Hypertension in the Elderly

ACCF/AHA 2011
Expert Consensus Document

Developed in collaboration with the American Academy of Neurology,

Association of Black Cardiologists, American Geriatrics Society, American
Society of Hypertension, American Society of Nephrology, American Society
for Preventive Cardiology, and the European Society of Hypertension
 Hypertension in the Elderly
Ten Things You Need to Know:

1. There is a dramatic increase in HTN prevalence with

aging; by age 70 yrs, the majority of people have HTN
2. In older adults, HTN is characterized by an elevated SBP
with normal or low DBP, due to age-associated stiffening of
large arteries.
3. HTN is a potent risk factor for CVD in the elderly.
4. Numerous randomized trials have shown substantial
reductions in CV outcomes in cohorts of patients 60-79 yrs
old with anti-HTN drug therapy though the effect on all-
cause mortality has been modest.
5. Although increases in the treatment and control of BP in
older hypertensive adults have occurred over the past 2
decades, BP control rates remain suboptimal in the elderly.
Ten Things You Need to Know
6. Non-pharmacologic lifestyle measures should be
encouraged in older adults, both to retard development of
HTN and as adjunctive therapy in those with HTN.
7. Although the specific BP at which antihypertensive therapy
should be initiated in the elderly is unclear, a threshold of
140/90 mm Hg in persons 65-79 yrs and a threshold SBP of
150 mm Hg in people age ≥80 yrs is reasonable.
8. Diuretics, ACEI, angiotensin receptor blockers, calcium
antagonists, and beta blockers have all shown benefit on CV
outcomes in randomized trials among elderly cohorts: choice
is dictated by efficacy, tolerability, comorbidities, and cost.
9. Initiation of antihypertensive drugs in the elderly should
generally be at the lowest dose with gradual increments as
tolerated.
10. The high prevalence of both CV and non-CV comorbidities
among the elderly dictates need for great vigilance to avoid
treatment-related side effects.
 Hypertension in the Elderly

1.There is a dramatic increase in the prevalence of

hypertension with aging; by age 70 years, the
majority of people have hypertension.
 Epidemiology of Hypertension and Aging

• Without treatment, approximately 30% of adults in

the U.S. have hypertension (HTN).1
• HTN prevalence increases markedly with age:2
-by 60 years, ~60% have HTN
-by 70 years, ~65% of men and ~75% of women have
HTN
-most prevalent in older African American women
• In Framingham Study, HTN eventually developed in
>90% of subjects with normal BP at age 55 years.3
1Ong Hypertension 2007;49:69-75
2BurtHypertension 1995;25:305-313
3Vasan N Engl J Med 2001;345:1291-1297
Prevalence of High Blood Pressure in Adults
by Age and Sex: NHANES 2005-2006
9 NHLBI.
Population Projections by Selected Age Groups
and Sex for the United States: (in 1000’s)
U.S. Census Bureau, 2008
 Mean Blood Pressure According to
Age, Sex and Ethnic Group in U.S. Adults
Chobanian N Engl J Med. 2007;357:789-96
 Hypertension in the Elderly

2. In older adults, hypertension is characterized by

an elevated systolic blood pressure (BP) with
normal or low diastolic BP, due to age-
associated stiffening of the large arteries.
Joint Influences of SBP and Pulse Pressure on
Coronary Heart Disease
Adapted from Franklin Circulation 1999;100:354-60
 Pathophysiology of
Hypertension in the Elderly
• Multiple changes occur in arterial media with aging, including reduced
elastin content with increases in non-distensible collagen and calcium
(e.g. arterial stiffening).
• Age-associated arterial stiffening results in a gradual increase in
systolic BP and a decrease in diastolic BP.
• Flow-mediated arterial dilation, primarily mediated by endothelium-
derived nitric oxide, declines markedly with aging.
• Neurohormonal profile of older hypertensive adults characterized by
increased plasma norepinephrine, low renin, and low aldosterone
levels.
• Many so-called “normal aging changes” in arterial structure and function
are blunted/absent in populations not chronically exposed to high
sodium/high calorie diets, low physical activity levels, and high rates of
obesity.
Conceptual Framework for CV Adaptations
to Arterial Stiffening Occurring with Aging

