Treating Hypertension in the Elderly—Whom to Treat, When, and with What?

DR. MOSER: Let us first define what we mean by hypertension in the elderly; explain some of the physiologic differences in the elderly compared to the young, especially in patients over 75 or 80 years of age, that might influence treatment decisions; then discuss the influence of comorbidities on therapy choices; and finally, discuss when and how to treat this rapidly growing segment of our population. Is monotherapy appropriate? Is combination therapy appropriate? Which approved drug classes are effective and which do not work? What should we expect when we treat the elderly hypertensive? Are results conclusive in terms of reduction of morbidity and mortality, or do we not have enough data thus far to make firm recommendations? Dr. Oparil, what about hypertension in the elderly? Please define it—both isolated systolic and systolic/diastolic hypertension. DR. OPARIL: Hypertension is hypertension. The standards do not change...the definitions of hypertension in adults do not change with different ages. Systolic/diastolic hypertension is defined as a systolic blood pressure (SBP) greater than 140 and a diastolic blood pressure (DBP) greater than 90 mm Hg. Isolated systolic hypertension (ISH) is defined as a systolic pressure equal to or greater than 140 mm Hg with a diastolic pressure of less than 90 mm Hg. This is the Joint National Committee (JNC) VI definition. DR. MOSER: Are the Europeans and the World Health Organization wrong in saying that we should continue to define ISH as above 160 mm Hg? What data do we have with pressures between 140 and 160 that risk is increased and that reducing pressure is beneficial? DR. GLASSER: Implicit in your question is exactly why there is a difference of opinion between the Europeans and others. I do not think it is a matter of right or wrong. We know that there is a graded, continuous, increased risk of cardiovascular events as SBP climbs above 140 mm Hg. But what we do not know for the group with pressures between 140 and 159 mm Hg is whether treatment reduces that risk. We have good data for treatment of SBP above 160 mm Hg, in terms of reducing risk. We can confirm increased risk but lack sufficient information about reducing the risk in this stage 1 group. At present there are limited drug treatment data that risk can be reduced between 140 and 159 mm Hg. Those who support this approach cite indirect evidence. DR. MOSER: Dr. Cushman, when we define ISH as above 140 mm Hg and implicitly inform practitioners that these levels should be treated, are we correct? DR. CUSHMAN: It depends on whether we consider the epidemiologic risk, in which case 140–159 mm Hg (stage 1 systolic hypertension) carries a 50% greater risk for a cardiovascular event compared to a SBP of <140, or whether we seek answers from prospective clinical trials on results of therapy. In terms of defining hypertension, it is fine to use 140 mm Hg and above for a definition of ISH. We should certainly initiate lifestyle changes in all patients in the stage 1 range. However, in light of prospective clinical trials, I might be inclined to change the number to 150 mm Hg. If you note the SBP levels in the placebo group in the Systolic Hypertension in the Elderly Program (SHEP), for example, they averaged in the 150s, whereas in the treatment group they averaged in the 140s. Subjects had a greatly reduced risk of cardiovascular events in the lower blood pressure (BP) group (140s). I extrapolate from these data that above 150 mm Hg we should treat with drugs. On the other hand, a great number of our older population have diabetes and other comorbid conditions, and I interpret the prospective clinical treatment trials to indicate that BP even lower than 140 mm Hg should be the goal in these patients. We have no data that treating diabetics with SBP below 140 mm Hg at entry is beneficial. We need more data. My expectation is that lower will be better, but I will credit the evidence and suggest medication at >150 mm Hg for most hypertensives and at >140 mm Hg for diabetics. DR. MOSER: That is an interesting point. Maybe we can agree with this modified definition. People are at greater risk above 140 mm Hg, but at present we do not have sufficient data for a blanket recommendation to treat people who have no other risk factors and a DBP of <90 mm Hg. Should we say that 150 mm Hg is the cut point to add medication, on the basis of better data than we have with lower BP cut points? Or do we advise adding medication if Bps stay above 140 mm Hg and/or 90 mm Hg after a suitable period of lifestyle modification? Obviously, in people with other risk factors, i.e., diabetics, smokers, and people with hyperlipidemia or known coronary heart disease, specific treatment should be started earlier. But perhaps drug therapy should not be tried unless the SBP is >150 mm Hg in a relatively healthy 75–80-year-old. DR. CUSHMAN: It is not because I disbelieve that patients in the 140–150 mm Hg group would benefit, but we do not yet know the long-term benefits of treatment. DR. MOSER: Other comments? DR. OPARIL: If you leave people untreated at 150 mm Hg and wait a few years, they will be at 160 mm Hg and then they will qualify for treatment regardless of the definition. DR. CUSHMAN: If BP is hovering around 150 mm Hg, I would be more prone to initiate drug treatment. DR. GLASSER: I would tend to agree with that, but as Dr. Moser noted, I would also tend to take into account other target organ damage or comorbidities. We should encourage lifestyle modifications in this borderline BP group and