oldest Old Journal of the American Geriatrics Society 2007, 55 (3), 383–388. Oates DJ et al. In a cohort of very old (80+yrs), hypertensive veterans, in subjects with controlled BPs (<140/90), subjects with lower BP levels had a lower 5-year survival than those with higher BPs. This suggests that clinicians should use caution in their approach to BP lowering in this age group. All patients were controlled to < 140/90 – but don’t push it too far….. Treatment goals

22. Conclusions Definitions and classification of BP levels are now independent of age Total cardiovascular risk should decide wether treatment should be given BP in supine posistiton after 1 and 5 mins – and 24 hrs BT are recommended in elderly persons Evidence for benefit of antihypertensive treatment in subjects >80 years with sustained systolic BP >160 mmhg is present! The 2007 guidelines focus particularly on elderly - and correspond better to ”best practice” in geriatric medicine than previous guidelines