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.

Abstract:

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. Specifi c 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.

Introduction

It is estimated that over 90% of normotensive people age 55-65 will eventually develop hypertension if they live an average lifespan.¹ Hypertension is not to be ignored as it is the
leading risk for death and disability in older people, and is both preventable and treatable.^2,3 Two-thirds of stroke and half of ischemic heart disease and heart failure are attributable
to elevated blood pressure, and the absolute risk from hypertension increases with age.⁴ Most older adults are or will become candidates for antihypertensive therapy.



Lifestyle changes can both prevent and treat hypertension. When used in combination with antihypertensive drugs, such changes can considerably reduce the number and doses of medication
required.⁵ Recent data indicate that few Canadians make lifestyle changes after a diagnosis of hypertension. In Canadians over age 60, there is only a 3.2% reduction in smoking after a
diagnosis of hypertension, and there is no change in body mass index, physical inactivity, or excess alcohol consumption.⁶ Lifestyle changes are thus markedly underutilized and this leads
to overreliance on pharmacotherapy.



As pharmacotherapy does offer important benefits, especially in light of the difficulty in promoting lifestyle changes that could result in lowered blood pressure, it is important to review the
principles of instituting antihypertensive therapy. This article aims to assist clinicians in selecting appropriate initial antihypertensive therapy.



Prior to prescribing antihypertensive drugs it is important to assess the person for white coat hypertension, secondary hypertension, and factors such as pain or stress that may temporarily increase
blood pressure. White coat hypertension and secondary hypertension are more common among older people. White coat hypertension can be easily detected and followed by home measurement of blood
pressure. Importantly the threshold for hypertension using home measurement of blood pressure is 135/85 mmHg or higher. Ambulatory blood pressure is recommended to be considered to confirm the
diagnosis of white coat hypertension.

Initiation of Therapy

There are a large number of specific antihypertensive drugs that both lower blood pressure and reduce death and disability for older people.⁷ The initial drug to be used is an important
choice. The blood pressure lowering to be expected by the use of one drug alone is about 9/5 mmHg; hence most people will require combinations of drugs to bring blood pressure down to recommended
levels for optimal cardiovascular protection (Table 1).⁸ Initial therapy using two antihypertensive drugs is a consideration if the pretreatment blood pressure is 160/100 mmHg or more (or
150/90 mmHg or more in people with diabetes).⁷

For older people, drug therapy generally should be initiated if the blood pressure averages above 140 mmHg systolic or 90 mmHg diastolic and in most people should be lowered to less than 140 mmHg
systolic and less than 90 mmHg diastolic.⁷ For people with diabetes or chronic kidney disease, treatment should be initiated if the blood pressure averages greater than 130 mmHg systolic
or 80 mmHg diastolic and should be lowered to less than these values.⁷ Systolic blood pressure is a more important cardiovascular risk than diastolic blood pressure in older adults, is
often less well controlled, and requires greater clinician attention.



In 2009, CHEP is emphasizing maintaining blood pressure below 130/80 mmHg in people with diabetes. Up to 80% of deaths in people with diabetes are due to cardiovascular disease and up to 75% of
specific cardiovascular complications in people with diabetes are attributable to high blood pressure.⁹ Controlling blood pressure in people with hypertension and diabetes results in very
large reductions in death and cardiovascular event rates, and reduces the progression of renal disease and retinopathy.^10,11 However, despite the strong clinical benefits of blood pressure
lowering, a recent Ontario survey found that two-thirds of individuals with diabetes and hypertension were not achieving blood pressure targets.¹² Both diabetes and hypertension commonly
coexist in older people, and hence clinicians need to be vigilant for the deadly duo and pay particular attention to blood pressure control.



There have been concerns that treatment may prevent stroke in the oldest old but increase other adverse events, including total mortality.¹³ However, in 2008, a large randomized controlled
trial demonstrated large reductions in cardiovascular events and total mortality by lowering blood pressure with a diuretic with or without a angiotensin-converting enzyme (ACE) inhibitor in people
over age 80.¹⁴ Most studies, including this latter trial, included predominantly healthy people. Caution should be exercised in lowering blood pressure in older adults who are frail or
have significant postural hypotension or have substantial comorbidity, in whom reduction in blood pressure would not be expected to improve quality or quantity of life.⁷

Uncomplicated Hypertension

Initial therapy should be selected from antihypertensive drugs that optimally reduce cardiovascular events. These include low-dose thiazide-type diuretics, ACE inhibitors, long-acting calcium channel
blockers and angiotensin receptor blockers.⁷ Beta-blockers are not as effective at preventing stroke as low-dose thiazide-type diuretics, long-acting calcium channel blockers, and
angiotensin receptor blockers in older adults and therefore should not be selected as initial therapy in those over age 60 unless there is a compelling indication (Table 2).^15-20
Currently, there are no clinical trials to assess whether direct renin inhibitors improve cardiovascular outcomes of hypertensive patients, hence prescription of the newly released class should only
be considered in patients where proven therapies are unable to control blood pressure.