consider specific therapy if there is no response. DR. MOSER: But is there a problem for an 80-year-old man to be told not to eat a steak and to cut sodium intake? DR. GLASSER: It depends on the degree to which you recommend that. DR. CUSHMAN: I would certainly tell him to go out and walk 30–60 minutes every day. DR. MOSER: Now, should these things we are talking about apply to people younger than 80 as well as over 80 years of age? Are we going to make any distinctions in our approach to the very old? DR. GLASSER: Clearly the data on people over 80 are much less abundant. We simply do not have the evidence yet to be dogmatic about recommendations in this age group. DR. MOSER: I just reviewed the data on a total of about 1500 people over the age of 80 in the clinical trials. A reduction in cardiovascular events was demonstrated in treated patients with systolic/diastolic as well as isolated systolic hypertension. Life may not be significantly prolonged, but strokes and heart failure are reduced. Therapy appears to be quite worthwhile. DR. GLASSER: I believe that additional studies are needed. I suspect that it would be beneficial to treat 80-year-old individuals who are physiologically younger. One must take into consideration what one is trying to achieve, given the person's overall state of health. DR. MOSER: Of course, in these patients you do not want to use any treatment that may decrease the quality of life. In the SHEP trial there were about 650 people over 80 years of age; treating those people with medication achieved benefit—mostly a reduction in nonfatal strokes and heart failure. Certainly the prospect of fewer strokes and episodes of heart failure is a reasonable objective. DR. CUSHMAN: In a recent study of nursing home patients, whom we often considered beyond needing treatment, there were fewer falls and fewer adverse effects in those treated for their hypertension, with better control of their BP, especially if they were on diuretics. Better control of BP may actually decrease postural hypotension. Regardless of whether your goal is to prevent strokes, heart attacks, or heart failure, even short-term benefits may actually be seen in the very old if BP is lowered. DR. MOSER: You may even prevent further osteoporosis with the use of a diuretic. Dr. Oparil, there are many physiologic changes in the elderly. Do these really affect management? What does the clinician have to know other than that cardiac output and renal function are decreased and that baroreceptor sensitivity is also blunted? How do these changes impact treatment? DR. OPARIL: There are a few things that happen in the elderly that are important. We lose nephrons as we get older, whether we are normotensive or hypertensive. If we are hypertensive, we lose nephrons faster and it is hard to judge the status of renal function because it is not very precisely reflected in the serum creatinine. Early on, a relatively large change in renal function might result in an insignificant change in serum creatinine levels and may be missed by the clinician. Conversely, once serum creatinine begins to increase in the elderly, there is already so much renal damage that specific antihypertensive treatment can push the patient into renal failure. Because older people have less muscle mass, antihypertensive treatment should be initiated at lower doses. As a ballpark figure, treatment should be initiated with one half the dose usually given to younger patients. There are also problems with of blood This not with increased pressure but also with older people a increase in heart and cardiac output may not as or as as in the a problem with postural and medication may be However, postural should not the from treating the it just BP should be with as well as the DR. MOSER: This is one why should not be as treatment. Dr. cardiac output in older but by BP we may actually increase and that is a beneficial Certainly renal function is we have to to because we elderly people with creatinine levels of or and if we a medication that renal function even a creatinine levels to or are some things one to But how are these Is it enough to advise just one half the dose of what you would and take the BP with the patient The is not on much evidence. DR. GLASSER: The Bps in the important. We all know this but I do not it Certainly it also to The I must was just out of the I not that I know of any studies that have that. DR. MOSER: Is it DR. GLASSER: it DR. CUSHMAN: I not that all are the or that the is in all We that with of to a of for as well or better in the elderly than in What we to is that a dose of of is more to changes in a and less antihypertensive than in the elderly, who it quite We actually were of to and that more adverse effects in but had no greater in or We had actually started at that many at a dose of an as well as other antihypertensive There is good evidence that we should not use of or other in the elderly if these are to BP to goal DR. MOSER: when we not know much about and we just to If 1 was not effective we the we the more the We know that most of the antihypertensive are effective at the lower range. Dr. Cushman, of in the elderly with a a an and a DR. CUSHMAN: for example, I would with and usually go to even we have demonstrated that above these levels this is a I would not increase it to I was and not goal DR. MOSER: would you add a or an or DR. CUSHMAN: If I an I would have to consider that the elderly might be need of If I a drug or or I would consider that is the range. I do not use for example, even some of these have approved by the at that DR. MOSER: You think they at