Lege Artis Medicinae

[Hypertension in the elderly - critical review of diagnostic-therapeutic guidelines and their background]

SZÉKÁCS Béla

SEPTEMBER 20, 2012

Lege Artis Medicinae - 2012;22(08-09)

[In the majority of old and very old hypertensive patients, the reduction of abnormally high blood pressure has been proved to provide a strategic defense of target organs. In patients younger than 80 years, both initial and target blood pressure (BP) values are similar to those of younger age groups. In those older than 80 years, a a systolic blood pressure level >160 mmHg is the threshold of indication for antihypertensive treatment and the therapeutic target value is<150 mmHg. Both values are evidence- based (HYVET). The latest ACCF/AHA guidelines (USA 2011) advise to achieve a BP below 140 mmHg if the use of one or two antihypertensive agents result in sufficient BP reduction. However, this strategy is not yet supported by unequivocal evidence regarding complications in target organs. It is not recommended to aim for target levels lower than the above values (especially the value defined by the ESH guidelines) even in elderly hypertensive patients at high cardiovascular risk, as the results of several studies suggest a J-curve effect. In multimorbid elderly patients it is highly important to adapt antihypertensive treatment to individual needs, rather than to use schematic approaches. The number and progression of comorbid diseases can greatly influence, in certain cases attenuate the aimed BP reduction. A similar medical decision should be made if the target BP level could only be achieved by the combination of multiple antihypertensive medications, which can remarkably impair quality of life in elderly patients. Among non-comorbid elderly patients with hypertension, there seems to be no convincing difference in the efficiency of target organ protection between antihypertensive treatments that have different target sites but can achieve similar target levels. However, the majority of elderly hypertensive patients have comorbidities with variable rates of progression. In those at even low cardiometabolic risk the use of beta-receptor blockers (BRB) and especially a combination of BRB+diuretic (DIU) is not recommended. The adequate therapeutic tactic includes the use of only moderate drug-doses and their early combination. This approach has been convincingly proved mainly with early combinations of RAS inhibitors+CCB-s and RAS inhibitors+small doses of DIU-s. It is very important to monitor the treated patients, as the BP and circulatory response to the same antihypertensive treatment can markedly change in elderly patients when either the enviromental conditions change or a new pathologic process develops and/or is treated. Strict control is also necessary because it occurs quite often that the earlier optimal compliance of elderly patients in taking antihypertensive medicines rapidly deteriorates. The efficiency of statins and acetylsalicylic acid decreases over 80 years of age, but this does not indicate that the previously efficient approach should be suspended.]

COMMENTS

0 comments

Further articles in this publication

Lege Artis Medicinae

[Rosuvastatin for the treatment of diabetic dyslipidaemia]

SIMONYI Gábor

[Cardiovascular disease is a leading cause of death. The incidence of type 2 diabetes is increasing worldwide as well as in Hungary. Diabetes mellitus is a high-risk state, and if associated with coronary disease, it is considered a very high-risk condition. According to the 5th Cardiovascular Consensus Conference and ESC/EAS, the target level of LDL-cholesterol should be <2.5 mmol/l in high-risk condition and <1.8 mmol/l in very high-risk condition. In diabetes, one of the main goals is to achieve target LDL-cholesterol levels, which require lifestyle changes as a first step, followed by statin treatment, in combination with with ezetimibe if necessary. Statins are also known to have diabetogenic effects, which are dose-dependent. The advantage of the preventive cardiovascular effects observed in nondiabetic patients substantially outweighs the risk of potentially developing diabetes mellitus, therefore, this risk should not hinder the use of statins. Statin treatment can substantially reduce cardiovascular events in patients with diabetes mellitus. The greatest reduction in LDL-cholesterol level can be achieved by the most efficient statin, rosuvastatin.]

Lege Artis Medicinae

[Music Therapy and Autism ]

KOLLÁR János

Lege Artis Medicinae

[Clinicoradiological consultation - why there is not any if there could be?]

HARKÁNYI Zoltán

Lege Artis Medicinae

[The One Who was a First-Class Gershwin – A Composer’s Life ]

KÖVES Péter

Lege Artis Medicinae

[Systemic diseases in pseudoexfoliation syndrome]

HOLLÓ Gábor

[Pseudoexfoliation syndrome is a condition associated with the production and accumulation of a pathological protein (pseudoexfoliation material). Originally, the syndrome was recognised on the basis of its intraocular symptoms and had been considered to be an isolated eye disease for a long time. However, some 20 years ago it became clear that in pseudoexfoliation syndrome pseudoexfoliation material is present all over in the body. In the past decade, vascular dysfunction associated with this syndrome has been also recognised. Recent studies have shown that pseudoexfoliation syndrome is caused by genetic alterations affecting a lysil oxidaselike (LOXL) protein, LOXL1. LOXL1 has an important role in the synthesis of extracellular material. To our current knowledge, pseudoexfoliation syndrome is a systemic elastosis associated with oxidative stress. Its complications are in part ocular (development of nuclear cataract, zonular damage and development of pseudoexfoliative glaucoma) and in part systemic (dysfunction of capillaries, muscular and elastic arteries, impairment of baroreflex function, increase of arterial rigidity, development of aorta aneurism, recurrent venous occlusions and neurosensory hearing loss). Despite the recognition of the above complications, currently it is not possible to set guidelines of a potential cardiovascular screening for patients with pseudoexfoliation syndrome, since the frequency and significance of systemic complications vary across different populations.]