Choosing between Possible First-Line Choices

Table 2 outlines the specific pharmacotherapeutic recommendations of CHEP (2009) in different clinical settings.⁷ There are often several different potential first-line therapies to choose
among. Some principals can be used to help guide the initial selection. In the absence of a specific indication for a drug class, in general, older people have a better hypotensive response to
monotherapy with a low-dose diuretic or long-acting calcium channel blocker.²¹ Thiazide-like diuretics are very inexpensive, are well tolerated, and have the same cardiovascular benefits
as other classes, and therefore, in the authors’ opinion, should be the default choice if there is no contraindication to diuretics or specific indication for a different drug class (Figure 1).
Persistence with diuretic therapy is slightly lower than other drug classes and erectile dysfunction related to diuretics occurs in about 2% of people. Active gout can be precipitated by diuretic
therapy and hence diuretics should be avoided as initial therapy in people who have gout unless they are already prescribed therapy to prevent gout (e.g., allopurinol). Diuretics can also cause a
slight increase in blood glucose and lipid levels. The outcomes of people with diabetes, impaired glucose tolerance, or normal glucose levels are improved to the same extent with diuretics as with an
ACE inhibitor or calcium channel blocker. Hence, these clinical situations are not a valid reason to avoid prescribing a diuretic.²² Initial starting drugs and doses include
hydrochlorothiazide 12.5-25 mg/day, indapamide 1.25-2.5 mg/day, and chlorthalidone 12.5-25 mg/day (1/4-1/2 tablet). If single-drug antihypertensive therapy is anticipated, using a combination
diuretic tablet (hydrochlorothizide 12.5-25 mg with spironolactone or amiloride) will reduce the risk of developing hypokalemia and dysglycemia.

In older people for whom initial use of a low-dose thiazide-like diuretic is not indicated, a long-acting calcium channel blocker will lower blood pressure to a similar extent or slightly greater
extent as a diuretic.²³ Edema is a more common problem with dihydropyridine (e.g., amlodipine, nifedipine) than nondihydropyridine calcium channel blockers (e.g., verapamil, diltiazam).
When using nondihydropyridine calcium channel blockers, be alert for potential drug interactions (nondihydropyridine calcium channel blockers are CYP 3A4 inhibitors), the contraindication in people
with systolic heart failure and the potential to cause heart block in people with atrio-ventricular (A-V) conduction defects or people who are using other drugs that reduce A-V conduction (e.g.,
beta-blocker). Typical initial choices of calcium channel blockers and their doses include amlodipine 2.5-5 mg/day, Adalat (nifedipine) XL 20-30 mg/day, diltiazam (in extended release form) 120-240
mg/day and verapamil (in extended release form) 240 mg/day. A recent randomized controlled trial has concluded that calcium channel blocker therapy paired with an ACE inhibitor is superior to a
diuretic paired to a ACE inhibitor.²⁴ However, methodological issues in the conduct of the trial may preclude the study affecting therapeutic recommendations.



Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers may be used as initial choices of antihypertensive drugs for older adults although, based on differing efficacy to lower
blood pressure, the National Institute of Clinical Evaluation suggests they be selected after considering a diuretic and calcium channel blocker first.^7,21 In general, the ACE inhibitors
and angiotensin receptor blockers are excellent to add to the initial choice if blood pressure targets are not achieved with single drug treatment.²¹ A large randomized controlled trial
using ACE inhibitors in isolated systolic hypertension has not been conducted, and hence CHEP does not recommend ACE inhibitors in that setting. Cough and angioedema are adverse effects of specific
concern with ACE inhibitors. Numerous ACE inhibitors and angiotensin receptor blockers with different starting doses are in common use.



Conclusion

Maximal blood pressure lowering effect from most antihypertensive drug classes requires about 4-6 weeks, and therefore titration of therapy in the absence of a medical urgency can occur at that
interval. About 80% of the blood pressure lowering of most drug classes is achieved at half of the maximum dose, while side effects are much more common in the higher half of the dose
range.⁸ Therefore, use a combination of two drugs if there is an inadequate response to the initial therapy at moderate dose. Notably, based on a new clinical trial in 2008, CHEP now
recommends the combination of an ACE inhibitor with a ARB only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy.



