TREATMENT OF HYPERTENSION IN THE ELDERLY

1. TREATMENT OF HYPERTENSION IN THE ELDERLY APPROACH TO MANAGEMENT. RESULTS OF TREATMENT

2. Isolated Systolic Hypertension Definition: >140 <90 mm Hg Etiology: Age related decrease in aortic compliance (increase in vascular stiffness) Decrease in elastic tissue In rigid aorta Increase in collagen deposition Intimal thickening Diastolic pressure remains constant or decreases. In rigid aorta elastic recoil that helps maintain DBP is decreased.

3. Algorithm for Management of the Elderly - • Primarily Systolic Hypertension • 1) Lifestyle changes • Low dose diuretic (12.5 mg HCTZ) • CCB B-Blocker ACE or ARB • 3) Stop, Look & Listen before dosages • Let the Baroreceptors reset • 4) Rx until goal achieved + + + + +

4. Trial of Non Pharmacologic Interventions in the Elderly (TONE) Reduction (%) in Incidence of Hypertension or CV Event -31 -30 -53 JAMA 1998;279:839-846

5. MANAGEMENT PROBLEMS • SYMPTOMS • DIZZINESS,-FATIGUE,- • POSTURAL HYPOTENSION

6. Blood Pressure (mm Hg) in SHEP and Syst-Eur Trials SHEP Syst-Eur Entry Goal (SBP) Baseline Achieved: Rx Achieved: Placebo 160-219/<90 160-219/<95 <160 <150 170/77 174/86 143/68 151/79 155/72 161/84

7. The Difficulty in Reducing SBP: STOP-2 Conventional ACEI based Calcium antagonist based  BP(mm Hg) SBP Goal DBP Goal 1 0 6 12 24 36 48 54 Months Hansson L, et al. Lancet. 1999;354:1751-1756.

8. -12-4-5 About mmHg Benefits of Lowering BP by Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%

9. REDUCTION OF STROKES WITH BP LOWERING - SHEP TRIAL No. of Patients: 4736 Follow-up: 4.5 years 37% in ischemic strokes 47% in lacunar infarcts 54% in hemorrhagic strokes Lower BPs - fewer strokes Am J Hypertension 2000;13:724-733

10. Public Health Implications of SHEP Study Reduction in Events on Active Treatment (per 1000 patients/5 years) CVA 30 CAD 16 CHD 55 Annually in USA: 24,000 fewer strokes 44,000 fewer major CV events 84,000 fewer hospital admissions

11. In the SHEP study the beneficial effect on cardiovascular events was attenuated in patients with potassium levels below 3.5 mmol d/L but were no greater than placebo

12. ISH: META-ANALYSIS OF OUTCOME TRIALS n=15,693—3.8-yr follow-up 1000 Nonfatal events Fatal events Treatment Control 835 800 734 T 656 647 600 C Total individuals affected (n) 387 373 342 400 327 293 279 100 329 200 244 193 136 100 0 T C T C T C T C T C Stroke30%<0.0001 CHD23%<0.001 AllCV events 26%<0.001 Totalmortality13%0.002 Non-CVmortality % odds reduction 2P value Adapted from Staessen et al. Lancet 2000;355:865

13. Diuretics or B-Blockers as Initial Therapy in 8 Randomized Controlled Hypertension Treatment Trials in Older Persons Risk Reduction (%) All reductions significant (p <.05) except CHD and death with B-blockers Cutler JA, et al. In Laragh JH, Brenner BM, eds, Hypertension 1995

14. 100 80 99 91 60 88 87 69 69 40 Number of Subjects with 1° Event 61 58 59 48 20 0 MN-6 AM 6 AM-Noon Noon-6 PM 6 PM-MN Unknown Time of Day of 1° End Point 76% of events had known time COER-v Standard of Care No significant difference in time of day of event

15. Is it Ever Too Late to Lower Blood pressure?

16. Meta-analysis of Hypertension Treatment Trials in People > 80 Years of Age 6 p=ns -22 p=ns -34 -39 p=.014 p=.01 Lancet 1999;353:793-796

17. Status of BP Control Among 800 Elderly Men in a 2-year Study • More than 40 percent of subjects had BPs > 160/90 mm Hg • Patient visits average 5-6/year • Medication was increased only 26% of the time in patients with BPs > 155/90 mm Hg • Medication was increased only 22% of the time in patients with BPs <90 but > 165 mm Hg N Engl J Med. 1998;339:1957.