HTN, Dyslipidemia, SIHD Flashcards
Incidence of hypertension increases…
As we age
Hypertension in older adults often presents as…
Isolated systolic hypertension (ISH)
SBP more closely correlated with CV risk in patients 50+
Some physiological changes associated with HTN include ____. This increases risk for…
Decreased baroreceptor response, impaired cerebral autoregulation
Increased risk for orthostatic hypotension
We should avoid overly-aggressive BP reductions because…
Risk of tissue hypoperfusion and ischemia - keep DBP above 60
There is good evidence from multiple epidemiological + clinical studies, that lowering high BP reduces risk of…
CV events - MI, stroke, sudden cardiac death
HF, peripheral artery disease
CKD
The SPRINT-MIND trial demonstrated…
Decreased risk of mild cognitive impairment with intensive BP control (<120) vs. standard (<140) control over 5 years
Health behaviour management is key to reducing BP - however, in older adults we should be careful with some aspects such as…
Advising weight reduction - may increase frailty
Sodium restriction = hyponatremia, increased risk for orthostatic hypotension
Consider frailty with physical activity levels
To avoid unnecessary HTN treatment, we should teach and reinforce…
Proper BP measurement - avoiding artifically high readings
The SPRINT-Elders trial showed…
Benefit for preventing CV related deaths with intensive BP management (<120)
Non-significant increase in AE’s (hypotension, syncope, AKI)
When analyzing the SPRINT-Elders trial, we need to be aware of practical considerations, such as…
Numerous patient population excluded - diabetes, post-stroke/MI, orthostatic hypotension, dementia (increased fall risk)
Avg of 1 more drug per person - can they handle it?
Orthostatic hypotension is defined as…
> 20 systolic or >10 diastolic drop in BP within 1-3 minutes of standing
Orthostatic hypotension is a risk factor for…
Falls, hospitalizations, CV events
Functional decline
Asymptomatic still increases fall risk
Orthostatic hypotension is associated with…
Increased age
Diabetes
Parkinson’s disease
Dementia
Medications
Diastolic hypotension is an issue because…
It can lead to myocardial ischemia - avoid DBP dropping below 60 in individuals with established coronary artery disease
We should avoid intensive BP targets in frail patients because…
Risks (orthostatic hypotension, falls) + treatment burden likely will outweigh benefits.
Time to benefit is ~2.5 years - is this applicable to patient?
Inquire about patient/family preference
We should reconsider intensive BP targets in patients when…
Functional dependency, limited life expectancy, dementia present
Orthostatic hypotension, diastolic hypotension
SPRINT exclusion criteria
Patient/family preference
When choosing antihypertensives, we should ask…
Is there a compelling indication for one or more of the antihypertensive agents?
Similar to general population
If there is no compelling indication for specific anti-HTN medications, we should choose…
Agents indicated for isolated systolic hypertension
ARB, TZD, DHP-CCB
HTN medications for diabetes include…
ACE/ARB for microalbuminuria - DHP-CCB > TZD 2nd line
No microalbuminuria = ACE/ARB, DHP-CCB, or TZD’s
HTN medications for CAD include…
ACE/ARB - beta-blocker or CCBs for patients with stable angina
HTN medications for HF include…
Remember quadruple therapy - ACE/ARB or ARNI, Beta-blocker, MRA, SGLT2i
HTN medications for past-stroke or TIA include…
ACE/ARB, TZD combination
HTN medications for non-diabetic CKD with proteinuria include…
ACE/ARB, diuretics as additive therapy
If our patients have persistently high blood pressure despite treatment, we should evaluate…
Adherence
Secondary causes of hypertension (medications - NSAID’s)
With diuretics, we need to monitor…
Electrolytes - specifically potassium + sodium
TZD’s may increase gout risk
Watch for orthostatic hypotension + worsening urinary urgency/incontinence
With ACEI/ARB’s we should monitor…
Electrolytes - potassium
SCr
Sitting + standing BP
Angioedema (rare)
Generally well tolerated
CCB’s can cause or exacerbate…
Peripheral edema, especially at higher doses
Non-DHP CCB likely to be constipating
Can split dose or take at nighttime to minimize
Non-DHP CCB’s should be avoided in…
HFrEF
Combination with beta-blockers
Non-DHP CCB’s may be useful to…
Control HR in AFib
Beta-blockers are not recommended as…
First line anti-HTN medications for adults 60+
Beta-blockers are recommended in older adults if compelling indications exist. This includes…
Post-MI
HFrEF
Rate control in AFib
May be used as add-on therapy for HTN
With beta-blockers we need to monitor…
Fatigue
Decreased exercise tolerance
Contribution to degree of frailty?
Statin use for secondary prevention of CV events…
Should be started/continued regardless of age - mild-moderate frailty
Benefits generally outweigh risks
Time to benefit ~2 years
Statin use for primary prevention of CV events after 75 years of age…
Lack of evidence to support who should receive statin therapy for primary prevention of CV events
Shared decision making regarding CV risk factors, functional status, medication burden, AE’s from statin
Generally benefits > risks but consider the individual
Evidence for high vs. moderate intensity statin therapy indicates…
High-dose statins for high-risk patient groups (Post-MI, post-stroke) - however, more susceptible to statin AE’s, but benefit > risk
Moderate-dose statins may be preferred in older adults especially outside of acute post-event period (1 year)
Do other cholesterol medications have a role in older adults?
Limited role
PCSK-9 inhibitor for familial hypercholesterolemia
Fibrates in severe hypertriglyceridemia
Ezetimibe - limited evidence for improving CV outcomes with/without statins
Consider deprescribing if appropriate to decrease pill burden
Stable coronary artery disease is defined by history of severe atherosclerosis. This includes…
Stable angina
Previous ACS or PCI
Coronary artery bypass grafting
Signs, symptoms, complications of inadequate blood flow to heart muscle due to atherosclerosis
Considered secondary CV disease prevention
CAD is considered stable when…
There is no CV event in the past year
When evaluating stable CAD, we should consider…
Time since event
Symptom stability
Activity level
Patient goals + preferences
Medication regimen post-ACS usually includes…
ACEI/ARB
Beta-blocker
Statin
ASA (indefinitely)
Other anti-HTN needed to control BP
Other anti-anginals if needed - CCB’s (if BB CI or not tolerated), nitroglycerin
If there is a history of GI bleed, this can be given with indefinite ASA…
PPI
Beta-blockers have evidence of ____ up to 3 years, ____
Reducing CV risk post-MI - titrated to resting HR of ~60 BPM
Beta-blockers can be re-evaluated post-MI based on…
Symptoms and comorbidities
Indefinitely for HFrEF, can continue if angina symptoms continue or for AFib requiring rate control
Poorly tolerated = re-evaluate of 3+ years post-MI
Short-acting nitroglycerin can be used for…
Rescue
Prophylactically, prior to activities which provoke symptoms
Always good to have just in case
With nitroglycerin, we should monitor for…
Dizziness, headache
Hypotension
Flushing
Edema
Ensure proper use
Long-acting nitrates (patches) may be added when…
BB +/- CCB’s are CI, not tolerated, or not providing adequate symptoms relief
Monitor BP - ensure adequate nitrate free period