When prescribing the initial drug it is reasonable to advise the patient that good blood pressure control usually requires lifestyle changes plus two or more drugs. This helps avoid the potential
disappointment and concerns if the initial therapy does not control the blood pressure.

The unhealthy lifestyles that cause hypertension (especially nutrition) usually elevate other cardiovascular risks, and hence a comprehensive approach to identifying and managing cardiovascular risks
is required. In particular, carefully screening for dyslipidemia and diabetes is required as these diagnoses will have a major impact on cardiovascular outcomes and treatments. Age itself is the
greatest risk factor for cardiovascular disease,⁴ and therefore all older adults with hypertension should be considered for blood pressure-lowering pharmacotherapy. Nevertheless, care
needs to be taken that the person truly has hypertension by excluding white coat hypertension and acute hypertensive responses to physical or emotional stresses, performing an appropriate diagnostic
work-up, and assessing the person for increased risks of hypotensive complications.



Appropriate antihypertensive pharmacotherapy is an effective mechanism to reduce cardiovascular morbidity and mortality in older adults. Individualized, simplified, but rational regimes of relatively
inexpensive antihypertensive drugs can control the blood pressure of most people. More information on treatment of hypertension including patient handouts can be found at "http://www.hypertension.ca">www.hypertension.ca.

Dr. Mohan has no stated conflicts of interest. Dr. Campbell has given talks sponsored by Bayer, Sanofi Aventis, Biovail, Bristol Myers Squibb, Pfizer, Novartis and Merck-Frosst, and also has
been on advisory boards for Novartis, Pfizer, Servier, Boehringer Ingelheim and Schering-Plough.

KEY POINTS / CLINICAL PEARLS

I am writing this article a day after attending a meeting of the soon-to-be PGY3’s in core internal medicine at the University of Toronto. The meeting was an information session on how to apply for subspecialty training in internal medicine. Part of the session showed the number of residents who entered various training programs in previous years. The number of trainees entering cardiology was staggering in comparison to those entering geriatrics. After my initial intense burst of jealousy, I had to acknowledge a few truths: cardiology is more popular than geriatrics, older patients have a high burden of CVS disease and need cardiologists, and most cardiologists see large numbers of older adults. Cardiovascular disease remains the most important cause of mortality among older adults, and even for those of us with a particular interest in dementia it is vital to recognize the important role of vascular disease in cognitive impairment. For these reasons (and many more), we offer a theme issue on cardiovascular disease each year. I would recommend the brilliant article in the April 2004 American Journal of Medicine by David Alter and David Naylor showing that modern cardiovascular interventions, if anything, benefit older people more than younger adults.

One of the most common problems we see in older adults is hypertension, and substantial data prove that blood pressure control is quite beneficial to older people. How to control the pressure is the content of the article “Selecting Initial Antihypertensive Therapy for Older Adults” by Dr. Norm Campbell and Dr. Sailesh Mohan. Angina is a common problem in older individuals (and can be quite atypical and difficult to diagnose). “Nonsurgical Management of Chronic Exertional Angina in Older Adults” by Dr. Kenneth Melvin and Lindsay Melvin addresses medical management of angina while Dr. Sameer Satija and Dr. Nanette Wenger review the topic of “Revascularization of Chronic Angina among Older Adults.” Antiplatelet therapy has been a great advance in the treatment of CVS diseases but does carry some risks. The article “Dual Antiplatelet Therapy for Cardiovascular Protection: Indication, Duration, and Other Considerations” by Nastaran Ostad and Dr. Glen Pearson addresses the topic of more intensive antiplatelet therapy.

As well as articles on our focus of CVS disease we have our usual varied group of articles. One of Canada’s most eminent geriatricians and also an expert on dementia, David Hogan, contributed the article “A Practical Approach to the Use of Cholinesterase Inhibitors in Patients Newly Diagnosed with Alzheimer’s Disease.” Usually when we talk about technology in medicine, we are thinking “high tech.” However, the article “Canes and Walkers: A Practical Guide to Prescribing” by Dr. Robert Lam and Alison Wong reminds us that some very low tech interventions can make an enormous difference for our older patients. The eyes are perhaps the “mirror to the soul,” but for older adults the eyes and vision are a vital connection not only to the soul but to the world around them. The article “Current Options in Low Vision Rehabilitation” by Dr. Samuel Markowitz is very important in order to maximize the visual capabilities of those with impairment.

Enjoy this issue,
Barry Goldlist

Ajay Sood, MD, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine; Louis Stokes Cleveland Veterans Affairs (VA) Medical Center, Cleveland, OH, USA.
David C. Aron, MD, MS, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine; VA Network 10 Geriatric Research, Education, and Clinical Centers, VA Health Services Research and Development Quality Enhancement Research Initiative Diabetes Clinical Coordinating Center; Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.

