Management of the Elderly Patient With Hypertension November 4, 2007 Joe Anderson, PharmD, PhC, BCPS Office: 272-3664 Em

1. Management of the Elderly Patient With Hypertension November 4, 2007 Joe Anderson, PharmD, PhC, BCPS Office: 272-3664 Email: janderson@salud.unm.edu College of Pharmacy University of New Mexico Health Sciences Center

2. Learning Objectives • Classify a patient’s blood pressure according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). • Define isolated systolic hypertension. • For a patient with hypertension, provide appropriate recommendations for lifestyle modification and pharmacotherapy. • Identify patient barriers to adherence with antihypertensive medication therapy. • Describe and demonstrate the proper procedure for measuring blood pressure according to recommendations from the American Heart Association (AHA).

3. Blood Pressure Classification: JNC VII BP = blood pressure; SBP = systolic blood pressure; DBP = diastolic blood pressure

4. Hypertension: a major risk factor for CVD • Prevalence: ~ 72 million people in the U.S. age > 20 yrs. • 1 in 3 adults have HTN • 2/3 of adults > 60 yrs have HTN • ~ 30% are unaware • 90 – 95% of cases are due to essential HTN • Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range • The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors.

5. Prevalence of Hypertensionin the United States* Hypertension Prevalence † Age *Based on NHANES 19992000 data. Hypertension is defined as blood pressure 140/90 mmHg or antihypertensive treatment. †Low reliability due to large relative error. Fields et al. Hypertension. 2004:44;398-404.

6. Hypertension Prevalence by Age and Race/Ethnicity in Men and Women Men Women Non-Hispanic WhiteNon-Hispanic BlackMexican American Hypertension Prevalence Age, y Age, y Based on NHANES 1999-2000. Error bars indicate 95% confidence intervals. Data are weighted to the US population. Hajjar I, Kotchen TA. JAMA. 2003;290:199-206.

7. Lifetime Risk of Developing HypertensionAmong Adults Aged 55 to 65 Years* Men Women Risk of Hypertension (%) Years *Residual lifetime risk of developing hypertension among adults aged 55 to 65 years with a blood pressure <140/90 mmHg. Vasan RS, et al. JAMA. 2002; 287:1003-1010.

8. 256 256 128 128 64 64 32 32 16 16 8 8 4 4 2 2 1 1 0 0 120 140 160 180 70 80 90 100 110 Blood Pressure: Lower is Better Ischemic Heart Disease Mortality Age at Risk (Y) Age at Risk (Y) 80-89 80-89 70-79 70-79 60-69 60-69 50-59 50-59 Ischemic Heart Disease Mortality Ischemic Heart Disease Mortality 40-49 40-49 Usual Systolic BP (mm Hg) Usual Diastolic BP (mm Hg) BP=Blood pressure Prospective Studies Collaboration. Lancet. 2002;360:1903-1913

9. Isolated Systolic Hypertension • SBP > 140 mm Hg with a DBP < 90 mmHg • The most prevalent form of HTN in the elderly • Results from arteriosclerosis and arterial calcification N Engl J Med 2007;357:789-96.

10. Isolated Systolic Hypertension and CVD Risk in Framingham Heart Study 2.5 ISH BP 160/<95 mmHg BP <140/95 mmHg 82 2.4 Age-adjusted annual CVD event rate per 1000 43 33 18 Men Women CVD=cardiovascular disease ISH = isolated systolic hypertension P<0.001 for difference between both men and women with ISH and blood pressure (BP) < 140/95 mmHg Wilking SV et al. JAMA. 1988;260:3451-3455.

11. Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%

12. BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 National Health and Nutrition Examination Survey, Percent II 1976–80 II (Phase 1) 1988–91 II (Phase 2) 1991–94 1999–2000 Awareness 51 73 68 70 Treatment 31 55 54 59 Control 10 29 27 34 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.

13. JNC 7 • Express—Succinct evidence-based recommendations. Published in JAMA May 21, 2003, and as a Government Printing Office publication. • Full Report—comprehensive justification and rationale.

