Αντιμετώπιση της ΑΥ στους ηλικιωμένους Α. Αχείμαστος Καθηγητής Παθολογίας
Absolute risk for stroke 20 18 16 14 12 10 8 6 4 2 0
18,4 14,6 11,9 10,5
10
6,2
80
2,4 0,5
1,6 0,3
1,3 0,2 88
Α.Κ. <45
3,8
93 Α.Κ. 45-64
0,9 98
1,9 103
DBP
Α.Κ.>65
Lancet 1995
2013 ESH/ESC Guidelines for the management of arterial hypertension (Mancia et al J. Hypert 2013)
Benefits of antihypertensive treatment in patients over 80 years old
THE HYPERTENSION IN THE VERY ELDERLY TRIAL Active treatment vs. placebo
Age > 80 years Ambulatory free dwelling living people SBP : 160-199 mmHg
Actif tt (indapamide Âą perindopril) vs placebo HR
95% CI
All Stroke
0.70
(0.49, 1.01)
Stroke Death
0.61
(0.38, 0.99)
All cause mortality
0.79
(0.65, 0.95)
NCV/Unknown death
0.81
(0.62, 1.06)
CV Death
0.77
(0.60, 1.01)
Cardiac Death
0.71
(0.42, 1.19)
Heart Failure
0.36
(0.22, 0.58)
CV events
0.66
(0.53, 0.82)
0.1
0.2
0.5
0
2
NEJM 2008;358
â&#x20AC;˘Lowering BP with Anti-HT treatment and prevention of Dementia?
The meta-analysis HYVET + 3 other similar studies
The Lancet Neurology, 7, 683 - 689, 2008
Should we treat ALL Hypertensives after 80?
Elderlyâ&#x20AC;Ś?
>80: very heterogeneous population
No association between SBP and CV morbidity in very old frail populations
ď Ž No association between SBP/DBP and total/CV mortality in elderly (87 yo) hospitalized in long stay hospital Meaume et al, Arterioscler Thromb Vasc Biol. 2001;21:204650
ď Ž No association between SBP and morbidity in a frail elderly nursing home population Askari M et al; Aging Clin Exp Res. 2004 16:206-11.
Molander et al, J Am Geriatr Soc 2008
HYVET
‡ Chute de la PAS ≥ 20 mmHg et/ou chute de la PAD ≥ 10 mmHg
Orthostatic hypertension in the very elderly The PARTAGE study (F. Valbusa et al, J Hypert. 2011)
OH = 17% 13% no possibility to evaluate
Drug Side effects in elderly hypertensives (drug/drug interactions) 50% over 70 y.o. are hypertensives 40% over 70 y.o. have >5 drugs Drug combinations often responsible for side effects: anti-HT1+ anti-HT2 anti-HT + psychotropic drugs ACEI + NSAI Beta blokers + antidiabetics Beta blokers + anti-cholinesterasiques
Drugs Side effects in the elderly hypertensives (Drug/Frailty interactions)
Frequent Severe Atypical
Side effects of drugs in the elderly hypertensives (Clinical manifestations)
Falls Confusion Deshydratation
Anti-hypertensive treatment strategies in the elderly Mancia et al, J. Hypertens 2013
Initial gerontological assessment (25 min)
•
Cognitive functions: MMSE (7 min)
•
Psychological status: GDS simplified (3 min)
•
Nutrition: BMI, BW Changes last 6 months, MNA (5 min)
•
Gait and posture: walk speed ; Get up and go (5 min)
•
Autonomy : ADL – IADL (5 min)
•
In addition to a complete Physical Examination
How to Treat the Elderly
Lifestyle modifications in the elderly
ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly
Lifestyle modifications in frail >80 years
ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly
Anti-hypertensive treatment strategies in the elderly Mancia et al, J. Hypertens 2013
Anti-hypertensive treatment in the elderly Drugs used Thiazides: do not exceed 25 mg/d, think about urine incontinence Furosemide: if clearance <60 ml/min Anti-aldosterone : No (unless HF stage IV) CCB: use mainly Dihydropyridines (unless Coronary Disease) ACEI, ARBs: first choice if HF, diabetes Beta blockers: first or second choice if HF, Coronary disease Other drugs (central anti-Ht, alpha blockers) if necessary
Anti-hypertensive treatment in the elderly
Start with 1 drug at low doses (Diuretics or CCB) Combine if necessary a second drug (ACEI, ARBs) Most hypertensives will need a combination therapy Use a third drug if necessary Do not exceed 3 drugs
Managment of arterial hypertension in the elderly >80 yo Conclusions • Age is not the main determinant ; • Frailty, degree of autonomy and multi-morbidity are the main determinants • Treat all “robuste” hypertensives • Focus on SBP (and PP after 70 y) • Target SBP 150 mmHg after 80y) • Start low (one drug for starting), Go slow • Not more than 3 anti-Htn drugs after 80 y • Check for orthostatic hypotension • Check for renal function
Managment of arterial hypertension in the elderly Conclusions • Gerontological assessment+++ • For frail, dependent people with multiple comorbidities the risk/benefice balance of treatment is unknown • High risk for iatrogenic problems (polymedication, frailty) • Individual approach for the very frail and disabled elderly : Quality of life is the first goal
Επίδραση της συστολικής και διαστολικής ΑΠ στη θνητότητα από Στεφανιαία Νόσο: Εξετασθέντες στην MRFIT (N=316.099)* Θνητότητα από CHD ανά 10.000 ανθρωποέτη
48,3
43,8
25,5
23.8
20,6
38,1
16.9
25,3 25,2
13.9
10,3
12,8
11,8
100+
90-99
11,8
8,5
80-89
24, 9
12,6
8,8
Διαστολική ΑΠ (mm Hg)
80,6
37,4
31,0
9,2
75-79 70-74
160+ 140120-139 159
Συστολική ΑΠ * Άνδρες 35-57 ετών που παρακολουθήθηκαν επί 12 έτη κατά μέσον όρο.(mm Hg) <70
Neaton et al. Arch Intern Med. 1992;152:56-64.
<120
mmHg 200
190
The difficulty in achieving SBP targets in clinical trials SBP
HOPE PROGRESS CAPPP
mmHg 120
INSIGHT
DBP
NORDIL
110 180
HOT
STONE
100
170 STOP-2
160
ALLHAT 1
90 LIFE
150 ALLHAT 2
80 140
ANBP2
INVEST
130
70 SCOPE
ASCOT VALUE
Adapted from Mancia G., Grassi G., J Hypertens 2002
Old subject
Young subject
Pulse wave velocity = 12m/s
Pulse wave velocity = 8m/s
systole
diastole
Measured wave
systole
Backward wave
diastole
Forward wave
ΕΠΕΙΓΟΥΣΑ ΑΝΤΙΜΕΤΩΠΙΣΗ Περιοχή η επιβίωση της οποίας εξαρτάται από τη συστηματική Α.Π.
Περιοχή ΑΕΕ