the lower DR. CUSHMAN: I think they and I not about the risk unless is If the patient is on a I would tend to at the lower DR. MOSER: What about postural and is the I have seen quite a few elderly people postural changes if are not DR. CUSHMAN: I think the is I do a when I an in who a This is or more in If the is no different when you the then you can go to DR. MOSER: go to that many elderly patients, especially the very old years of do not well to an by why not add a dose of a to the dose of the than the A better is than with drug with a degree of and or no increase in DR. CUSHMAN: Obviously, what I saying to be in I over the age of on a unless there is some I use an or other as a in an older with a of at a diuretic. DR. OPARIL: In the case of many the The of an dose to do with the of even the very will for a few The of of the depends in on the dose to more and in on the specific DR. CUSHMAN: you agree that you an DR. OPARIL: DR. MOSER: I have to In heart failure I believe that the of an are usually but I would not push an above especially in the elderly and especially those who are on a diuretic. I have seen many of and postural hypotension. what about renal DR. OPARIL: In patients who are on and an we have to about renal failure, but this very DR. MOSER: I think you agree that in patients with relatively renal function you would use a not a DR. OPARIL: I DR. MOSER: Dr. would you use a with a in this DR. GLASSER: Let first add one about the is a more in the elderly and because of this I tend to go lower and with the just to the few patients who might I was more about these as monotherapy years a point of if one of and to pressure and one would think that a would be the to studies to support the use of to a greater in the elderly. The VI a as therapy in the elderly population and a with a if this is not Certainly in patients and in patients with hypertension and are first the studies indicate that morbidity and in patients with heart failure, when to therapy. However, as monotherapy in an elderly I not that this is first therapy is a different DR. MOSER: It was to many people that were not as effective in the elderly in reducing coronary heart morbidity and in the by some of our these in the elderly, is that significantly reduced strokes and heart failure. are events we want to There are also data in patients who are at risk and in patients with heart failure, whether or not they are hypertensive, to indicate that morbidity and are reduced some about the of these on of the benefits of can be for by their reduction of the of the may also increase the of The VI recommendation for the use of a a in the elderly good of us the use of in the elderly. do these into the treatment of the elderly patient with or comorbid I we can that about of the elderly have some comorbid DR. GLASSER: There is a long-term trial in the elderly on the use of a This the Systolic a reduction in strokes and overall cardiovascular events in treated compared to control so a may be an should a be or not well There is about the cardiovascular is that these adverse events with and not with the or other classes of as or DR. MOSER: There is also a study in the elderly, with about people in an group compared to about people on a diuretic. events were equal with but not fewer than with a diuretic. At we have some data that the are in the elderly, but thus far no data that they are any better than other That to the should we use are in the elderly. Dr. Cushman, should continue this DR. CUSHMAN: I think they We have a number of trials that are going to the studies in diabetics with a few patients that more cardiovascular events with than with but these studies are to It is of some to that in the in elderly hypertension therapy with a and/or a was as effective as therapy with an or but and heart were more with than with also have not to be as beneficial in these in other trials. This enough that I would be to use a as monotherapy in an elderly I have no about it in a in patients. are very effective at BP in the elderly, so if a patient is a or or a and the BP is not then a would be a good to It is not a good to use a as and a because of about cardiac and DR. MOSER: I agree with Dr. are effective blood pressure in the elderly, perhaps even more so as monotherapy than a or an but all of the data I have in or trials, have to that they are as effective or more effective in reducing morbidity and than other I believe that it is to data from the large As Dr. noted, were just as effective as or in reducing morbidity and in elderly patients. However, there was a significantly greater of and heart failure with the as compared to My first in the treatment of the elderly is a on the I would use a as an in ISH. I agree with Dr. that these are as therapy in a patient not to other therapy. with DR. GLASSER: I DR. OPARIL: I also agree with that, with one of the trials that have have out in with I think that for the elderly, and there are do have a if a by is not The other interesting is that there is quite a of evidence that if an is with a some of the adverse effects of the are as of the and There is a there for this of combination therapy. DR. MOSER: You are of However, as Dr. group if you use any medication with a you a better result than if you use a combination that does not a diuretic. Is that Dr. DR. CUSHMAN: In that is I have to qualify that by saying that we compared all that a all those that we the to a a There are studies that suggest that the combination is quite effective at DR. MOSER: I think we all agree Hypertension in the elderly, even in people over should be of us might to on