HTn in Elderly

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Information about HTn in Elderly

Published on March 10, 2014

Author: dr.ankurshah82


PowerPoint Presentation: Dr Ankur Shah MBBS MD MSc (UK) History of WKD: History of WKD World Kidney Day started in 2006 and has not stopped growing ever since. Every year, the campaign highlights a particular theme. 2014 Chronic Kidney Disease (CKD) and aging 2013  Kidneys for Life - Stop Kidney Attack! 2012  Donate - Kidneys for Life - Receive 2011  Protect your kidneys: Save your heart 2010  Protect your kidneys: Control diabetes 2009  Protect your kidneys: Keep your pressure down 2008   Your amazing kidneys! 2007 CKD: Common, harmful and treatable 2006  Are your kidneys OK? Objectives: Objectives Raise awareness about our "amazing kidneys " Highlight that diabetes and high blood pressure are key risk factors for Chronic Kidney Disease (CKD). Encourage systematic screening of all patients with diabetes and hypertension for CKD. Encourage preventive behaviours . Educate all medical professionals about their key role in detecting and reducing the risk of CKD, particularly in high risk populations. Stress the important role of local and national health authorities in controlling the CKD epidemic. Health authorities worldwide will have to deal with high and escalating costs if no action is taken to treat the growing number of people with CKD. On World Kidney Day all governments are encouraged to take action and invest in further kidney screening. Encourage Transplantation as a best-outcome option for kidney failure, and the act of organ donation as a life-saving initiative. If detected early , Chronic Kidney Diseases can be treated--thereby reducing other complications and dramatically reduce the growing burden of deaths and disability from chronic renal and cardiovascular disease worldwide . Chronic Kidney Disease and Aging: Chronic Kidney Disease and Aging HYPERTENSION IN ELDERLY: HYPERTENSION IN ELDERLY PowerPoint Presentation: HYPERTENSION K I L L E R I S E N T L O W PowerPoint Presentation: Benefits of Lowering Blood Pressure Antihypertensive Therapy has been associated with reductions in: Stroke Incidence (35-40 %). MI (20-25 %). Heart Failure ( averaging > 50 %) CKD Pathogenesis of systolic hypertension in the elderly and clinical consequences: Pathogenesis of systolic hypertension in the elderly and clinical consequences PowerPoint Presentation: Bentley Dw, Izzo JL. J Am Geriatr Soc . 1982; 30:352-359. Stroke Volume Aorta Resistance Arterioles Pressure (Flow) Young Artery Systole Diastole Elastic Vessel Arteriosclerotic Artery Stiff Vessel Systole Diastole Arterial Wall Compliance and Pulse Pressure Wave Hypertension, chronic kidney disease, and the development of cardiovascular risk: a joint primacy by John P Middleton and Patrick H Pun : Hypertension, chronic kidney disease, and the development of cardiovascular risk: a joint primacy by John P Middleton and Patrick H Pun How are high blood pressure and kidney disease related?: How are high blood pressure and kidney disease related? They are related in two ways : High blood pressure is a leading cause of CKD High blood pressure can also be a complication of CKD Guidelines (JNC VII) : Guidelines ( JNC VII ) The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure uses the following guidelines to define HTN in adults: Category Systolic Diastolic Normal <120 and <80 Pre-hypertension 120-139 or 85-89 Stage 1 hypertension 140-159 or 90-99 Stage 2 hypertension > 160 or > 100 JNC 8 Guidelines New features & key guidelines: JNC 8 Guidelines New features & key guidelines • First-line and later-line treatments should now be limited to 4 classes of medications: thiazide-type diuretics, calcium channel blockers (CCBs), ACE inhibitors, and ARBs. • Second- and third-line alternatives included higher doses or combinations of ACE inhibitors, ARBs, thiazide-type diuretics, and CCBs. Age Ass. conditions Goal BP 1. ≥ 60 yr don’t have DM or CKD < 150/90 mm Hg 2. 18 to 59 yrs without major comorbidities < 140/90 mm Hg ≥ 60 yrs have DM, CKD, or both conditions Cont. : Cont. • When initiating therapy, patients of African descent without CKD should use CCBs and thiazides instead of ACE inhibitors. • Use of ACE inhibitors and ARBs is recommended in all patients with CKD regardless of ethnic background, either as first-line therapy or in addition to first-line therapy. • ACE inhibitors and ARBs should not be used in the same patient simultaneously. • CCBs and thiazide-type diuretics should be used instead of ACE inhibitors and ARBs in patients over the age of 75 years with impaired kidney function due to the risk of hyperkalemia , increased creatinine, and further renal impairment PowerPoint Presentation: 135/85 Ambulatory Pressure 140/90 Clinic Pressure Sustained Hypertension White Coat Hypertension True Normotension Masked Hypertension Lifetime Risk of Developing Hypertension in Middle Aged (Vasan et al, JAMA 2002; 287: 1010): Lifetime Risk of Developing Hypertension in Middle Aged ( Vasan et al, JAMA 2002; 287: 1010 ) Risk for Hypertension in a 55 year old Time, yr Women Men 52% 56% 72% 78% 83% 88% 25 91% 93% Diagnostic Evaluation of the Hypertensive Patient- How much is enough? : Diagnostic Evaluation of the Hypertensive Patient- How much is enough? How high is the blood pressure? Why is it high? What is the risk? Clinical Manifestations I: Clinical Manifestations I Physical exam: Abdomen Funduscopic Vascular Cardiac Pulmonary