Glycemic goals and the decision to intensify glycemic control among older adults with diabetes must be individualized based on comorbid conditions and the risks associated with treatment. The duration of diabetes mellitus, baseline glycosylated hemoglobin value, prior history of cardiovascular disease, and history of severe hypoglycemia are important factors to consider. This article reviews how the management of diabetes mellitus in this subgroup is changing in view of three recently reported randomized trials of intensive glycemic control.
Key words: diabetes, older adults, glycemic control, cardiovascular disease, glycemic goal.

Jason Andrade, MD, Division of Cardiology, University of British Columbia, Department of Medicine, Vancouver, BC.
Aneez Mohamed, MD, Division of Cardiology, University of British Columbia, Department of Medicine, Vancouver, BC.
Chris Rauscher, MD, Division of Geriatric Medicine, University of British Columbia, Department of Medicine, Vancouver, BC.

Infective endocarditis (IE) is a rare but potentially devastating clinical entity with a well-delineated pathogenesis. While previously thought to be a disorder of younger individuals, older adults now represent one of the highest risk groups for the acquisition of and adverse outcomes related to IE. Prior to focusing on the updated recommendations for IE prophylaxis and the rationale behind them, we briefly review the clinical aspects of IE in the general population, as well as special considerations for older adults.
Key words: endocarditis, prophylaxis, older adults, cardiovascular disease, antibiotics.

Pamela Katz, MD, Department of Endocrinology and Metabolism, University of Toronto, Toronto, ON.
Jeremy Gilbert, MD, FRCPC, Staff Endocrinologist, Toronto General Hospital, University Health Network, Toronto, ON.

The global prevalence of diabetes has increased substantially in recent years, attributable to an increase in new cases and declining mortality. Aging is associated with changes in beta cell function and insulin resistance that predispose to diabetes. Cardiovascular disease is the leading cause of death among older adults with diabetes. In order to reduce the excessive risk of cardiovascular disease, all coronary risk factors must be addressed and treated aggressively. This article will focus on the importance of blood pressure and glycemic control and lipid lowering with statin therapy. Specific considerations in this patient population include high rates of comorbid disease, shorter life expectancy, polypharmacy and falls risk. These factors may alter the therapeutic goals. Treatment should therefore be individualized with consideration given to patient preference and quality of life.
Key words: diabetes, cardiovascular disease, older adults, metabolic syndrome.

Jeffrey Schiff, MD, FRCP(C), Instructor, Division of Medicine, University of Toronto; Division of Nephrology and Multi-Organ Transplant Program, Toronto General Hospital, Toronto, ON.

Due to the excellent outcomes of renal transplantation, there is an increasing number of people surviving with, or receiving a transplant, at an older age. While the transplant centre usually manages the immunosuppression and renal problems, these individuals also require primary care. This article will review the common health issues that primary care physicians encounter routinely among these patients. Common problems include managing cardiovascular risk factors, screening for malignancy, vaccinations, treatment of uncomplicated infections, and bone disease. Important drug interactions will be reviewed. Communication between the primary care physician and the transplant centre will also improve care of these patients.
Key words: renal transplantation, primary care, cardiovascular disease, drug interactions, chronic kidney disease.

Nicholas J. Giacomini, BS, Research Assistant, University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA, USA.
Roberta K. Oka, RN, ANP, DNSc, Associate Professor, University of California, San Francisco, School of Nursing, Department of Community Health Systems, San Francisco, CA, USA.

Peripheral arterial disease (PAD) is a common but frequently undetected and undertreated condition among older adults. Untreated PAD and cardiovascular disease (CVD) risk factors results in functional impairment, poor quality of life and increased risk for cardiovascular disease morbidity and mortality. The increased risk for CVD events associated with PAD necessitates raising public awareness of PAD and the potential impact on health, and placing greater emphasis by providers on detection and management of PAD to maximize survival and life quality. This article briefly describes the detection and medical management of PAD, with greater emphasis on lifestyle modification among older adults with PAD.
Key words: vascular disease, cardiovascular disease, risk factor reduction, lifestyle modification.

Every time I write an introduction for Geriatrics & Aging, I seem to stress how important the focus of this particular issue is for the care of older adults. Often I compare the condition with heart disease to emphasize its importance. This month we address the gold standard for what is important in caring for older adults, namely vascular disease. Vascular disease is still the most common cause of death among older adults, and vascular disease is often the final end for many other common problems faced by older adults, such as diabetes mellitus or chronic renal disease. Vascular disease is frequently a cause or a contributor to dementia in old age as well. Traditionally, February is the month to be aware of the heart and it is only fitting, therefore, that we make this month our heart month as well.

