1. HYPERTENSION Suggestions for Lecturer -1-hour lecture
-Use GRS slides alone or to supplement own teaching materials.
-Refer to GRS for further content, including strength of evidence (SOE) levels.
-Supplement lecture with handouts.
-See GRS8 questions 100, 122, 129, 316, and 328 for case vignettes on hypertension.
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2. OBJECTIVES
Know and understand:
How the diagnosis and treatment of hypertension differ in older adults
When to recommend lifestyle modification
How to choose among the various classes of antihypertensive agents
The principles of adjusting therapy

3. TOPICS COVERED Epidemiology and Physiology Clinical Evaluation
Treatment
Lifestyle Modification
Pharmacologic Treatment
Follow-up Visits
Special Considerations
Hypertensive Emergencies and Urgencies
Hypertension in the Long-term-care Setting

4. EPIDEMIOLOGY
BP increases with age, especially SBP and pulse pressure (difference between SBP and DBP)
67% of non-institutionalized Americans ≥60 years have hypertension (HTN):
Highest among blacks
Higher in women than men
BP is poorly controlled in many older people despite treatment
According to the National Health and Nutrition Examination Survey (NHANES) 1999– 2004, 67% of the noninstitutionalized adults ≥60 years old had hypertension, which was significantly higher than the 58% reported in NHANES III (1988–1994). Although hypertension prevalence increased in all age groups, in both sexes, and in non- Hispanic whites and non-Hispanic blacks, the increase was greatest among older black Americans, especially women.
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5. CLASSIFICATION OF BP LEVELS
Category
Systolic
(mm Hg)
Diastolic
Normal
<120
and
<80
Prehypertension
120–39 or
80–89
Hypertension
Stage 1
Stage 2
140–159
>160
90–99
>100
NOTE: Diagnoses should be based on the average of two or more readings taken at each of two or more visits after an initial screening.
SOURCE: Data from JNC 7 Express: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, MD: National High Blood Pressure Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health, US Department of Health and Human Services; May 2003:3 (Table 1).
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6. PHYSIOLOGIC CHANGES WITH AGE
Increased arterial stiffness
Decline in baroreflex sensitivity
Increase in sympathetic nervous system activity
Heightened vasoconstriction
Alterations in renal function and neurohumoral systems involved in sodium balance  sodium-sensitive HTN
In addition to the increase in blood-pressure level, blood-pressure dysregulation in aging renders older adults at increased risk of orthostatic and postprandial hypotension. Maintaining normal blood pressure and cerebrovascular and coronary perfusion in the face of hypotensive stimuli related to postural challenge, meals, or medications requires the integrated coordination of multiple compensatory mechanisms both centrally and peripherally.
The age-associated decline in baroreflex sensitivity and changes in sympathetic nervous system function impair the dynamic regulation of blood pressure. Because of the blunted sensitivity of the baroreflex, a greater decrease in blood pressure occurs before the increase in heart rate and other compensatory mechanisms are activated.
Other pathophysiologic changes that impair blood-pressure regulation include arterial and cardiac stiffness and a decrease in early diastolic filling. Finally, changes in the circadian control of blood pressure predisposes older adults to higher relative night- time blood pressure and greater early morning blood-pressure rise, both leading to increased risk of stroke and myocardial infarction.
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7. DIAGNOSIS OF HYPERTENSION
Use the average of several readings taken at each of 2-3 visits
Consider ambulatory BP monitoring for patients with extreme BP variability or possible “white coat” HTN
Determine SBP by palpation to avoid auscultatory gap
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8. CLINICAL EVALUATION Exclude secondary forms of HTN
Identify target organ damage
Determine CVD risk factors and identify comorbidities
Inquire about lifestyle (smoking history, dietary intake of sodium and fat, alcohol intake, physical activity, social stressors)
Although most older patients have essential hypertension, secondary forms of hypertension should be suspected in the presence of malignant hypertension, a sudden increase in diastolic blood pressure, worsening level of control, or poorly controlled blood pressure on a regimen of three antihypertensive medications. Renovascular disease is the most common secondary form of hypertension among older patients.
