1. Hypertension In elderly population

2. JNC VII BP Classification SBP mmHgDBP mmHg Normal<120<80 Prehypertension120–13980–89 Stage 1 Hypertension 140–15990–99 Stage 2 Hypertension >160>100

3. Relook at hypertension Hypertension is a major cardiovascular risk factor, but knowledge about the real magnitude of the problem and its determinants is lacking. Hypertension is poorly controlled in most patients with a high risk of cardiovascular disease. Uncontrolled hypertension is frequently associated with poor control of other risk factors.

4. Swedish trial Screened: 27,936 subjects (10,953 men and 16,983 women), 45 to 73 years old 16 648 subjects (60%) had hypertension 23 % received treatment 77 % untreated 88.2% had BP levels > or =140/90 mm Hg 49.5% had BP levels >or =160/100 mm Hg Li C et al, Stroke. 2005 Apr;36(4):725-30. Epub 2005 Mar 3

5. US study According to the third National Health and Nutrition Examination Survey (NHANES III), approximately 60% of the 50 million Americans with hypertension are at increased risk for cardiovascular disease resulting from uncontrolled hypertension. This is because only 53% of hypertensive patients are being treated and only 24% have their hypertension under control. Dosh SA et al, J Fam Pract. 2002 Jan;51(1):74-80

6. Patient awareness- US study 91% reported that a health care provider had told them that they have hypertension or high BP 41% of patients did not know their BP level, while 28% of all patients correctly identified the meaning of HTN as "high blood pressure." 34% of patients correctly identified SBP as the "top" number of their reading; 32% correctly identified diastolic blood pressure (DBP) as the "bottom“ Oliveria SA et al, J Gen Intern Med. 2005 Mar;20(3):219-25

7. Impact of uncontrolled hypertension

8. Sudden death Congestive heart failure (CHF) Peripheral vascular diseases StrokeCoronary artery disease (CAD) Hypertension is dreadful. Renal failure LVH

9. Risk of complications For individuals aged 40 to 70 years, each increment of 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP doubles the risk of CVD across the entire BP range from 115/75 to 185/115 mm Hg. JNC VII

10. Higher incidence of stroke Per 100 000 person- year 2.5 times higher Li C et al, Stroke. 2005 Apr;36(4):725-30. Epub 2005 Mar 3

11. Elderly hypertensives Framingham Heart Study suggest that individuals who are normotensive at 55 years of age have a 90% lifetime risk for developing hypertension. Hypertension and the presence of other cardiovascular risk factors in older persons (i.e., obesity, left ventricular hypertrophy, sedentary lifestyle, hyperlipidemia, and diabetes) make this population at high risk for morbidity and mortality. Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

12. Isolated systolic hypertension Multiple studies have demonstrated that isolated elevated systolic blood pressure is more prevalent in older persons because of increased large-artery stiffness. Recommendations from the JNC state that systolic blood pressure should be the primary target for the diagnosis and care of older persons with hypertension.

13. Goals of Therapy Treating systolic BP and diastolic BP to targets that are less than 140/90 mm Hg is associated with a decrease in CVD complications. In patients with hypertension with diabetes or renal disease, the BP goal is less than 130/80 mm Hg. JNC VII What is the goal BP?

14. Although most data support the treatment of older patients with stage 2 isolated systolic hypertension (systolic blood pressure higher than 160 mm Hg), JNC 7 recommends treating older patients with stage 1 isolated systolic hypertension (systolic blood pressure 140 to 159 mm Hg) equally aggressively.

15. Benefits of Lowering BP In clinical trials, antihypertensive therapy has been associated with 35% to 40% mean reductions in stroke incidence; 20% to 25% in myocardial infarction; and more than 50% in HF. It is estimated that in patients with stage 1 hypertension and additional cardiovascular risk factors, achieving a sustained 12-mm Hg decrease in systolic BP for 10 years will prevent 1 death for every 11 patients treated. JNC VII

16. Evidence based medicine

17. STOP-2 Swedish Trial in Old Patients with Hypertension-2 study Mean age in years Mean follow up in years Initial blood pressure (mm of Hg) Blood pressure after treatment (mm of Hg) Regimens 765194/98~158/80 in both groups Beta blocker or thiazide (older drugs) vs. ACE inhibitor or calcium channel blocker (newer drugs) Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

18. STOP-2 Regimens did not differ in rates of stroke, cardiovascular events, or mortality. ACE inhibitor better than calcium channel blocker for myocardial infarction (NNT = 26) and congestive heart failure (NNT = 28).