CBF indicates coronary blood flow;

DBP, diastolic blood pressure; EF,
ejection fraction; LA, left atrial; LV,
left ventricular; SBP, systolic blood
pressure; ↑, increased; and ↓,
decreased.
 Hypertension in the Elderly

3. Hypertension is a potent risk factor for

cardiovascular (CV) disease in the elderly.
 Coronary Heart Disease Rates by SBP
and Age
Adapted from Lewington et al. Lancet. 2002; 360:1903-1913
180 mm Hg

160 mm Hg
256
140 mm Hg
128 120 mm Hg

64

32
Coronary Heart
Disease 16
Mortality
8

40-49 50-59 60-69 70-79 80-89

Age
 Hypertension as a Risk Factor in the Elderly

• In older adults, hypertension (HTN) is the most prevalent modifiable

CV risk factor: antecedent HTN is estimated in:
– ~70% of patients with incident myocardial infarctions
– ~77% of patients with incident strokes
– ~74% with chronic heart failure
– ~90% with acute aortic syndrome
– 30% to 40% with atrial fibrillation

• HTN is also a major risk factor for conditions directly influencing CV

risk in the elderly:
– Diabetes
– Metabolic syndrome
– Chronic kidney disease

• The number of deaths attributable to HTN in the U.S. rose 56%

between 1995 and 2005, largely reflecting the increasing number of
older Americans and high prevalence of HTN in the elderly.
 Hypertension in the Elderly

4. Numerous randomized trials have shown

substantial reductions in CV outcomes in cohorts
of patients 60-79 years old with anti-
hypertensive drug therapy though the effect on
all-cause mortality has been modest.
In HYVET, antihypertensive therapy reduced all-
cause mortality in people ≥80 years old by 21%.
Randomized Hypertension in the Very Elderly Trial
(HYVET)

• In 3,845 patients ≥80 years old with SBP ≥160 mm Hg, at

1.8-year follow-up, those randomized to indapamide vs
placebo had:
– 30% nonsignificant decrease in fatal/nonfatal stroke
– 39% significant decrease in fatal stroke
– 21% significant decrease in all-cause mortality
– 23% insignificant decrease in CV death
– 64% significant decrease in heart failure
HYVET: Treatment of hypertension in patients 80 years of age or older.
N Engl J Med. 2008;358:1887-98.
 Hypertension in the Elderly

5. Although increases in the treatment and control

of BP in older hypertensive adults have occurred
over the past 2 decades, BP control rates
remain suboptimal in the elderly.
Extent of Awareness, Treatment and Control of
High Blood Pressure by Age
NHANES: 2005-2006
Frequency of Untreated Hypertension
According to Subtype and Age
Chobanian N Engl J Med. 2007;357:789-96
 Hypertension in the Elderly

6. Non-pharmacologic lifestyle measures should be

encouraged in older adults, both to retard
development of hypertension and as adjunctive
therapy in those with hypertension.
Non-Pharmacologic Lifestyle Measures Shown
Beneficial in Elderly Hypertensive Subjects

• Regular physical activity

• Sodium restriction
• Weight control
• Smoking cessation
• Avoidance of excessive alcohol intake
 Hypertension in the Elderly

7. Although the specific BP at which

antihypertensive therapy should be
initiated in the elderly is unclear, a
threshold of 140/90 mm Hg in persons 65-
79 years and a threshold systolic BP of
150 mm Hg in people age 80 years and
older is reasonable.
 Risk of Adverse Outcomes Among
Elderly CAD Patients by Age and BP
Denardo et al. Am J Med 123:719-726, 2010

BP nadirs indicate BP’s with lowest hazard

ratio at each age.
 Hypertension in the Elderly

8. Diuretics, ACE-inhibitors, angiotensin

receptor blockers, calcium antagonists,
and beta blockers have all shown benefit
on CV outcomes in randomized trials
among elderly cohorts.

