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hypertension

Choosing a First-Line Drug for Older Adults with Hypertension: An Evidence-Based Approach

Choosing a First-Line Drug for Older Adults with Hypertension: An Evidence-Based Approach

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2
Teaser: 

James M. Wright, MD, PhD, CRCP(C), Professor, Departments of Anesthesiology, Pharmacology & Therapeutics and Medicine, University of BC, Coordinating Editor, Cochrane Hypertension Review Group, Vancouver, BC.

Abstract
Choosing the optimal first-line drug for patients with hypertension must address a hierarchy of treatment goals: reduction in mortality and morbidity, efficacy in lowering blood pressure, ensuring tolerability, and minimizing cost. This article examines the evidence for the different classes of first-line antihypertensive drugs in light of these four goals. The evidence indicates that first-line low-dose thiazides are better than or equivalent to other antihypertensive drug classes for each of the goals of therapy in both people with hypertension in general and in older adults ≥ 60 years of age.
Keywords: hypertension, thiazide, first-line, older adults, evidence-based.

Selecting Initial Antihypertensive Therapy for Older Adults

Selecting Initial Antihypertensive Therapy for Older Adults

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2
Teaser: 

Norm Campbell, MD, FRCPC, Departments of Medicine, Community Health Sciences, and Pharmacology and Therapeutics, University of Calgary, Calgary; Libin Cardiovascular Institute, Calgary, AB.
Sailesh Mohan, MD, MPH, Departments of Medicine, Community Health Sciences, and Pharmacology and Therapeutics, University of Calgary, Calgary; Libin Cardiovascular Institute, Calgary, AB.

As over 9 in 10 older adults will develop hypertension, it is important for clinicians to routinely assess blood pressure. It is as important to treat hypertension in older adults as it is in younger people. In general, select a low-dose diuretic. Beta-blockers are not as effective at preventing stroke as other major antihypertensive drug classes. Specific indications for drug classes are provided. Target the blood pressure levels to <140/90 mmHg in general, <130/80 mmHg in people with diabetes or chronic kidney disease, and focus on systolic blood pressure control. If blood pressure control is not achieved using a moderate dose of your initial selection, add a second antihypertensive drug.
Key words: hypertension, antihypertensive drugs, pharmacotherapy, cardiovascular disease, stroke.

Treating Hypertension in the Very Elderly Reduces Death and Disability: New Information from the HYVET Trial

Treating Hypertension in the Very Elderly Reduces Death and Disability: New Information from the HYVET Trial

Teaser: 

M. Faisal Jhandir, MD, RVT, Clinical Assistant Professor of Medicine, Co-Chair Vascular Risk Reduction Program, University of Calgary, Calgary, AB.
Robert J. Herman, MD, FRCPC, Professor of Medicine, Head, Division of General Internal Medicine, University of Calgary, Calgary, AB.
Norm R.C. Campbell, MD, FRCPC, Professor of Medicine, Physiology and Pharmacology and Community Health Sciences, University of Calgary and Libin Cardiovascular Institute, Calgary, AB.

The World Health Organization has named hypertension the leading risk for death globally in adults. Antihypertensive therapy reduces the risks of major cardiovascular complications. As blood pressure increases with increasing age, frequent screening for hypertension is advisable in older adults. The risk of developing hypertension is about 90% even in normotensive 65 year olds. Until recently, data supporting antihypertensive therapy in the very old had been inconclusive. However, the HYVET trial published in 2008 shows a clear reduction in cardiovascular events and mortality. Based on this study the Canadian Hypertension Education Program recommends treating hypertension regardless of age. Attention should also be given to reducing overall cardiovascular risk.
Key words: hypertension, high blood pressure, older adults, recommendations, HYVET study.

Treatment of Hypertension in Older Adults

Treatment of Hypertension in Older Adults

Teaser: 


Wilbert S. Aronow, MD, FACC, FAHA, AGSF, Department of Medicine, Cardiology Division, New York Medical College, Valhalla, NY, USA.