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9. BENEFITS OF TREATMENT
Treatment reduces overall mortality, CVD events, heart failure, and stroke
Mortality benefit has been consistently demonstrated in those between years old
The Hypertension in the Very Elderly Trial (HYVET) study also showed decreased mortality in those older than 80 years
Until the Hypertension in the Very Elderly Trial (HYVET) study was completed in 2007, few participants in randomized controlled trials of hypertension treatment were >80 years old and almost none were >85 years old. This randomized controlled trial of 3,845 participants >80 years old ended early when its data safety monitoring board identified a significant 21% reduction in total mortality (10.1% vs. 12.2%, absolute risk reduction 2.2%, number needed to treat = 45 over a median of 1.8 years) in the intervention group (extended-release indapamide plus perindopril if needed to achieve a goal systolic blood pressure of 150 mm Hg) relative to the placebo control group (relative risk [RR] 0.76; 95% confidence interval [CI], 0.62–0.93; P=.007). The treatment group also demonstrated improvements in fatal and nonfatal stroke (RR ; 95% CI, 0.40–0.88; P=.009) and heart failure and reported fewer adverse events.
It is important to note that the participants in this trial were generally healthy, community-living older adults. Those with dementia, living in nursing homes, or an inability to walk were excluded. The study design also required participants to have a standing blood pressure above 140 mm Hg at entry into the trial. For these reasons, the HYVET study results cannot be generalized to apply to frail, very old individuals. A HYVET substudy that assessed cognitive function and the rate of dementia developing in study participants, HYVET-COG, identified similar rates of incident dementia in the treatment and control groups.
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10. TREATMENT TARGETS
Balance benefits of treatment with potential impact on functional status and quality of life
Treatment approach to target:
SBP < 140 mm Hg
DBP < 90 mm Hg
Diabetics: same target as above
It is clear that any increase in blood pressure above normal (>115/80 mm Hg) is positively and linearly associated with morbidity and mortality, but some studies have shown increased mortality with blood-pressure reduction—especially diastolic blood pressure (<50 mm Hg)—below a certain threshold, creating a J-shaped curve in relation to mortality. The significance of these concerns remains controversial.
The relationship has been evaluated in older participants enrolled in the Systolic Hypertension in the Elderly Trial. This post hoc analysis suggested that an on- treatment diastolic blood pressure <50 mm Hg was associated with more cardiovascular events only in those with a history of underlying coronary heart disease. Cardiovascular mortality was not increased as a function of lower diastolic pressures to as low as 55 mm Hg, but hazard ratios were higher for noncardiovascular mortality. It therefore seems reasonable to attempt to avoid excessive reductions in diastolic blood pressure (eg, diastolic levels <70 mm Hg), especially in individuals with coronary heart disease.
Treatment should focus on systolic blood pressure because among older hypertensive adults, it is a stronger predictor of adverse outcomes than diastolic blood pressure. The systolic blood pressure alone correctly classifies the blood-pressure stage of >99% of older hypertensive adults. In addition, analysis of data from the Systolic Hypertension in the Elderly Trial demonstrates a significant relationship between pulse pressure and the risk of stroke and overall mortality that is independent of the level of mean arterial pressure.
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11. LIFESTYLE MODIFICATION
Adjunct to drug therapy for all hypertensive patients
Components:
Weight reduction
Increased physical activity
Stress reduction
Reduction in sodium intake
Increased intake of potassium in the form of fruits and vegetables
The randomized Trial of Nonpharmacologic Interventions in Elderly study, which evaluated the effects of dietary sodium restriction and weight loss in older adults, demonstrated that relatively modest reductions in dietary sodium intake (1.8 g/day) and in body weight (4 kg) are accompanied by a 30% decrease in the need to reinitiate pharmacologic treatment. A meta-analysis of randomized trials assessing the effects of dietary sodium restriction demonstrated a significant reduction in systolic blood pressure (a mean decrease of 3.7 mm Hg for each decrease of g/day of sodium) but not in diastolic blood pressure. This differential reduction in systolic blood pressure is particularly well suited for the older hypertensive patient.
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12. GENERAL TREATMENT RECOMMENDATIONS FOR HYPERTENSION
Begin with a nonpharmacologic approach
Base drug selection or combination therapies on individual patient characteristics
Diuretics ( thiazide-like), calcium channel blockers, ACEI or ARBs can all be used as initial therapy.