The choice of specific agents is dictated by

efficacy, tolerability, presence of specific
comorbidities, and cost.
 Antihypertensive Treatment-Related
Side Effects

The high prevalence of both CV and non-CV

comorbidities among the elderly dictates need
for great vigilance to avoid treatment-related
side effects such as:
– Electrolyte disturbances
– Renal dysfunction
– Excessive orthostatic BP decline
 Hypertension in the Elderly

9. Initiation of antihypertensive drugs in the

elderly should generally be at the lowest
dose with gradual increments as tolerated.
 Physiologic Changes with Aging:
Potential to Influence Antihypertensive Drug Pharmacokinetics

Absorption and distribution of antihypertensive drugs are unpredictable in the

elderly
 Physiologic Changes with Aging:
Potential to Influence Antihypertensive Drug Pharmacokinetics

Continued

Half life of most antihypertensive drugs is increased in the

elderly
 Percent of Elderly People in Outcomes Trials
Taking ≥Two Antihypertensive Medications

ACCOMPLISH (131 mmHg)

CONVINCE (136 mmHg)
INVEST (136 mmHg)
Trial Name/SBP Achieved

ALLHAT (138 mmHg)

HYVET (138 mmHg)
Australian HTN (142 mmHg)
LIFE (143 mmHg)
SHEP (146 mmHg)
STONE (147 mmHg)
STOP-2 (151 mmHg)
EWPHE (151 mmHg)
Syst-Eur (151 mmHg)
MRC-Elderly (153 mmHg)
Syst-China (not reported)
0 10 20 30 40 50 60 70 80 90 100
(mean SBP achieved)
(Mean SBP achieved) Percent (%)
0
 Hypertension in the Elderly

10.The high prevalence of both CV and non-

CV comorbidities among the elderly dictates
need for great vigilance to avoid treatment-
related side effects.
 Target Blood Pressure Goals
in the Elderly

Although the optimal BP treatment goal in the

elderly has not been determined, a therapeutic
target of <140/90 mm Hg in persons aged 65-79
years and a SBP of 140-145 mm Hg, if tolerated,
in persons aged ≥80 years is reasonable.
 Principles of Hypertension Treatment in the Elderly
Lifestyle Modifications

Not at Target BP

Initial Drug Choices

Without Compelling Indications With Compelling Indications

Stage 1 Hypertension Stage 2 Hypertension Compelling Indication Initial Therapy Options*

SBP 140-159 mmHg or SBP ≥160 mmHg or • Heart Failure THIAZ, BB, ACEI, ARB, CA,
DBP 90-99 mmHg DBP ≥100 mmHg ALDO ANT
• Post myocardial infarction BB, ACEI, ALDO ANT, ARB
ACEI, ARB, CA, diuretic, Majority will require ≥2 drugs to • CAD or High CVD risk THIAZ, BB, ACEI, CA
or combination reach goal if ≥20 mmHg above • Angina Pectoris BB, CA
target. Initial combinations
• Aortopathy/Aortic Aneurysm BB, ARB, ACEI, THIAZ, CA
should be considered. The
• Diabetes ACEI, ARB, CA, THIAZ, BB
combination of amlopidine with
an RAS blocker may be preferred • Chronic kidney disease ACEI, ARB
to a diuretic combination, though • Recurrent stroke prevention THIAZ, ACEI, ARB, CA
either is acceptable. • Early dementia Blood pressure control
*Combination therapy
Not at Target BP
Optimize dosages or add additional drugs until goal BP is achieved.
Refer to a clinical hypertension specialist if unable to achieve control.
 Hypertension in the Elderly

• Summary and Conclusions

– Very highly prevalent

– Major, treatable risk factor for CV disease
– Typically, SBP elevation with low DBP (“stiff arteries”)
– Many comorbidities make management challenging
– Life style modification useful, even with drug therapy
– Begin with low drug doses and titrate drugs slowly
– For those ≥80 years, 140-145 mm Hg is acceptable
SBP goal