Paraskevi 2 Axeimastos

Page 1

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


•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?


Elderly‌?

>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


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