HTN Flashcards
What is the leading cause of death in older adults and why?
CVD; HTN is a significant RF for CVD
How does age affect HTN?
HTN increases with age, especially elevated SBP
What does elevated SBP lead to in older adults?
Isolated systolic HTN (ISH)
In patients 65 and older, reduction by 10mmHg in SBP and 5mmHg in DBP correlates to what?
15% reduction in MI
40% reduction in stroke
50% reduction in CHF
10-20% in mortality
What is labile HTN?
Variability in BP readings
What is ISH?
SBP meeting HTN criteria while DBP remains normal
Generally quantified as SBP >/= 140 mmHg and DBP < 90 or 80 mmHg
Above what age do BP goals become less clear?
80 and above; aggressive therapy may present a risk rather than a benefit
What is the J-curve as it relates to events/mortality with BP?
As DBP is lowered below a certain point (100mmHg), CV events decline
At a certain point (possibly 55 or 60mmHg), CV events increase
What is the general recommendation per JNC-8 for patients aged 60+ for BP in those w/o DM or CKD?
< 150/90
Why does the 2014 JNC 8 minority committee worry about the <150/90 goal?
They are concerned that a more conservative treatment will put the high risk patients at a bigger risk of CV events
What is the AHA’s BP goal in the elderly?
< 140/90 but state this is more an expert recommendation rather than evidence-based given the lack of data in the population > 65 years
What were the drugs and conclusions in SHEP 1991?
BB/thiazide
60+ yo with ISH treated
Reduced fatal stroke and major CV events
What were the drugs and conclusions of STOP 1991?
BB/thiazide
Reduced primary endpoint, stroke morbidity/mortality/total mortality
What were the drugs and conclusions of Syst-Eur 1997?
CCB +/- ACEi/thiazide
Decreased nonfatal strokes and all nonfatal/fatal CV endpoints
CV mortality was not significantly lower
What were the drugs and conclusions of MRC 1992?
Diuretic/BB
Both reduced BP
Thiazides reduced stroke/CHD events/CV events
BB did not significantly reduce these endpoints
What BP was shown to be associated with the highest mortality in 85+ yo?
Low BP (<140/90)
What is the J curve in regards to HTN in the elderly?
An optimal DBP of 70 mmHg was found for those with ISH.
DBP may be associated with negative outcomes.
Lower DBP (and higher pulse pressure) has been associated with higher mortality.
In frail elderly, DBP < 60 mmHg –> reduced survival independent of arterial stiffness or LV function
What was shown in all antihypertensives in 80+ yo?
Decreased rates of stroke, major CV events HF
No benefit in CV death, death from all causes
What were the drugs and conclusions of of HYVET 2008?
Diuretic +/- ACEi
Goal BP < 150/80 in 80+ yo
Decreased rate of fatal/nonfatal stroke, death from stroke, death from any cause and CV death, incidence of HF w/therapy
What were the drugs and conclusions of ACCOMPLISH 2008?
Benazpril/amlodpine > benazepril/thiazide in reducing:
CV events in patients with HTN at high risk
What were the drugs and conclusions of SPRINT 2015?
Thiazide +/- ACE/ARB +/- CCB
SBP < 120 showed benefit and had decreased MI, CHF, Stroke and death
What are the pros for thiazides in elderly patients with HTN?
Reduce intravascular volume, peripheral vascular resistance and BP
Generally well tolerated
What are the cons for thiazide in elderly patients with HTN?
Lose efficacy at CrCl < 30
Decreased volume may predispose pts to orthostatis
Potential for electrolyte abnormalities and arrhythmias
ADEs consist of glucose intolerance, hyperuricemia, and dyslipidemia all of which are characteristics of conditions prominent in elderly patients
What are the pros of ACEi in elderly patients with HTN?
Decreased mortality in patients with certain disease states (HF, previous MI) and decreased progression to/of nephropathy
Well studied in older adults with positive outcomes
What are the cons of ACEi in elderly with HTN?
Hyperkalemia
AKI
What are the pros of ARBs in elderly with HTN?
Decreased mortality in those with HF
Nephro-protection
What are the cons of ARBs in elderly with HTN?
Hyperkalemia
AKI
What are the pros of DHP-CCB in elderly with HTN?
Amlodipine is well studied in older adults with positive outcomes
What are the cons of DHP-CCB in elderly with HTN?
Peripheral edema
Postural hypotension with shorter acting agents (Nifedipine IR)
Risk of precipitating MI (Nifedipine IR)
HA
What are the pros of nonDHP-CCB in elderly with HTN?
Several indications which may be beneficial in this population(angina, arrhythmias, migraines)
What are the cons of nonDHP-CCB in elderly with HTN?
Constipation
Bradycardia
Heart block
In those with underlying conduction disorders
What are the pros with BBs in elderly with HTN?
May have benefit in those with compelling indications (CAD, HF, arrhythmias, migraines, tremor)
What are the cons with BBs in elderly with HTN?
Decreased beta-receptor sensitivity in older adults d/t increased catecholamines (down-regulation)
May cause or worsen depression
Data in older patients for HTN has does not support regular use w/o compelling indications
What are the pros with Central alpha-agonists in elderly with HTN?
Potent blood pressure lowering
Reserved for resistant HTN
May be used as an adjunct therapy for neuropathic pain, menopausal sx, migraines, etc
Available in a patch for those unable to take oral medications
What are the cons with Central alpha-agonists in elderly with HTN?
Commonly associated with orthostasis
No good data for morbidity or mortality in any conditions
Is the degree of lowering or which medication more important?
Degree of lowering that is obtainable by a particular medication is more important
Which antihypertensive medications have been demonstrated to be efficacious in older adults?
All
What is the choice of agent based on in HTN?
Patient factors (compelling indications, potential for AEs, Likelihood patients can adhere to therapy, cost)
What are the first line HTN medications?
Thiazides, ACEi/ARB, long-acting CCBs (mostly DHPs)
What are the second line HTN medications?
BB - should not be used as monotherapy in older adults, reserve for those with compelling indications (h/o MI, CAD, systolic dysfunction)
What are the non-preferred HTN medications?
Vasodilators
Central alpha agonists
CV benefits are not as clear over what age?
80
What is the SBP goal in patients with ISH?
<150 mmHg
<140 mmHg if achievable w/o significant AEs
What should the DBP goal be in patients with ISH?
> 60 mmHg if possible
