1. Flying Blind Without Instruments Treating Hypertension in the Elderly Will Bynum, MD Attending Faculty, NCC Family Medicine Residency Fort Belvoir, VA

2. Outline Limitations of JNC-8 guidelines Practical approach to avoiding adverse events Brief overview of recommended medications Overall Goal: to increase awareness of the complexities of treating hypertension in the highly heterogenous elderly population

3. Case Mrs. S is a 92 year old who you are seeing in the nursing home. No complaints today. PMHx: HTN, HLP, CAD s/p stent in 1997, severe OA Meds: ASA 81 mg, lipitor 20 mg, Vit D 1000 IU Recent Vital Signs P 75 BP 164/72 P 68 BP 162/71 P 80 BP 157/68 Today’s Vital Signs P 73 RR 18 BP 166/70 T 98.4 *Remainder of physical exam unremarkable *Recent labs normal

4. In addition to advising lifestyle change, would you start a medication?

5. Treating Blood Pressure in Elderly Patients Part I: The (mis)guidelines

6. What does JNC-8 say? In adults > 60 yo, initiate pharmacologic therapy for BP >150/90 Treat to a goal of <150/90 If patient is already on anti-hypertensive and SBP is less than 140, no need to stop medication if the patient is tolerating it well JAMA. Feb 5 2014;311(5):507-520

7. What does “general population” mean? What about the diastolic blood pressure? What do these studies show and in whom?

8. StudyAge of ParticipantsMean BP of Participants Study Population Characteristics SHEP > 60 Mean: 71 (SD 6.7) 14% were >80 yo 170/76 Community Dwelling 94% had no impairment in ADLs 0.4% had e/o cog. impairment Syst-Eur > 60 Mean: 73 yo (SD 6.7) 174/85Community dwelling MRC > 60 Mean: 70.4 180s/90sCommunity dwelling Meta-Analysis (8 studies) > 60 174/83Community dwelling The Data Randomized Controlled Trials Primary Finding 36% reduction in stroke 13% reduction in all- cause mortality 42% reduction in stroke 31% reduction in non- fatal CV events 25% reduction in stroke 17% reduction in all CV events Active treatment… 13% reduction all-cause 18% reduction CV deaths 30% reduction stroke 23% reduction coronary

9. What about patients >80 years old? HYVET Trial

11. The HYVET Trial – Results 30% reduction in non-fatal stroke 39% reduction in stroke-related mortality 21% reduction in all-cause mortality 29% reduction in CV-related mortality 64% reduction in CHF incidence Fewer adverse effects in the treatment group (358) than the placebo group (448) NEJM 2008 ;358(18)1887-98

12. Inclusion Criteria - AGEAge >80 Inclusion Criteria - BPSBP > 160, DBP < 110 Exclusion CriteriaSecondary HTN, hemorrhagic stroke in last 6 months, heart failure requiring an anti-HTN med, Cr >1.7, diagnosis of clinical dementia, and a requirement of nursing care Who was actually enrolled? 80 – 84 yo: 74% >90 yo: 4.6% 85 – 89 yo: 22.4% Who was actually enrolled? Mean BP: 173/ 90 This study best applies to a patient… who does not have dementia who does not have a borderline DBP in his/her early 80’s who is functional HYVET – a deeper look

13. The (mis)guidelines Re-cap HTN studies in the elderly only represent a healthy subset of the population Guidelines do not take heterogeneity into account Thus, the guidelines may not apply to the patient in front of you

14. Treating Blood Pressure in Elderly Patients Part II: First do no harm ?

15. First Do No Harm The Mortality Curve J

16. The Lancet. 1987;329(8533):581-584 Mortality & MI

17. Annals of Internal Medicine. 2006;144(12):884-893 Data from the INVEST trial Mortality & MI

18. Low diastolic blood pressure is associated with increased risk of mortality and MI There is no evidence that sets a safe minimum DBP Expert Opinion : In the elderly treat to a minimum DBP of… 60 in patients without CAD 65 in patients with CAD Mortality & MI

19. Gait Speed & Mortality Gait speed is a “strong and consistent predictor of adverse outcomes” in community-dwelling older people” Slowed gait speed is a predictor of functional disability Also a marker for falls and increased mortality The Journal of Nutrition, Health & Aging. Dec 2009;13(10):881-

