Professional Documents
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Degree of aging
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Comorbidities
Put the patient in the center to determine the benefits and side effects of antihypertensive
treatment, thereby determining the target blood pressure and which medication needed to
treat, mono-therapy or coordination.
For healthy aging, blood pressure control can be achieved the same as adults (< 60 years
of age). Avoid symptoms of postural hypotension.
For frail patients, setting target blood pressure depends on the degree of clinical
impairment, the best is around systolic 140-145 mmHg. Monitoring closely for symptoms
of postural hypotension.
For end-of-life stage, mainly palliative care, avoid hypertensive crisis, avoid hypotension.
Minimum antihypertensive drugs if possible.
III. COMORBIDITIES
- Elderly hypertensive patients often have comorbidities including chronic complications
of hypertension such as coronary artery disease, chronic heart failure, chronic kidney
disease; risk factors such as diabetes, sedentary.. ; and comorbidities like osteoarthritis...
- Pay attention to comorbidities to specify which antihypertensive medication is the most
appropriate (also called mandatory indication).
IV. THE IMPORTANT NOTES
Always remember the triangle disease in elderly patients: hypertension - comorbidities the degree of aging.
Take the patient in the center to choose the target blood pressure, and which medication.
Start with a low dose, increase the dose slowly.
Avoid symptoms of postural hypotension, never let systolic < 120 mmHg and diastolic <
60 mmHg.
All current antihypertensive drugs can be used depending on the comorbidities.
If there are no comorbidities, appropriate drugs for the elderly consist of three: diuretics,
calcium channel blockers, and inhibition of the reninangiotensin system (RAAS).
V. MEDICATIONS
Diuretic
RAAS blockers
than other drug classes. However, these agents have less robust BP-lowering effects than
CCBs and diuretics in the elderly, likely because of their volume-expanded/reninsuppressed state. As shown in ALLHAT and VALUE, these renin-angiotensin system
antagonists have less favorable outcomes than diuretics or CCBs when used as initial
therapy in the elderly hypertensive. They are most useful in combination therapy with a
diuretic or CCB.
Other Drug Classes. Beta-blockers, adrenergic blockers, centrally acting agents, direct
vasodilators, and mineralocorticoid (aldosterone) receptor antagonists are useful in
lowering BP and in treating some forms of target organ damage/concomitant conditions
in elderly hypertension, particularly when used in combination with the agents discussed
above. However, these drug classes lack outcomes data to support their use as first-line
treatment of uncomplicated hypertension in the elderly.
VI.
Lifestyle Modifications. Weight loss for most patients, and increased physical activity
for all, are effective in reducing BP in elderly patients who are adherent to
exercise/dietary prescription. Dietary modification and moderation of alcohol intake, as
indicated are also helpful. These measures are indicated for all hypertensive persons,
because they are effective in reducing cardiovascular risk factors and they enhance the
efficacy of pharmacologic treatment.
VII.
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References
1. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension.
2003;42:1206-1252. Abstract
2. Julius S, Kjeldsen SE, Weber M, et al. Outcomes in hypertensive patients at high
cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE
randomized trial. Lancet. 2004;363:2022-2031. Abstract
3. regimen
of amlodipine
adding
perindopril
as
required
versus
atenolol
adding
4. Psaty BM, Lumley T, Furberg CD, et al. Health outcomes associated with various Dahlf B,
Sever PS, Poulter NR, et al. Prevention of cardiovascular events with antihypertensive
antihypertensive therapies used as first-line agents: a network meta-analysis. JAMA.
2003;289:2534-2544. Abstract
5. Carter BL, Ernst ME, Cohen JD. Hydrochlorothiazide versus chlorthalidone: evidence
supporting their interchangeability. Hypertension. 2004;43:4-9. Abstract
6. Evidence-Based Guideline for the Management of High Blood Pressure in AdultsReport
From the Panel Members Appointed to the Eighth Joint National Committee (JNC
8) Hypertension. 2006;47:352-358. Abstract Angeli F, Verdecchia P, Reboldi GP, et al.
Calcium channel blockade to prevent stroke in hypertension: a meta-analysis of 13 studies
with 103,793 subjects. Am J Hypertens. 2004;17:817-822. Abstract 2014
7. Schafer, H H; De Villiers, J N; Sudano, I; Dischinger, S; Theus, G R; Zilla, P; Dieterle, T
(2012). Recommendations for the treatment of hypertension in the elderly and very elderly--a
scotoma within international guidelines. Swiss Medical Weekly, 142:w13574,
http://dx.doi.org/10.4414/smw.2012.13574.
8. Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update and
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