When starting drug therapy, begin at half the usual dosage, increase dosage slowly, and continue nonpharmacologic therapies
Gauge treatment goals by SBP
Avoid excessive reduction in DBP (<50 mmHg)
The general approach to pharmacologic management of older hypertensive adults is similar to that presented in the JNC-7. Initial drug choice is influenced by the presence or absence of comorbid conditions (eg, diabetes mellitus, coronary artery disease or history of myocardial infarction, heart failure, prostatism), cost, and compliance. A once-a-day regimen with long-acting medications is more likely to be successful. Medications should be started at the lowest dosage and cautiously increased during follow-up visits (every 4–6 weeks). If the response is inadequate or there is evidence of adverse events, a drug from a different class can be substituted. However, before adding new drugs, the following should be considered: polypharmacy, nonadherence, and drug interactions.
Thiazide diuretics, calcium channel blockers, and ACE inhibitors are all effective as initial treatment. Centrally acting agents (eg, clonidine, methyldopa) and α-blockers are not recommended as first choice. β-Blockers in noncardiac patients are also not recommended for first choice. Many patients will not reach their systolic blood pressure goal on a single medication; JNC-7 recommends starting patients on two medications if their initial blood pressure is >20 mm Hg above the target level. However, adding two medications simultaneously may lead to a precipitous drop in blood pressure that may be tolerated less well in older patients than in younger patients. Therefore, caution should be exercised if two medications are to be started.
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13. DIURETICS Significant benefits in mortality, stroke and CV events
Chlorthalidone is preferred over HCTz
Adverse event profile: hypokalemia, hyperuricemia, hypomagnesemia, hyponatremia and possible glucose intolerance
More likely with higher dosages
Potassium replacement is important to prevent arrhythmias, minimize glucose intolerance
Thiazide diuretics are also well suited for use in combination therapies because of synergistic effects with other classes of antihypertensive medications. Loop diuretics may be used for hypertension but are usually reserved for patients with heart failure or chronic kidney disease. Their adverse-event profile includes increasing glucose concentration, headaches, ototoxicity, and electrolyte disturbances. Aldosterone antagonists (spironolactone, eplerenone) are also useful in hypertension and may be used in patients who are prone to hypokalemia.
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14. Can be used as initial monotherapy for HTN in older patients
ACE INHIBITORS
Can be used as initial monotherapy for HTN in older patients
Adverse event profile: cough (higher in Asians), hyperkalemia, angioedema, renal insufficiency (especially in renal artery stenosis) and rare neutropenia and agranulocytosis
Well suited to patients with diabetes and those with LV systolic dysfunction
ACE inhibitors block the production of angiotensin II and are effective in lowering blood pressure in older hypertensive adults. They lower peripheral vascular resistance through their humoral and structural effects on the vasculature without causing reflex tachycardia, as seen with direct vasodilators. They are also effective in slowing the progression of hypertension nephrosclerosis and are particularly advantageous in patients with concomitant diabetes or heart failure. Their use in African Americans has been questioned, but data from the African American Study of Kidney Disease and Hypertension (AASK) trial showed a significant beneficial effect in African Americans. Black Americans are at greater risk of cough and angioedema than white Americans.
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15. ANGIOTENSIN-RECEPTOR BLOCKERS
Block the effect of angiotensin II on the type 1 angiotensin receptor
Use as first-line therapy or as an alternative to ACE inhibitor, especially in those with diabetes, heart failure, or microalbuminuria
An option for patients who cannot tolerate ACE inhibitors
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16. Significantly more expensive
RENIN INHIBITORS
As effective as ACE inhibitors or ARBs in blood-pressure lowering effects– long-term data are still not robust.
Significantly more expensive
Associated with diarrhea and no data on safety in those with a GFR <30 mL/min
Renin inhibitors are as effective as ACE inhibitors or ARBs in lowering blood pressure, with the advantage of no dose-related increases in adverse events in older adults. However, no outcome data are available for older adults, and renin inhibitors are significantly more expensive than other antihypertensives.