the definition of isolated systolic hypertension, but it can be defined as a SBP of >140 or >150 mm Hg and a DBP of <90 mm Hg, with or comorbidities. if there are and most elderly people have specific treatment should be than in should be one half the dose in a younger is There are physiologic as a reduction in cardiac renal and baroreceptor that may a in and but we can treat most not elderly people One take the BP in the and use this to treatment. We have just which we would use in the elderly. But be more If you use a or a what would you with and when would you and add a DR. GLASSER: I tend to be on the and at lower to the few patients who might have an adverse or I would at and consider going to I would at and go to if I tend not to push than I to push to the dose of one drug adding but we no do we tend to add a a diuretic. DR. MOSER: What about of DR. OPARIL: The most is The dose in younger people is but I would an older with DR. MOSER: how would you go adding a for DR. OPARIL: to the of the dose about DR. MOSER: any of you agree with the VI recommendations that combination therapy is as We that on data that monotherapy in about 50% of people and that that affect different physiologic are effective in about of patients. How many Dr. You have a of with DR. CUSHMAN: I think it is an but I most often use one increase the and then add other drugs. I do this in the elderly. are to going beyond a drug and this is one for failure to goal The first I tell patients, for example, is that most patients need or drugs. If I can results with one i.e., a combination of then DR. MOSER: not is and faster with a combination than with many elderly patients are already or or more a day. one is different from adding or There are a of to a combination when you expect a of about or DR. CUSHMAN: But I would to have more especially on and I with even I consider it a good DR. GLASSER: I have a different I patients on one usually a diuretic. If goal pressure is not achieved and I to add a that is when I use a combination This is not really adding a drug most of the but adding a combination in a dose as the DR. OPARIL: We have not of therapy in the elderly. I have a and most of the patients who to have a of about the they have treated I to out the are they to the or to the That is why I to use a combination as in the elderly. DR. MOSER: That but I have that of different few There is some to the VI recommendations the use of as therapy. The of this is that they might be not as therapy but as treatment if a first drug What about data to We have some good data with and in compared to monotherapy with and are as effective or more with relatively few these the may not be for this DR. CUSHMAN: A about I would push to of of or of I would use a drug or a On the other hand, I would not with a dose of a medication and the patient had a trial of a I would go to an VI dose of a drug that there is no response. We do increased with increased of an or a DR. MOSER: In the elderly, in whom of goal Bps with an an or a as monotherapy are not why not patients with a dose of a or an right from the and get a good DR. CUSHMAN: I but of I already by saying I would therapy a diuretic. DR. MOSER: Dr. what do you expect from treatment in the people over the age of In what do you that you are going to be to lower BP to a goal of Or do you a goal of 150 mm Hg and for that DR. GLASSER: It depends on the BP the elderly with a SBP of mm Hg, it will take to the pressure and it may be to mm Hg But even a Hg reduction reduces the risk of heart failure or a We may have to for less than but in some patients goal pressures can be DR. MOSER: Dr. Oparil, have you the DR. OPARIL: I agree with that. in a of elderly patients do you 140 mm Hg if you at a as mm Hg if we believe in the of beneficial it is that over a period of years you may get better DR. MOSER: Dr. Cushman, I know you agree with that and I going to you the do you think are to treat patients with Bps of mm Hg or mm Hg? Is it the about the DBP much as you the coronary does the DBP result in increased coronary events in patients with heart so How much does this with the to treat systolic DR. CUSHMAN: a this had a greater I think that much of the about treating systolic hypertension in the of DBP is the lack of that systolic a much risk than diastolic The may be on a on I about the DBP when treating to a SBP of mm Hg. There are data to suggest that a diastolic to below mm Hg, for example, risk, but not that it to do with the treatment DR. MOSER: But if the SBP from to 150 mm Hg and the DBP from 75 to mm Hg, does that mean we should be about the systolic pressure any DR. CUSHMAN: I would the at that point. On the other hand, if the systolic to 140 mm Hg and the diastolic is mm Hg, as of I would a DR. MOSER: there is a cut point at which we should and it is around the mm Hg range. DR. CUSHMAN: That is is that it is really a of and risk and that the treatment is really not any However, in the of data from treating to that of I think we need to on the of for the DR. OPARIL: I but also that it often a great of to SBP to below 160 mm Hg. DR. MOSER: BP in the systolic/diastolic or cardiovascular risk. if SBP is to >140 mm Hg, it should be treated and reduced to mm Hg, but this is often should be given at lower and to especially postural hypotension. BP should be in the in reducing and cardiovascular events in elderly patients of BP, even in patients years of of therapy a if this is the use of other i.e., and therapy is reasonable in this age group. are that this should not therapy the VI recommendations that combination therapy is effective of and are