Numerous double-blind, randomized, placebo-controlled studies have documented that antihypertensive drug therapy reduces cardiovascular events in older adults. In the Hypertension in the Very Elderly Trial, individuals 80 years of age and older treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30% reduction in fatal or nonfatal stroke, a 39% reduction in fatal stroke, a 21% reduction in all-cause mortality (p=0.02), a 23% reduction in death from cardiovascular causes, and a 64% reduction in heart failure. The goal of treatment of hypertension in older adults is to reduce the blood pressure to <140/90 mmHg and to <130/80 mmHg in older persons with diabetes or chronic renal insufficiency. Older adults with diastolic hypertension should have their diastolic blood pressure reduced to 80-85 mmHg. Diuretics should be used as initial therapy in persons with no associated medical conditions. The selection of antihypertensive drug therapy in persons with associated medical conditions depends on their medical conditions. If the blood pressure is >20/10 mmHg above the goal blood pressure, drug therapy should be initiated with two antihypertensive drugs, one of which should be a thiazide-type diuretic. Other coronary risk factors must be treated.
Key words: hypertension, older adults, antihypertensive drug therapy, angiotensin-converting enzyme inhibitors, beta-blockers.

Blood Pressure and Survival in the Very Old

Blood Pressure and Survival in the Very Old

Teaser: 


Kati Juva, MD, PhD, Department of Psychiatry, Helsinki University Central Hospital, Helsinki, Finland.
Sari Rastas, MD, PhD, Department of Neuroscience and Neurology, University of Kuopio, Kuopio, Finland; Kauniala Disabled War Veterans’ Hospital, Espoo, Finland.
Tuula Pirttilä, PhD, Professor, Department of Neuroscience and Neurology, University of Kuopio and Kuopio University Hospital, Kuopio, Finland.

The harmful effects of high blood pressure on cardiovascular morbidity and mortality are well established. However, hypertension in the very old is an extremely complex issue. Current epidemiological data suggest that high blood pressure may be a marker of survival in the very old, and lowering blood pressure may lead to an increase in total mortality. In this review we will summarize the evidence on the association between blood pressure and mortality and discuss the implications of the data.
Key words: older adults, hypertension, survival, very old, blood pressure.

Management of Hypertension among Older Adults: Where Are We Now?

Management of Hypertension among Older Adults: Where Are We Now?

Teaser: 


Anita W. Asgar, MD, FRCPC, Interventional Cardiology Fellow, Montreal Heart Institute, Montreal, QC.
Renee L. Schiff, MD, FRCPC, Echocardiography Fellow, Montreal Heart Institute, Montreal, QC.
Reda Ibrahim, MD, CSPQ, FRCPC, Interventional Cardiologist, Montreal Heart Institute, Associate Professor of Medicine, Universite de Montreal, Montreal, QC.

Hypertension is a common health concern among older adults and constitutes an important risk factor for cardiovascular disease. Despite its prevalence, it is a constant management challenge. We review four aspects of hypertension management that have been of interest over the past year.
Key words: hypertension, diabetes, drug therapy, gender differences, resistant hypertension.

Gender and Congestive Heart Failure

Gender and Congestive Heart Failure

Teaser: 


Silja Majahalme, MD, PhD, FESC, Cardiologist and Clinical Hypertension Specialist, Appleton Heart Institute/Appleton Cardiology Associates, Appleton, WI, USA.

Heart failure (HF) is an increasing problem in the older adult population, specifically among women. The majority of health care expenses are generated in the last few years of life, and hospitalization for HF is one of the major medical conditions influencing the expenditure. The nature of women’s HF differs from men: coronary artery disease is the most common etiologic factor for HF in men while women more often suffer from hypertensive heart disease, which results in stiffness of the left ventricle with relaxation problems, and diastolic HF. Most commonly there is a long history of poorly controlled hypertension. In acute situations these patients often present with florid edema and congestion along with significantly elevated blood pressure levels, which are both challenging to treat. This short review covers issues related to gender differences in etiology and epidemiology of HF, and evaluates current evidence for drug therapies.
Key words: epidemiology, heart failure, gender, myocardial infarction, hypertension.