Neurological Lab tests: Urinalysis Blood Chemistry ECG Renal ultrasound Echocardiogram Vascular studies Differential Diagnosis: Differential Diagnosis Rule out isolated incident of increased blood pressure. Rule out secondary hypertension related to: Renal disease Cushing's disease Pheochromocytoma Hyperthyroidism Hyperparathyroidism Complications: Complications Complications as a result of HTN include: Stroke Dementia Myocardial Infarction Congestive Heart Failure Retinal Vasculopathy Aortic Dissection Renal Disease or Failure Management: Management Variety of medications to treat chronic kidney disease, most are designed to control blood pressure and help regulate the body’s chemistry Cholesterol or lipid (fat) lowering medications   Blood pressure medication   Phosphate binders Erythropoietin (EPO)  - Used to treat anaemia  Folic Acid with vitamins B12 and B6  - Used to lower amino acid levels.  Bicarbonate supplement  - Used to treat acidosis.  Aspirin -  Low doses of aspirin may be given to improve blood circulation. Goal: Goal Primary goal is to reduce cardiovascular and renal morbidity and mortality. Other keys to management are: Prevention Patient education Life-style modification Medication Hospitalization should be considered if: Hospitalization should be considered if Very high BP Severe headache Chest pain Neurologic symptoms Altered mental status Acutely worsening renal failure S & S of hypertensive emergency DOES ELDERLY HYPERTENSION HAVE SPECIFIC CHARACTERISTICS?: DOES ELDERLY HYPERTENSION HAVE SPECIFIC CHARACTERISTICS? PowerPoint Presentation: CHARACTERISTICS OF HYPERTENSION IN THE ELDERLY Increased Systolic blood pressure and pulse pressure Left ventricular mass and wall thickness Arterial stiffness Calculated total peripheral resistance Decreased Cardiac output and heart rate Renal blood flow, plasma renin activity, and angiotensin II levels Arterial compliance and blood volume Diastolic blood pressure Black H. JCH 2003; 5:12 Do lifestyle measures really work for elderly hypertension?:  Do lifestyle measures really work for elderly hypertension? PowerPoint Presentation: Modification Approximate SBP Reduction (range) Weight Reduction 5-10 mmHg/10kg Adopt DASH eating plan 8-14 mmHg Dietary sodium reduction 2-8 mmHg Physical activity 4-9 mmHg Moderation of alcohol consumption 2 – 4 mmHg Lifestyle Modifications PowerPoint Presentation: Bar graph shows change in mean arterial blood pressure used to define salt responsivity as a function of age in normotensive [open bars] and hypertensive [color bars] subjects. Change in Mean Arterial Blood Pressure Weinberger M. Hypertens 1991; 18:69 PowerPoint Presentation: Effect of 30 minute walk 3 days a week Age 70 – 79 Systolic Diastolic Exercise Group Baseline 156 ± 10 mm Hg 86 ± 8 mm Hg 3 months 151 ± 15 mm Hg 80 ± 6 mm Hg Control Group Baseline 153 ± 7 mm Hg 85 ± 8 mm Hg 3 months 156 ± 10 mm Hg 85 ± 6 mm Hg Conone et al. Med Scl in Sports and Exercise. 1991 What is the effect of drug therapy related to age? Are the recommendations different?:  What is the effect of drug therapy related to age? Are the recommendations different? Antihypertensive Drugs : Antihypertensive Drugs A ACEI, ARBs B Beta Blocker C CCB D Diuretic D low dose HCTZ A B C Recent Guidelines JNC 7 Guidelines Preferred Agents for the Treatment of Hypertension in Chronic Kidney Disease: Preferred Agents for the Treatment of Hypertension in Chronic Kidney Disease PowerPoint Presentation: Algorithm for Management of the Elderly - Primarily Systolic Hypertension 1) Lifestyle changes ACEI or ARB – 1 st line therapy combination CCB B-Blocker Low dose diuretic 3) Stop, Look & Listen before dosages Let the Baroreceptors reset 4) Rx until goal achieved + + + PowerPoint Presentation: Barriers to Optimal Control of Hypertension Inaccurate measurement of blood pressure (BP) Focusing on diastolic BP rather than systolic BP goal Failure to consider absolute global risk Failure to advocate lifestyle modifications Failure to use polypharmacy Failure to use effective drug combinations Failure to titrate doses upward Fear of reaching excessively low diastolic BP The patient with truly resistant hypertension Behavioral barriers Franklin S. JCH 2006; 8:524 What can my family do?: What can my family do? It’s a good idea to get your whole family involved in your care: high blood pressure often runs in families , some of your family members may also be at increased risk of developing high blood pressure and CKD . You should encourage them to learn all they can about high blood pressure and to have their blood pressure checked at least once a year : For persons over age 50, SBP is a more important than DBP as CVD risk factor. Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD. Key Messages Key points to remember: Key points to remember High blood pressure and kidney disease are closely related . High blood pressure is both a cause and a complication of kidney disease. Having high blood pressure increases the chance that kidney disease will get worse and that heart problems will develop. Keeping blood pressure well-controlled reduces the chance of these complications. High blood pressure usually causes no symptoms. The only way to find out if your blood pressure is too high is to have it measured. Your blood pressure should be checked at every visit to your doctor or clinic . Your treatment will include making changes to a healthier lifestyle and taking medications.

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