From a public health point of view, control of hypertension and smoking cessation are two of the most important interventions that doctors can pursue with their patients. Some estimates conclude that one third or more of all older adults have hypertension, and persuasive evidence exists to control hypertension even in extreme old age (although data for those over 80 are very limited). However, some individuals have difficult-to-control hypertension, and this topic is addressed by Dr. Mohammed Shafiee, Dr. Fatemeh Akbarian, and Dr. Vahid Ghafarian in their article “Treatment-Resistant Hypertension among Older Adults.” This article is also the basis for this month’s CME program. Another of our cardiovascular features is “Essentials of Hypertrophic Cardiomyopathy” by Gursharan Soor, Adriana Luk, Dr. Anna Woo, Dr. Anthony Ralph-Edwards, Dr. Heather Ross, and Dr. Jagdish Butany. The commonest reason for hospital admission for older adults in North America is heart failure. This statistic suggests that our current management paradigms could be improved, which is the point of the article “Heart Failure: Old Disease, Older Adults, Fresh Perspective” by Drs. George Heckman, Catherine Demers, David Hogan, and Robert McKelvie. I recently had the pleasure of hearing Dr. Heckman present grand medical rounds on this topic, and I think you will be just as impressed with the article as I was with the presentation. Cardiology is the most technical of internal medicine specialties, and some of that technology is discussed in the article “The Role of Implantable Cardiac Devices in the Prevention of Sudden Cardiac Death” by Dr.Vikas Kuriachan and Dr.Robert Sheldon. Our Drugs & Aging column this month also has a cardiac focus, namely, “An Update on the Role of Digoxin in Older Adults with Chronic Heart Failure” by Dr. Ali Ahmed.

As usual, our nonfocus articles are also superb. Dr. Bhaskar Ghosh and Dr. Oksana Suchowersky present in the Movement Disorders column the article “Chorea among Older Adults.” Our Women’s Health column, “Pelvic Organ Prolapse among Older Women” is by Dr. Emily Saks and Dr. Lily Arya. Our GI Disorders column this month is on the topic “Low-Dose Acetylsalicylic Acid and the Use of Gastroprotectors among Older Adults” and is written by Dr. Neeraj Bhala and Dr. Angel Lanas.

Enjoy this issue,
Barry Goldlist

Katherine R. Schlaerth, MD, Fellow, American Academy of Pediatrics; Fellow, American Academy of Family Practice; Fellow, Pediatric Infectious Disease Society; Associate Professor, Department of Family Medicine, Loma Linda University School of Medicine, Loma Linda, California; Associate Professor Emeritus, Departments of Family Practice and Pediatrics, University of Southern California School of Medicine, Los Angeles, California, USA.

Most practitioners assume that the use of illegal or “street” drugs is confined to the young. However, a recent phenomenon has been the use of such drugs by individuals above the age of 50. Social trends play a part: many older addicts began using in the 1960s. Others share the use of illegal drugs with other family members as a mode of family recreation. The latter trend is probably more common in inner cities where drugs are more easily obtained. Older men are twice as likely to use illegal drugs as are older women, though the latter outnumber the former demographically. Many illegal drugs, especially cocaine, methamphetamines, and even marijuana have cardiovascular effects that are especially dangerous when they occur in older individuals who may already have underlying cardiovascular disease. Practitioners must be vigilant about querying patients about their use of illegal drugs, no matter what their age, and especially if cardiovascular illness is involved.
Key words: older adults, illegal drugs, cardiovascular disease, cocaine, methamphetamines.

Nahid Azad, MD, Associate Professor, Faculty of Medicine, University of Ottawa, Ottawa, ON.
Arlene S. Bierman, MD, MS, FRCPC, Ontario Women’s Health Council Chair in Women’s Health, Centre for Research on Inner City Health, St. Michael’s Hospital; Faculties of Medicine and Nursing, University of Toronto, Toronto, ON.

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality for both men and women. Among individuals with coronary heart disease (CHD), there are gender differences in clinical epidemiology, prevalence of risk factors, clinical presentation, and quality and outcomes of care. Older adults and older women in particular are at risk for underdiagnosis and suboptimal management of CHD and its risk factors. Adherence to clinical practice guidelines for diagnosis and management of CHD can improve outcomes of care for older men and women with CHD and narrow gender disparities in clinical outcomes.
Key words: cardiovascular disease, gender, older adults, quality of care, women’s health, coronary heart disease.