14. Hypertension: Goals of Therapy • Reduce CVD and renal morbidity and mortality. • Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease. • Goals the same for ISH • To avoid hypoperfusion: • If SBP < 160 mmHg, goal < 140 mmHg • If SBP 160 – 179 mmHg, interim goal a decrease of 20 mmHg • If SBP > 180 mmHg, interim goal (< 160 mmHg)

15. Patient Evaluation • Evaluation of patients with documented HTN has three objectives: • Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. • Reveal identifiable causes of high BP. • Assess the presence or absence of target organ damage and CVD.

16. CVD Risk Factors • Hypertension* • Cigarette smoking • Obesity* (BMI >30 kg/m2) • Physical inactivity • Dyslipidemia* • Diabetes mellitus* • Microalbuminuria or estimated GFR <60 ml/min • Age (older than 55 for men, 65 for women) • Family history of premature CVD (men under age 55 or women under age 65) *Components of the metabolic syndrome.

17. Identifiable Causes of Hypertension • Sleep apnea • Drug-induced or related causes • Chronic kidney disease • Primary aldosteronism • Renovascular disease • Chronic steroid therapy and Cushing’s syndrome • Pheochromocytoma • Coarctation of the aorta • Thyroid or parathyroid disease

18. Target Organ Damage • Heart • Left ventricular hypertrophy • Angina or prior myocardial infarction • Prior coronary revascularization • Heart failure • Brain • Stroke or transient ischemic attack • Chronic kidney disease • Peripheral arterial disease • Retinopathy

19. Laboratory Tests • Routine Tests • Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR, and calcium • Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides • Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio • More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

20. Without Compelling Indications With Compelling Indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 Hypertension(SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist. Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices

21. Antihypertensive Treatment: Compelling Indications *ARBs may be used in patients unable to tolerate ACEIs

22. Management of HTN: Lifestyle Modification

23. Management of HTN: Lifestyle Modification • Institute of Medicine Dietary Sodium & Potassium Recommendations • Sodium • Age < 50 yrs: 65 mmol/day (~ 3.8 gm/day) • Age 51 – 70 yrs: 55 mmol/day (~ 3.2 gm/day) • Age > 71 yrs: 50 mmol/day (~ 2.9 gm/day) • Potassium • All adults: At least 120 mmol/day (~ 4.7 gm/day) • Increase dietary K+/Na+ ratio from 0.2 to 2.0 N Engl J Med 2007;356:1966-78.

24. Treatment of Hypertension: Clinical Studies Randomized Controlled Trials in Isolated Systolic Hypertension (ISH) ns ns ns ns SHEP: Systolic Hypertension in the Elderly, n=4,736; 1st drug: chlorthalidone Syst-Eur: Systolic Hypertension in Europe, n=4,695; 1st drug: nitrendipine BP differences between randomized treatment groups were 12/4 in SHEP, 10/4 in Syst-Eur

25. Treatment of Hypertension: Clinical Studies • Meta-analysis of 8 trials in elderly patients with ISH (SBP > 160 & DBP < 95 mmHg) • Treatment for mean 3.8 years: • Decreased mortality by 13% • Decreased CV mortality by 18% • Decreased stroke by 30% • Decreased CHD events by 23% Lancet 2000;355:865-72.

26. Treatment of Hypertension: Clinical Studies • The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) • Randomized, double-blind, multi-center clinical trial • Determine whether occurrence of fatal CHD or nonfatal MI is lower for high-risk hypertensive patients treated with newer agents (CCB, ACEI, alpha-blocker) compared with a diuretic • 42,418 high-risk hypertensive patients ≥ 55 years JAMA 2002;288:2981-2997.

27. .2 .16 .12 Cumulative CHD Event Rate .08 .04 0 Cumulative Event Rates for the Primary Outcome (Fatal CHD or Nonfatal MI) by ALLHAT Treatment Group Chlorthalidone Amlodipine Lisinopril www.allhat.org JAMA 2002;288:2981-2997 0 1 2 3 4 5 6 7 Years to CHD Event Number at Risk: Chlorthalidone 15,255 14,477 13,820 13,102 11,362 6,340 2,956 209 Amlodipine 9,048 8,576 8,218 7,843 6,824 3,870 1,878 215 Lisinopril 9,054 8,535 8,123 7,711 6,662 3,832 1,770 195