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17. CALCIUM CHANNEL ANTAGONISTS (CCAs)
Use at low doses (pharmacokinetics change with advancing age)
Do not use short-acting CCAs to treat HTN
Adverse events: ankle edema, headaches, postural hypotension, constipation
Therapy with long-acting dihydropyridine calcium-channel antagonists (CCAs) (nifedipine-like) is effective in reducing stroke risk in older hypertensive patients. Calcium-channel antagonists in combination with ACE inhibitors have been shown to be superior to the diuretic–ACE inhibitor combination in patients with multiple vascular risk factors. Non-dihydropyridine CCAs can suppress left ventricular function and may precipitate heart block in older adults with conduction defects. Unless there is a strong indication for their use, they should be avoided as first choice for hypertension management.
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18. -RECEPTOR ANTAGONISTS
Not recommended for first-line monotherapy
Compared with placebo, provide no reduction in all-cause mortality, myocardial infarction, or stroke
Use in those with CAD, those with a history of MI, and certain patients with heart failure
Several meta-analyses have questioned the efficacy of β-blockers in treating uncomplicated hypertension. Based on available evidence, β-blockers are not preferred as first-line agents, unless there is a strong indication, such as heart failure, prior myocardial infarction, acute coronary syndrome, stable angina, prevention of perioperative cardiac complications, or hypertrophic obstructive cardiomyopathy.
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19. α-RECEPTOR ANTAGONISTS
High risk of postural hypotension in older patients
When used as monotherapy, associated with a high rate of CVD events (new-onset heart failure) in a large-scale clinical trial
May be considered, usually in combination with another drug, for older men with prostatism

20. OTHER CLASSES
Direct vasodilators (hydralazine and minoxidil) are considered last-line therapy due to tachycardia, arrhythmia, fluid retention
Centrally acting agents (clonidine) are poorly tolerated and associated with sedation, bradycardia, and reflex hypertension (and tachycardia if abruptly stopped)
Alpha-beta blockers:: Labetalol useful in hypertensive urgencies and carvedilol in congestive heart failure

21. FOLLOW-UP VISITS Assess adherence to therapy
Monitor for adverse effects, especially postural hypotension
Measure supine and standing BP
Encourage BP monitoring outside clinic
Use interdisciplinary team approach if available
Adjust dosage cautiously
Reinforce lifestyle modifications
Evaluate for refractory hypertension
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22. FREQUENCY OF FOLLOW-UP
Should reflect degree of BP elevation at presentation
In general, allow 4–6 weeks between visits
Except in hypertensive emergencies, rapid reduction of BP is unnecessary and may be deleterious

23. ADJUSTING THERAPY
Assess adherence to therapy and review other medications
If more than 2 antihypertensive medications are needed, one of them should be a diuretic
If BP target not attained on 3-drug regimen, evaluate patient for refractory hypertension
Consider stepping down treatment once patient has maintained target BP for >1 year
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24. HYPERTENSIVE EMERGENCIES
Definition
Vascular compromise of vital organs due to extreme BP elevation (eg, hypertensive encephalopathy, pulmonary edema, aortic dissection, unstable angina)
Management
In hospital with continuous BP monitoring
Parenteral administration of antihypertensive
Do not initially target a normal BP level
Try to achieve 160/100 mm Hg gradually over first 6 hours
Examples of true hypertensive emergencies in older adults include hypertensive encephalopathy, acute heart failure with pulmonary edema, dissecting aortic aneurysm, and unstable angina. These patients present with symptoms and signs of vascular compromise of affected organs. Management of these emergencies requires an acute hospital setting, with the parenteral administration of a short-acting antihypertensive agent and continuous blood-pressure monitoring to immediately reduce blood pressure, although not initially to a normal target level. Blood pressure should not be lowered emergently more than 25% within the first 2 hours, with a goal of achieving 160/100 mm Hg gradually over the first 6 hours of therapy.