Hypertensive Retinopathy as a Risk Marker of Cardiovascular Disease

Hypertensive Retinopathy as a Risk Marker of Cardiovascular Disease

Teaser: 


Rachel L. McIntosh, B.Orth, Grad Dip Journ, Research Orthoptist, Retinal Vascular Imaging Centre, Eye Research Australia, University of Melbourne, Melbourne, Australia.
Tien Y. Wong, FRANZCO, FRCSE, PhD, Associate Professor of Ophthalmology, Retinal Vascular Imaging Centre, Eye Research Australia, University of Melbourne, Melbourne, Australia.

Hypertensive retinopathy has long been regarded as a risk indicator of mortality in persons with severe hypertension, but its value in contemporary clinical practice is uncertain. New population-based studies now show that hypertensive retinopathy signs are common in the general population of adults age 40 and older, including persons without a clinical diagnosis of hypertension. Some hypertensive retinopathy signs are associated not only with concurrent blood pressure levels, but with past blood pressure levels as well, suggesting that they reflect chronic hypertensive damage. Mild hypertensive retinopathy, such as generalized and focal retinal arteriolar narrowing and arteriovenous nicking, are only weakly associated with cardiovascular diseases. In contrast, moderate hypertensive retinopathy, such as retinal hemorrhages, cotton wool spots, and microaneurysms, are strongly associated with both subclinical and clinical cardiovascular diseases, including stroke and congestive heart failure. Thus, a clinical assessment of hypertensive retinopathy signs in older persons may provide useful information for cardiovascular risk stratification.
Key words: hypertensive retinopathy, retinal microvascular disease, hypertension, cardiovascular disease.

Hypertension in the Older Adult: An Update on Canadian Hypertension Education Program Recommendations

Hypertension in the Older Adult: An Update on Canadian Hypertension Education Program Recommendations

Teaser: 


Norm R.C. Campbell, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
J. George Fodor, MD, FRCPS, PhD, Ottawa Heart Institute, Ottawa, ON.
Robert Herman, MD, FRCPC, Division of General Internal Medicine, University of Calgary, Calgary, AB.
Pavel Hamet, MD, FRCPC, PhD, Research Center, CHUM, Montréal, QC (for the Canadian Hypertension Education Program).

Hypertension is a leading risk for morbidity and mortality in Canada. The older population is at greater risk from hypertension and has a greater reduction in cardiovascular risk with treatment than young patients. Frequent screening for hypertension is prudent as the estimated risk of developing hypertension is about 90%, even in normotensive 65-year-olds. Systolic blood pressure is a more relevant risk factor than diastolic blood pressure in older patients and is more difficult to treat to target. Most hypertensive patients will have multiple cardiovascular risks that require screening and management to reduce cardiovascular risk optimally. Lifestyle therapy is efficacious. Effective first-line drug therapies that reduce hypertension complications include thiazide-type diuretics, ACE inhibitors, long-acting calcium-channel blockers, and angiotensin-receptor blockers. Most patients require two or more drugs to achieve current blood pressure targets.
Key words: high blood pressure, hypertension, guidelines, recommendations, evidence-based medicine.

Hypertension Management and Early Morning Risk in Older Patients

Hypertension Management and Early Morning Risk in Older Patients

Teaser: 


The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Yves Lacourcière, MD, FRCP, Hypertension Research Unit, CHUL du CHUQ, Laval University, QC.

There are many reasons why gaining control over high blood pressure (BP) in older patients is desirable. When choosing an antihypertensive agent for older patients, physicians should seek a drug that sustains BP control, especially in the last six hours of the dosing interval or if a dose is missed. Agents with a long duration of action that inhibit the renin-angiotensin system (RAS) are likely to be more useful in controlling the early-morning surges in norepinephrine that have been linked to target organ damage and stroke, particularly in older patients.

Key words: hypertension, renin-angiotensin, angiotensin-receptor blockers, norepinephrine, peroxisome proliferator-activated receptor (PPAR).