Principles of Blood Pressure Control in the Elderly

Posted on October 18, 2011 - 2:00pm

THE PROBLEM

Hypertension can be difficult to manage in the elderly. They are at an increased risk of high blood pressures, are more likely than younger patients to have conditions in which blood pressure control is important (such as heart failure or aortic aneurysm), but also have increased risks of adverse drug reactions and orthostatic hypotension, which can increase the risk of falls and fainting.

In general, many internists are more liberal with blood pressure control goals in elderly patients (for instance having goal systolic blood pressures in the 140-150’s mmHg, instead of < 130mmHg). However,  there has been increasing evidence that even patients over 80 years old could benefit from lower target blood pressure (for instance  as discussed in the HYVET trial).

The Journal of American Cardiology recently published new guidelines on the management of high blood pressure in elderly patients. It includes a brief summary of the pathophysiology of hypertension in the elderly as well as the benefits and the risks of tight blood pressure goals in the elderly.

The following is a LIMITED summary of their major recommendations (it does not include recommendations from competing groups (many of whom would disagree with some of the recommendations below), or my personal recommendations). 

NOTE THAT THE MANAGEMENT OF BLOOD PRESSURE NEEDS TO BE INDIVIDUALIZED FOR A PATIENT, AND THE FOLLOWING SHOULD NOT BE TAKEN AS RECOMMENDATIONS FOR A PARTICULAR PATIENT.

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DIAGNOSIS OF HYPERTENSION

To diagnose hypertension, JACC recommends measuring blood pressure three times in at least two separate visits, with five minute intervals after the patient has been seated, arms and feet supported.

Physicians should be aware of common conditions which can lead to the misdiagnosis of hypertension.

Pseudohypertension: Falsely elevated systolic pressures because of calcified arteries that are difficult to compress. More common in the elderly. Suspect in patients with resistant hypertension, lack of evidence of end-organ damage or symptoms of overmedication.

White coat hypertension: High blood pressure in the office not seen at home. Recommendation:  ambulatory blood pressure monitoring with hypertension without evidence of end-organ damage, when suspect syncope or hypotensive episodes. Reasonable to consider ambulatory blood pressure monitoring for all elderly hypertensive patients because of the risks of over-control of blood pressure.

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BLOOD PRESSURE GOALS

The goal of blood pressure treatment for uncomplicated hypertension is to get to a BP< 140/90. In general, this is the same in elderly patients, but this is based on expert opinion, rather than randomized controlled trials.

The Goal BP for patients > 80 years old is generally to reach a Systolic Blood Pressure (SBP)= 140-145: However, there is limited data about the best agents to use in the elderly (most trials excluded patients over 80 years old).

  • It is not clear if the blood pressure goals should be different in patients 65-79 years old than those > 80 years old. The task force pooled data from multiple trials, which showed that patients treated for hypertension had a reduced morbidity from heart attack and stroke but also, that there was a trend toward increased all-cause mortality.
  • Patients > 80 years old on blood pressure medications should have frequent visits with their seated and standing blood pressures checked.
  • Avoid BP < 130/65.

Specific Co-morbidities:

Hypertension + coronary artery disease: Some guidelines recommend a goal blood pressure < 130/80 but there are only limited data in elderly patients. Nadir for BP risk 135/75 among patients 71-80 years and 140/70 in patients over 80 years old.

Heart failure: In associated heart failure, expert opinion recommends goal blood pressure < 130/80.

Diabetes: Consensus recommend target blood pressure < 130/80 but reasonable goal < 140 based on ACCORD BP trial (no benefit to BP < 120 compared to SBP < 140 in patients > 55 years old) in INVEST trial (increased mortality at SBP < 115 or DBP < 65).

Resistant hypertension: After appropriate work-up and management of possible causes, consider combination of an behavioral combination. ACEi or ARB, calcium channel blocker and appropriately dosed loop diuretic.