All articles in the issue

Related contents

Lege Artis Medicinae

[The importance of differences between diuretics in the treatment of hypertension - Metabolic neutrality in focus]

ALFÖLDI Sándor

[Indapamide is a “second-generation” vasodilatatory thiazide diuretic. Its antihypertensive efficacy when used at a low dose is equivalent to those of the other first-line antihypertensive drugs. Unlike other thiazide diuretics, low-dose indapamide was not found to have any adverse glucose or lipid effects in previous studies, moreover, it decreased insulin resistance in patients with hypertension. The risks of hypokalemia and hyperuricemia were also substantially lower. In the large, randomized, placebo-controlled HYVET-study, low-dose, indapamide-based antihypertensive therapy significantly decreased the risks of cardiovascular diseases and mortality in elderly (age >80 years) patients with hypertension. According to new guidelines, indapamide is preferred to other thiazide diuretics for patients with hypertension associated with metabolic syndrome or diabetes mellitus.]

Hypertension and nephrology

[Summary of guidelines for American, European and International Companies in diabetes mellitus type 2 associated with hypertonia]

KÉKES Ede, DOLGOS Szilveszter

[The importance of hypertension in type 2 diabetes mellitus, the method of continuous blood pressure control and patient’s careas well as the forms of non-drug and drug therapy have been disclosed by presenting therapeutical recommendations from American, European scientific societies and international organizations. It has been established that the principles of care and treatment of hypertonia have basically remained unchanged in diabetes all over the world, despite the recent widespread debate over the interpretation of normal blood pressure and the consideration of the benefits of intensive or standard treatment.]

Lege Artis Medicinae

[Cardiovascular risk factors and risk assessment]

KÉKES Ede

[The author summarises the most important cardiovascular risk factors. Concerning public health, the three most important synergistic factors are smoking, hypertension and abnormal cholesterol. Abnormal total lipid profile, visceral obesity, elevated glucose and uric acid levels and hypertonia all contribute to the global cardiometabolic risk. A number of studies and metaanalyses have confirmed the correlations of the risk factors and cardiovascular events (organ damage, clinical events, mortality). The concomitant occurance of risk factors increases the rate of risk. Risk estimation methods have been designed on the basis of proven correlations and they have been continuously improved and made more reliable owing to the assessment of more and more factors.]

Hypertension and nephrology

[Antihypertenive effect of rilmenidine. Evaluation of the Hungarian multicenter VERITAS study]

FARSANG Csaba

[The VERITAS study showed that in hypertensive patients the imidazoline I1 receptor agonist, rilmenidine significantly decreased the office blood pressure as well as the blood pressure measured by ambulatory blood pressure monitoring (ABPM). The white-coat reaction and left ventricular hyperthrophy (LVH) were also decreased. Ain a separate study involving hypertensive subjects rilmenidine significantly increased baroreflex sensitivity. This effect may contribute - mainly during daytime - to the antihypertensive effect.]

Hypertension and nephrology

[Monitoring of the blood pressure lowering effectiveness of ramipril-amlodipine fix combination – a non-interventional trial (RAMONA study)]

TOMCSÁNYI János

[Purpose: Monitoring the effectiveness and safety of the fix combination formulation Egiramlon® therapy containing ramipril and amlodipin in patients, suffering from mild or moderate hypertension despite antihypertensive treatment. Patients and methods: Open, prospective, phase IV clinical observational study, which involved 9169 patients (age >18) with mild or moderate hypertension [TUKEB No: 16927- 1/2012/EKU (294/PI/12.)]. Ramipril/Amlodipin 5/5, 5/10, 10/5, 10/10 mg combinations were administered/ titrated in three visits, during the four months period according to the physician’s decision Blood pressure was measured by validated blood pressure sphygmomanometry and ABPM (Meditech, Hungary). The dosis of the fix combination formulation was determined individually during the visits by the 923 doctors involved in the study. The target blood pressure value was 140/90 mmHg, but in case of high risk patients population (diagnosed cardiovascular disease, diabetes), 130/90 mmHg target value was determined. Results: In 70.1% of the patients had no protocoll deviation. Patients data and examination results were processed according to this 6423 patient population. The average age of the patients were 60.2 year, in 50-50% sex distribution. The average duration of the treated hypertension was 9.8 years and the average blood pressure value was 157/91 mmHg. Till the end of the study, systolic blood pressure has decreased with 26.4 mmHg and diastolic pressure with 11.8 mmHg. An average 5.5 bpm heart rate frequency decreasing was observed at the end of the study. As a result of the treatment 52.4% of the patient population has reached the target blood pressure value.]