20. Fast Walkers Slow Walkers No Walkers Archives Intern Med. 2012;172(15):1162-1168 <4 seconds to walk 10 feet >4 seconds to walk 10 feet Unable to participate in test 2,340 patients >65 years old

21. Fast Walkers: Elevated SBP (>140) associated with increased mortality risk (OR 1.35) Slow Walkers: no association between elevated BP and mortality No Walkers: Elevated SBP (>140) and DBP (>90) associated with decreased mortality risk (HR 0.38 and 0.10) Gait Speed & Mortality Archives Intern Med. 2012;172(15):1162-1168

22. Gait Speed & Mortality Use gait speed to help determine if your patient is a good candidate for anti-hypertensive therapy Consider therapy in fast walkers Use extreme caution in non-walkers BP >140/90 appears to be most protective in patients with significantly lower functional ability

23. Incidence of orthostasis in 21% (Syst-Eur) and 17% (SHEP) of patients after starting treatment The Lancet. 1997;350(9080):757-764 JAMA. 1991;265(24):3255-3264 Orthostasis is associated with increased risk of… Falls Future CV events Congestive heart failure Incidental atrial fibrillation Hypertension. 2010;56(1):56 Hypertensio n. 2012;59(5):913-8 J Intern Med. 2010;268(4):383-9 J Am Geriatr Soc. 2011;59(3):383-9 Am J Med. 2000;108(2):106-111 Orthostasis

24. Screen for orthostatic hypotension… BEFORE starting anti-hypertensives in the elderly In patients already on anti-hypertensives who have borderline blood pressure Orthostasis

25. Being on an anti-hypertensive is a known risk factor for falls (OR 1.2 – 1.4 if no prior fall, 2.1 – 2.3 if prior fall) Arch Intern Med. 2009;169(21):1952 JAMA Int Med 2014;174(4):588-95 Falls are strongly associated with hip fractures 90% of hip fractures in the elderly occur following a simple fall Baumgaertner MR, Higgins TF. Femoral neck fractures. Falls & Hip Fractures

26. Arch Intern Med. 2012;172(22):1739-1744 Case series that evaluated association between initiation of an anti-hypertensive in the elderly and risk of immediate hip fracture after initiation Average age of patients = 81 yo. All were community dwelling Falls & Hip Fractures

28. Increased risk of hip fracture in the 45 days following initiation of therapy (OR 1.45 for all classes) Beta blockers (OR 1.58) ACEI/ARBs (OR 1.53) Thiazides (OR 1.33) CCB’s (OR 1.30) Consider the patient’s fall risk when making the decision to start an anti-hypertensive Mitigate other falls risk factors, especially in the first 45 days after initiation of therapy

29. Re-Cap Use caution in starting/continuing anti-hypertensive therapy in the following: Borderline diastolic BP (60-65) Low functional status Increased falls risk Underlying orthostatic hypotension Non-community dwelling Old old (>85 yo) Permissive systolic hypertension appears to be protective

30. Treating Blood Pressure in Elderly Patients Part III: The meds

31. Medications Initial Monotherapy Thiazides: appear to be the best overall 1 st line choice CCB’s: 1st line but may have increased risk of heart failure ACEI/ARBs: acceptable but best used as 2 nd /3 rd line Avoid Beta Blockers & Vasodilators as 1 st line treatment JAMA 2002;288(23):2981-2997

32. Medications Combination Therapy ACCOMPLISH trial (mean age 68, mean BP 145/80) showed…ACEI + CCB >> ACEI + Thiazide NEJM. 2008;359(23):2417 ESH/ESC & JNC-8 recommend any combination of ACEI, CCB, and thiazide

33. Putting it All Together The decision to treat, not treat, or continue treatment in elderly patients is very complex The guidelines are based on studies of community- dwellers who were more or less healthy, young-old, and with mean SBP 170-180 The benefits of treating SBP >160 are tremendous in relatively healthy, community-dwelling, young-old patients However, hypertension may be protective, especially in patients with lower functional ability

34. The data shows a consistent association between low DBP and mortality. Remember 65 & 60 Other risks include MI, falls (especially 1 st 45 days), and orthostasis Start treatment with a thiazide in most patients. Calcium channel blockers are also first line option Any combination of thiazides, CCBs, and ACE/ARB is acceptable Putting it All Together

35. Questions?