28. .1 .08 .06 Cumulative Stroke Rate .04 .02 0 0 1 2 3 4 5 6 7 Years to Stroke Cumulative Event Rates for Stroke by ALLHAT Treatment Group Chlorthalidone Amlodipine Lisinopril www.allhat.org JAMA 2002;288:2981-2997 Number at risk: Chlor 15,255 14,515 13,934 13,309 11,570 6,385 3,217 567 Amlo 9,048 8,617 8,271 7,949 6,937 3,845 1,813 506 Lisin 9,054 8,543 8,172 7,784 6,765 3,891 1,828 949

29. Cumulative Event Rates for All-Cause Mortality by ALLHAT Treatment Group .3 .25 .2 Chlorthalidone Amlodipine Lisinopril .15 Cumulative Mortality Rate .1 .05 www.allhat.org JAMA 2002;288:2981-2997 0 0 1 2 3 4 5 6 7 Years to Death Number at risk: Chlor 15,255 14,933 14,564 14,077 12,480 7.185 3,523 428 Amlo 9,048 8,847 8,654 8,391 7,442 4,312 2,101 217 Lisin 9,054 8,853 8,612 8,318 7,382 4,304 2,121 144

30. Cumulative Event Rates for Combined CVD by ALLHAT Treatment Group .5 .4 .3 Chlorthalidone Amlodipine Lisinopril Cumulative Combined CVD Event Rate .2 .1 www.allhat.org JAMA 2002;288:2981-2997 0 0 1 2 3 4 5 6 7 Years to Combined CVD Event Number at risk: Chlor 15,255 13,752 12,594 11,517 9,643 5,167 2,362 288 Amlo 9,048 8,118 7,451 6,837 5,724 3,049 1,411 153 Lisin 9,054 7,962 7,259 6,631 5,560 3,011 1,375 139

31. Cumulative Event Rates for Heart Failure by ALLHAT Treatment Group .15 .12 Chlorthalidone Amlodipine Lisinopril .09 Cumulative CHF Rate .06 .03 www.allhat.org JAMA 2002;288:2981-2997 0 0 1 2 3 4 5 6 7 Years to HF Number at risk: Chlor 15,255 14,528 13,898 13,224 11,511 6,369 3,016 384 Amlo 9,048 8,535 8,185 7,801 6,785 3,775 1,780 210 Lisin 9,054 8,496 8,096 7,689 6,698 3,789 1,837 313

32. Treatment of Hypertension • Thiazide diuretics have repeatedly been demonstrated to prevent the cardiovascular complications of hypertension, and are 1st line drugs for uncomplicated hypertension • Thiazide diuretics enhance the efficacy of most other antihypertensive drugs and are therefore useful as add-on therapy • ACE inhibitors, angiotensin receptor antagonists, or beta-blockers should be used as 1st line treatments in patients with compelling indications • Most patients will require at least 2 drugs to achieve goal BP

33. Follow-up and Monitoring • Follow-up should occur at least monthly until goal BP is reached • Serum potassium and creatinine should be monitored 1-2 times per year • Once BP is at goal and stable, follow-up can occur every 3-6 months; more frequently if the patient has other co-morbidities

34. Follow-up and Monitoring: Drugs • Thiazides • Adverse Effects • loop/thiazide diuretics: hypokalemia, hypomagnesemia, hyperuricemia, hyperglycemia • Monitoring • blood pressure • serum creatinine and BUN • serum potassium, magnesium, glucose

35. Follow-up and Monitoring: Drugs • Thiazides • Adverse Effects • loop/thiazide diuretics: hypokalemia, hypomagnesemia, hyperuricemia, hyperglycemia • Monitoring • blood pressure • serum creatinine and BUN • serum potassium, magnesium, glucose

36. Follow-up and Monitoring: Drugs • ACE-inhibitors • Adverse Effects • dry, non-productive cough (1-10% incidence), taste disturbances (2-7% incidence), skin rash (1-7% incidence), hyperkalemia (1-4% incidence), angioedema (very rare, but very serious) • elevations in serum creatinine and BUN (common) • neutropenia (rare) • Monitoring • blood pressure • serum potassium, • serum creatinine and BUN • CBC