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RECOMMENDATIONS FOR EVALUATION:

The following are based on expert opinions of the American College of Cardiology Task Force because there is limited data about the BP management in the elderly:

  • Identify reversible and treatable causes
  • Obtain focused history, collecting information on the duration and severity of high blood pressure.
  • Collect  information on prior treatments and adverse drug reactions
  • Obtain past medical history including history of heart disease, stroke, renal dysfunction and diabetes.
  • Consider search for renal artery stenosis in patients with refractory hypertension.
  • Look for evidence of end-organ damage
  • Check urine for albuminuria and hematuria,
  • Check blood chemistries including potassium and creatinine.
  • Assess for other cardiovascular risks
  • Check total cholesterol, low-density cholesterol, high-density cholesterol, triglycerides.
  • Check fasting glucose and consider checking hemoglobin A1c if risk factors for diabetes.
  • Check EKG
  • In selected elderly patients consider checking transthoracic echocardiogram for evidence of left ventricular hypertrophy
  • Identify barriers to treatment adherence. A large number of elderly patients do not follow their treatment recommendations. Risk factors to non-adherence include:
  • Increasing age,
  • Previous non-adherence,
  • Competing health problems,
  • Non-white race,
  • Low socioeconomic status,
  • Treatment regimen complexity,
  • Side effects,
  • Costs.

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RECOMMENDATIONS FOR MANAGEMENT

1. Non-pharmacological measures may be sufficient to control blood pressure, or allow reduced doses of blood pressure medications:

  • Stop smoking
  • Weight reduction if overweight Associated with lower blood pressures in overweight people.
  • Reduce stress
  • Decrease sodium in diet
  • Reduce alcohol intake: Two or more alcoholic drinks per day are associated with higher blood pressures, and BP tends to decrease with reduced alcohol intake. Note: there is limited evidence in the elderly of the effects of reducing alcohol intake on blood pressure.
  • Increase physical activity: Moderate exercise leads to decreased blood pressures.
  • Increased potassium intake: Diets higher in potassium (such as high in fruits or vegetables) or potassium pills are associated with lower blood pressures, especially in people with high sodium diets.
  • Involve a multidisciplinary team Include nurses, pharmacists, physician assistants, clinical psychologists and others.
  • Consider technological enhancements such as telemedicine and reminders.

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2. Pharmacological interventions:

PRINCIPLES:

  • START LOW AND GO SLOW: Start antihypertensive at a low dose and titrate up slowly to the maximum tolerated dose, to a target of SBP < 140 mmHg in patients < 80 years old. If the blood pressure is > 20/10 mmHg above target consider start two agents.
  • In many cases the choice of agent isn’t as important as using whatever regimen works to attain the goal blood pressure, as tolerated. There are many exceptions to the rule; see more below.

Specific drug class to consider:

  • Thiazides, for instance hydrochorothiazides, chlorthalidone, bendrofluazide.As for younger patients, these agents are recommended first line for hypertensive patients without a history of heart disease or diabetes, history of a stroke with an ACEi, patients with osteoporosis, patients > 80years old, other medical conditions dictating choice of other agent.
    • Advantages:  They initially cause a reduction in intravascular volume, peripheral vascular resistance and blood pressure, and are well-tolerated in most patients. They are associated with decreased cardiovascular events in the elderly.
    • Disadvantages:  In the elderly can increase risk of orthostatic hypotension. Diuretics can increase the risk of electrolyte abnormality and increase risk of sudden cardiac death. Diuretics can exacerbate gout, glucose intolerance and dyslipidemia. Avoid in diabetes or pre-diabetes.
  • Angiotensin receptor blockers: Selectively block AT1-receptor. Reduce blood pressure, are well-tolerated, protect the kidney, and decrease mortality and morbidity in patients with heart failure. Are considered first line for elderly patients with diabetes. Are an alternative agent in patients with hypertension and heart failure in patients intolerant of ACEi. Often effective in patients with resistent hypertension.
  • Angiotensin converting enzyme inhibitors. Use in elderly patients with systolic dysfunction and coronary artery disease, history of a stroke with a diuretic, chronic kidney disease with proteinuria > 300 mg/d, or diabetes, patients > 80years old if lack medical conditions dictating choice of other agent:
    • Advantages:  Block conversion of angiotensin I to II, leading to decreased peripheral vascular resistance and blood pressure without causing a reflex increase in heart rate and contractility. They are associated with decreased morbidity and mortality in patients with a history of heart failure, decreased systolic function after a myocardial infarction, and slow progression of kidney disease in patients with hypertension or diabetes. May be the most effective agents for reduction of left ventricular mass.
    • Disadvantages:  Adverse drug reactions include hypotension, cough, angioedema and rash, renal failure if renal artery stenosis, high potassium (especially if renal failure or taking potassium supplements). Rarely can cause neutropenia and agranulocytosis. Not as effective as single agents for blood pressure controls in Blacks unless combined with diuretics or calcium channel blockers.
  • Non-thiazide diuretics:
    • Indapamide:  A sulfonamide diuretic. Associated with increased blood glucose but not uric acid. Can prolong QT independent of potassium. Use with caution in a patient on lithium.
    • Furosemide, torsemide, bumetanide:  Consider for patients with diastolic heart failure and fluid retention. Loop diuretics, frequently used to control blood pressure in patients with heart failure or kidney disease. Associated with increased blood glucose, headaches, fever, anemia and electrolyte abnormalities. May want to avoid with osteoporosis because associated with decreased plasma calcium.
    • Spirinolactone, eplerenone:  Sodium transport channel antagonists. Useful as a secondary agent in blood pressure management. Associated with potassium retention. Consider in patients with history of calcium oxalate stones because associated with decreased urinary calcium.
  • Beta blockers. Recommended first line for patients with history of coronary artery disease or if have history of supraventricular or ventricular tachyarrhythmias, heart failure, hypothyroid, pre-operative hypertension, migraine or essential tremor.
    • Advantages:  May have benefits in combination with other agents. Useful for management of other diseases common in the elderly (for instance heart disease). Newer beta blockers with significant decrease in adverse drug events.
    • Disadvantages:  Does not have convincing evidence of benefit in the elderly for hypertension as a single agent. Older beta blockers associated with depression, sexual dysfunction, dyslipidemia, glucose intolerance.
  • Alpha blockers: Effective for blood pressure control. Not used first line in elderly because shown in ALLHAT trial to be associated with increased risk of heart failure and stroke (doxazosin versus chlorthalidone)
  • Calcium channel blockers, such as diltiazem, verapamil, amlodipine, nifedipine. Consider especially ii a patient with a history of supraventricular tachycardia and angina.
    • Advantages: Shown safe and effective in the elderly. May be particularly good choice in the elderly because they have increased risk of stiff vessels and diastolic dysfunction. ACCOMPLISH trial showed calcium channel blockers with ACEi lead to a greater reduction in cardiovascular events in diabetics than ACEi + hydrochorothiazides.
    • Disadvantages:  Dihydropyridines (such as amlodipine and nifedipines) are associated with vasodilation (edema, headache and postural hypotension). Verapamil and diltiazem can cause heart block and should not be used if conduction system disease. Nifedipine, verapamil and diltiazem should be avoided in patients with left ventricular dysfunction.
  • Direct renin inhibitors, for instance alikrein. Recommended with beta blockers and long-acting calcium channel blockers in patients with a history of coronary artery disease and reduced systolic function:
    • Advantages: As effective as ARBs or ACEi for blood pressure control. Not associated with dose-related increases in adverse events in the elderly. Appears to be well-tolerated in patients > 75 years old.
    • Disadvantages: Limited data in benefits compared to beta blockers, ACEi and black hypertensive patients. Associated with diarrhea. No data about use in patients with GFR < 30 mL/min/1.73 mm2.
  • Non-specific vasodilators, such as hydralazine, minoxidil, clonidine. Considered fourth in line because of multiple adverse effects. Used alone, these drugs cause tachycardia, whereas minoxidil is associated with fluid retention and atrial arrhythmias and clonidine with sedation and bradycardia, and abrupt withdrawal with exacerbation of hypertension and heart rate.

Selected combination regimens:

  • ACEi + long-acting calcium channel blocker: Shown the in the ACCOMPLISH trial to have decreased mortality and morbidity in high risk hypertensive elderly patients compared to ACEi-HCTZ.
    • ACEi + beta blocker + diuretic + aldosterone antagonist: Consider this combination in elderly patients with hypertension and systolic dysfunction, if no hyperkalemia or renal dysfunction. If ACEi intolerable consider ARB. If black, consider hydralazine + isosorbide dinatrate in place of the ACEi or ARB.
    • Diuretic + ACEi: Consider for patients with history of stroke.
    • ACEi/ARB + beta blocker: Consider for patient with history of aortic aneurysm.

Adjust regimen if inadequate blood pressure control on one agent:

  • Add an additional agent from another class:
  • Consider if unable to meet goal blood pressure at maximum tolerated dose of first agent.

  • FIRST CHECK ADHERENCE, EFFECTS OF POLYPHARMACY AND DRUG INTERACTIONS.

  •  If a diuretic not already in place, is generally recommended as a second agent. Consider a third agent if response inadequate on the maximum doses of two agents.

Author:

Liesbeth I. Tryzelaar, MD, is an Internist and Geriatrician living in Mass.

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Reference:

Wilbert, S et al. 2011. “ACCF/AHA 2011 Expert Consensus Document on Hypertension in the elderly: A report …” JACC. 57:2037-2114.