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25. HTN IN THE LONG-TERM-CARE SETTING
HTN affects about 33% to 66% of residents of long-term-care facilities
Postprandial hypotension
Affects about 33% of residents
Independent risk factor for falls, syncope, stroke, mortality
Increased risk if antihypertensive medications were given around meal time (pre-breakfast)
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26. MANAGEMENT OF HTN IN LONG-TERM-CARE SETTING
Risk-benefit ratio of treatment is unclear in this population:
Patients of advanced age
Patients with multiple comorbidities, taking multiple medications
Some evidence suggest an association between diuretic use and falls in LTC residents– assess orthostatic vitals in all LTC residents on antihypertensive medications
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27. Lifestyle modification is recommended
SUMMARY
Treatment of HTN reduces the risk of CVD events and mortality in older adults
Lifestyle modification is recommended
first-line drug therapy can include any antihypertensive class except BB (in non- cardiac patients) or alpha blockers.
“Start low and go slow”—monitor for falls, postural hypotension, and other adverse events
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28. CASE 1 (1 of 3)
A 92-year-old woman comes to the office for follow-up. History includes osteoarthritis, well-controlled hypertension, gastroesophageal reflux disease, and a recent cold. Prescribed medications include chlorthalidone and lisinopril.
On examination, blood pressure is 162/70 mmHg and pulse is 76 beats per minute. On further questioning, the patient states that her daughter has been giving her OTC ibuprofen because she has had knee discomfort, which is now resolved. She has also been taking an OTC preparation of pseudoephedrine, 30 mg, three times a day for several days for congestion.
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29. CASE 1 (2 of 3)
Which of the following is the most likely cause of her high blood pressure?
Pseudoephedrine
Arthritic pain
NSAIDs
Renal artery stenosis
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30. CASE 1 (3 of 3)
Which of the following is the most likely cause of her high blood pressure?
Pseudoephedrine
Arthritic pain
NSAIDs
Renal artery stenosis
ANSWER: C
NSAIDs can increase blood pressure in people with and without hypertension. Use of NSAIDs increases the risk of myocardial infarction and stroke and can exacerbate heart failure, especially in patients with known cardiovascular disease. If NSAIDs must be used for pain control, naproxen is the agent of choice. Any use of NSAIDs should be of limited duration in patients with hypertension or patients who have or are at risk of cardiovascular disease.
Although advanced age contributes to an increase in blood pressure, it is unlikely to cause a sudden change in a person with previously controlled hypertension. While the use of pseudoephedrine is often avoided in patients with hypertension, the available data indicate that, when used in therapeutic doses, it has no effect on blood pressure in patients with well-controlled hypertension. Arthritic pain can increase blood pressure, but this patient is not currently in pain. Renal artery stenosis is a secondary cause of hypertension, but it would not be part of the differential diagnosis unless the blood pressure remained increased after the NSAID was discontinued.
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31. CASE 2 (1 of 3)
A 70-year-old man comes to the office because of concern about increased BP.
History includes DM that he has controlled with diet, exercise, and weight loss.
He checks his BP at home regularly; over the last month, his systolic BP readings have been consistently >160 mm Hg.
Blood pressure today is 158/86 mm Hg, up from 148/84 mm Hg at his last office appointment 4 months ago.
His creatinine level is 1.4.
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32. CASE 2 (2 of 3)
Which of the following is the most appropriate antihypertensive drug for this patient?
Chlorthalidone
Metoprolol
Amlodipine
Lisinopril
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33. CASE 2 (3 of 3)
Which of the following is the most appropriate antihypertensive drug for this patient?
Chlorthalidone
Metoprolol
Amlodipine
Lisinopril
ANSWER: D
Choice of medication to control blood pressure should be guided by the patient’s other cardiovascular risk factors. For a hypertensive patient with diabetes mellitus and nephropathy, the first-line agent should be an ACE inhibitor or an angiotensin receptor blocker. ACE inhibitors and angiotensin receptor blockers are protective of renal function; these agents can reduce microalbuminuria and slow progression of diabetic nephropathy.
Although thiazide and thiazide-like diuretics are usually first-line agents for hypertension in older adults, ACE inhibitors are preferred for patients with renal insufficiency. β-Blockers have not been shown to improve outcomes in older patients who do not have coronary artery disease. Calcium channel blockers are not first-line agents for hypertension and diabetes mellitus.
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34. Copyright © 2013 American Geriatrics Society
GRS Slides Editor: Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Author: Ihab Hajjar, MD, MS, FACP
GRS8 Question Writer: Rebecca Boxer, MD
Medical Writers: Beverly A. Caley
Faith Reidenbach
Managing Editor: Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society
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