37. Follow-up and Monitoring: Drugs • Angiotensin II receptor antagonists • Adverse Effects • angioedema (very rare, but very serious, potential for cross reactively b/w ACEIs) • elevations in serum creatinine and BUN (common) • Monitoring • blood pressure • serum potassium, • serum creatinine and BUN

38. Follow-up and Monitoring: Drugs • Beta-blockers • Adverse Effects • smooth muscle constriction (bronchospasm and cold extremities) • exaggerated cardiac response (bradycardia, heart block, decreased contractility) • CNS penetration (insomnia, fatigue, dizziness, depression); may be more common with lipophilic agents • Monitoring • blood pressure • heart rate • query patient regarding CNS disturbances • symptoms of heart failure, breathing difficulties, etc. in patients predisposed to these problems

39. Follow-up and Monitoring: Drugs • Calcium Channel Blockers • Dihydropyridines • Adverse Effects • hypotension, dizziness • peripheral edema • Non-Dihydropyridines • Adverse Effects • hypotension, dizziness • constipation (esp. verapamil) • bradycardia • exacerbation of heart failure

40. BP classification SBP* mmHg DBP* mmHg Lifestyle modification Initial drug therapy Without compelling indication With compelling indications Normal <120 and <80 Encourage Prehypertension 120–139 or 80–89 Yes No antihypertensive drug indicated. Drug(s) for compelling indications. ‡ Stage 1 Hypertension 140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications.‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension >160 or >100 Yes Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Management of HTN: JNC VII *Treatment determined by highest BP category. †Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

41. T.J. is a 63-year-old African-American male who has been referred to the pharmacist-managed hypertension clinic. Following 3 separate determinations, T.J.’s BP averages 158/108 mm Hg. He also has diabetes and hyperlipidemia. All laboratory values are normal except for a serum creatinine of 1.7 mg/dL and 2+ proteinuria. His ECG meets the criteria for left ventricular hypertrophy. He weighs 72 kg.

42. How should T.J.’s hypertension be classified? A. Prehypertensive B. Stage 1 C. Stage 2 D. Hypertensive urgency

43. What is an appropriate treatment strategy for T.J. at this point? • Lifestyle modification alone • Lifestyle modification + single-drug therapy • Lifestyle modification + 2-drug therapy • Single-drug therapy alone • 2-drug therapy alone

44. What is T.J.’s goal BP? • < 120/75 mmHg • < 120/80 mmHg • < 130/80 mmHg • < 130/90 mmHg • < 140/90 mmHg

45. Which of the following lifestyle interventions should be recommended for T.J.? I. Low salt diet II. Low potassium/high calcium diet III. Abstinence from alcohol • I only • III only • I and III only • II and III only • All of the above should be recommended

46. Considering the management of risk factors and coexisting conditions, the preferred antihypertensive regimen for T.J. would be which one of the following? • Atenolol + HCTZ • Nifedipine GITS + HCTZ • Doxazosin + lisinopril • Captopril + amlodipine • Furosemide + metoprolol • HCTZ + benazepril

47. Adherence to Medication “Drugs don’t work in patients who don’t take them.” — C. Everett Koop, M.D. • Adherence to medications for chronic disease is estimated to be 50% • Recent study of patients treated for both HTN and Hyperlipidemia revealed adherence to both medications was only 44% at 3 months, 36% at 6 months and 36% at 12 months N Engl J Med 2005;353:487-97. Arch Intern Med. 2005;165:1147-1152

48. Adherence to Medication • Factors Contributing to Medication Adherence • Misunderstanding of the condition or treatment • Denial of illness because of lack of symptoms • Perception of drugs as symbols of ill health • Lack of patient involvement in the care plan • Unexpected adverse effects of medications • Cost of medications

49. Adherence to Medication • Clinicians contribute to patients’ poor adherence • Prescribing complex regimens • Failing to explain the benefits and side effects of a medication adequately • Not considering the patient’s lifestyle • Not considering the cost of the medications • Having poor therapeutic relationships with their patients

50. Adherence to Medication • Methods of Improving Medication Adherence • A patient-centered strategy is crucial for treatment success • encourage a positive attitude about achieving treatment goals • educate patients about medication side effects • educate patients about the disease and its complications • keep care inexpensive and simple • maintain contact with patients; consider telecommunication • encourage patients to monitor BP at home