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preventing hypertension in older adults


preventing hypertension in older adults

The Epidemiology and Severity of Hypertension in Senior AdultsHypertension, which is one of the main modifiable risk factors of cardiovascular disease (CVD), increases with age. The US National Health and Nutrition Examination Surveys (NHANES) show that hypertension is a major risk factor for cardiovascular disease in older adults. In 2014, 15% of the US population had hypertension. This figure is expected to rise to 20% by 2052. Despite being at the highest risk for CV morbidity or mortality and hypertension, older adults are often undertreated for high blood pressure (BP). These patients have been historically excluded from clinical trials or underrepresented due to concerns about frailty and fall risk, poor kidney function, abnormal hemodynamic adaption, higher risk of autonomic dysfunction, cognitive impairment, and polypharmacy. As we age, the gap between biological and chronological age increases. Therefore, it is possible that chronological age is a poor indicator of biological age. Furthermore, guidelines for identifying older patients are inconsistent. BP treatment targets remain controversial. Hypertension Guidelines Reviewed Several major medical societies have published guidelines on hypertension that highlight the difficulties of managing BP in elderly patients. The American College of Physicians and the American Academy of Family Physicians (AAFP), released guidelines in January 2017 for managing BP in adults over 60 years. For persistently high systolic BP (SBP>=150 mmHg), pharmacotherapy is recommended to lower the risk of atherosclerotic heart disease (ASCVD). (Table 1). Table 1: Comparison of blood pressure thresholds and targets between ACC/AHA and ACP/AAFP and ESC/ESH guidelines ACC/AHA 2017 ACP/AAFP 2017 ESC/ESH 2018 Definition of older patients >=65 years >=60 years Elderly 65-79 Very Old >=80 Years BP Threshold to Initiate Pharmacotherapy Very Old >=160/90mmHg Blood Pressure Target 130/80mmHg SBP 150mmHg sBP 130-139mmHg DBP 70-79mmHg The American College of Cardiology/American Heart Association (ACC/AHA), hypertension guideline, introduced new definitions of BP management in November 2017. (Table 1). The blood pressure can now be classified as normal, elevated, or stage 1 or 2. Normal blood pressure is 120/80mmHg, while elevated blood pressure is 120-129/80mmHg. Stage 1 hypertension can be defined as SBP 130-139mmHg, and/or diastolic bp (DBP), 80-89mmHg. Stage 2 hypertension refers to SBP >=140mmHg and/or diastolic BP (DBP) >= 90mmHg. Based primarily upon the Systolic blood pressure intervention trial (SPRINT), a higher target SBP of 130 mmHg for most adults is recommended. This guideline acknowledges that there are no randomized controlled trials (RCTs), for patients who have a history of falls or advanced cognitive impairment.

The 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH BP guideline) categorizes older adults into two subgroups. "Elderly" refers to patients aged 65 to 79 years, while "very old" refers to those over 80 years (Table 1). The guideline suggests that older patients should receive pharmacologic treatment if their SBP is greater than 160 mmHg. Patients over 65 years old can have a lower therapeutic target (SBP 130-139) and DBP 70-79 mg mmHg. However, this is not recommended for patients older than 80 years. Fit individuals over 80 years old with an initial SBP of >=160 mmHg or DBP >=90 mmHg may be eligible for pharmacologic therapy. The treatment will aim to achieve a BP between 130-139/70 -79 mmHg.9 This decision should be based upon a complete review of comorbidities and a clinical assessment of biological age. Particularly for frail patients, the side effects of treatment should be monitored closely. Although the American and European guidelines have different treatment thresholds and definitions, they both recognize the importance of BP treatment for older adults to lower the risk of atherosclerotic heart disease (ASCVD). However, they recommend a cautious approach and careful monitoring of these patients. Table 1 lists the hypertension treatment goals for older adults according to American guidelines and European guidelines. Hypertension Management for Older Adults With History of Coronary Artery Disease (CAD). The 2017 ACC/AHA guideline-recommended a target BP of 130/80 mmHg in older patients (age >=65 with stable ischemic cardiomyopathy (SIHD).8 However, this target DBP only received a level of evidence C (limited data meta-analysis) and was based on expert opinion. Moreover, the ACC/AHA guideline did not address the issue of lowering the BP thresholds in older patients with SIHD. Due to a dearth of RCTs, the guideline does not address the issue of BP thresholds that are less intensive for older patients with SIHD. In SPRINT, patients over 75 years old were assigned to intensive BP lowering. The primary CV endpoint was nonfatal myocardial injury (MI), acute coronary syndrome (not resulting in an MI), and CV mortality. However, the hazard ratio (HR), 0.66 vs 0.8 was higher in older subjects. The analysis did not include SAEs that could have been directly or possibly linked to the intervention, which might have led to higher rates of events in the intensive treatment group.

Sources:

https://www.cdc.gov/bloodpressure/prevent.htm

https://www.hopkinsmedicine.org/health/conditions-and-diseases/high-blood-pressure-hypertension/hypertension-what-you-need-to-know-as-you-age




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