19. LIFE Losartan Intervention For Endpoint reduction in hypertension study Mean age in years Mean follow up in years Initial blood pressure (mm of Hg) Blood pressure after treatment (mm of Hg) Regimens 704174/98~145/81 in both groups ARB (losartan) vs. beta blocker (atenolol) Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

20. LIFE ARB better than beta blocker for stroke and combined end point of cardiovascular mortality, stroke, and myocardial infarction. Regimens did not differ in rates of total mortality.

21. ALLHAT Antihypertensive and Lipid-Lowering Treatment to prevent Heart Attack Trial Mean age in years Mean follow up in years Initial blood pressure (mm of Hg) Blood pressure after treatment (mm of Hg) Regimens 675146/84~134/85 in all groups Thiazide (chlorthalidone) vs. ACE inhibitor (lisinopril) vs. calcium channel blocker (amlodipine) Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

22. ALLHAT Regimens did not differ in combined end point of fatal coronary heart disease or nonfatal myocardial infarction. Thiazide better than calcium channel blocker for congestive heart failure and angina. Thiazide better than ACE inhibitor for stroke, cardiovascular disease, congestive heart failure, or revascularization. Regimens did not differ in rates of total mortality.

23. INVEST International Verapamil-Trandolapril study Mean age in years Mean follow up in years Initial blood pressure (mm of Hg) Blood pressure after treatment (mm of Hg) Regimens 662150/87~131/77 in both groups Calcium channel blocker (verapamil) plus ACE inhibitor (trandolapril) vs. beta blocker (atenolol) plus thiazide (hydrochlorothiazide) Regimens did not differ in rates of cardiovascular outcomes or total mortality.

24. ANBP-2 Second Australian National Blood Pressure study Mean age in years Mean follow up in years Initial blood pressure (mm of Hg) Blood pressure after treatment (mm of Hg) Regimens 724168/91~142/79 in both groups ACE inhibitor (enalapril) vs thiazide (hydrochlorthiazide) Lory M. Dickerson et al, Am Fam Physician 2005;71:469-76

25. ANBP-2 ACE inhibitor better than thiazide for primary end point of all cardiovascular events or total mortality (NNT = 72) and for myocardial infarction (NNT = 125). Regimens did not differ in rates of total mortality.

26. Management of hypertension in elderly

27. Thiazide-type diuretics Thiazide-type diuretics should be used as initial therapy for most patients with hypertension, either alone or in combination with 1 of the other classes (ACE inhibitors, ARBs, Beta-blockers, CCBs) demonstrated to be beneficial in randomized controlled outcome trials. JNC VII

28. Thiazide-type diuretics Thiazide-type diuretics have been the basis of antihypertensive therapy in most outcome trials. In these trials, including the recently published Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, diuretics have been virtually unsurpassed in preventing the cardiovascular complications of hypertension. Diuretics enhance the antihypertensive efficacy of multidrug regimens, can be useful in achieving BP control, and are more affordable than other antihypertensive agents. JNC VII

29. Compelling indications IndicationsAntihypertensives as initial therapy Heart failureDiuretic, Beta blocker, ACE inhibitor, ARB, Aldosterone antagonist Post MIBeta blocker, ACE inhibitor, Aldosterone antagonist High coronary disease risk Diuretic, Beta blocker, ACE inhibitor, CCB JNC VII

30. Compelling indications IndicationsAntihypertensives as initial therapy DiabetesDiuretic, Beta blocker, ACE inhibitor, ARB, CCB Chronic kidney disease ACE inhibitor, ARB Recurrent stroke prevention Diuretic, ACE inhibitors JNC VII

31. JNC VII - Tips Treat isolated systolic blood pressure Thiazide diuretics should be first-line treatment Second-line treatment should be based on comorbidities and risk factors

32. JNC VII - Tips Patients with systolic blood pressure higher than 160 mm Hg or diastolic blood pressure higher than 100 mm Hg usually will require two or more agents to reach goal Treatment should be initiated with a low dose of the chosen antihypertensive agent, and titrated slowly to minimize side effects such as orthostatic hypotension

33. JNC VII - Tips Weight loss and sodium reduction have been shown to be feasible and effective interventions in older patients with hypertension. To improve adherence with antihypertensive regimens, involve patients in goal setting, and ensure that the patient's cultural beliefs and previous experiences are incorporated in a treatment plan. Simplify the medication regimen, keeping in mind how much it costs.

34. Need of an hour Implementation of guidelines Closing the gap between experts’ recommendations and poor blood pressure control in medical practice.

35. Patient behavior change: Motivation improves when patients have positive experiences with and trust in their clinicians. JNC VII +

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