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Angeli F, Verdecchia P, Masnaghetti S, Vaudo G, Reboldi G. Treatment strategies for isolated systolic hypertension in elderly patients. Expert Opin Pharmacother 2020; 21:1713-1723. [PMID: 32584617 DOI: 10.1080/14656566.2020.1781092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hypertension is a major and modifiable risk factor for cardiovascular disease. Its prevalence is rising as the result of population aging. Isolated systolic hypertension mostly occurs in older patients accounting for up to 80% of cases. AREAS COVERED The authors systematically review published studies to appraise the scientific and clinical evidence supporting the role of blood pressure control in elderly patients with isolated systolic hypertension, and to assess the influence of different drug treatment regimens on outcomes. EXPERT OPINION Antihypertensive treatment of isolated systolic hypertension significantly reduces the risk of morbidity and mortality in elderly patients. Thiazide diuretics and dihydropyridine calcium-channel blockers are the primary compounds used in randomized clinical trials. These drugs can be considered as first-line agents for the management of isolated systolic hypertension. Free or fixed combination therapy with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and calcium-channel blockers or thiazide-like diuretics should also be considered, particularly when compelling indications such as coronary artery disease, chronic kidney disease, diabetes, and congestive heart failure coexist. There is also hot scientific debate on the optimal blood pressure target to be achieved in elderly patients with isolated systolic hypertension, but current recommendations are scarcely supported by evidence.
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Affiliation(s)
- Fabio Angeli
- Department of Medicine and Surgery, University of Insubria , Varese, Italy.,Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS Tradate , Varese, Italy
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS and Division of Cardiology, Hospital S. Maria Della Misericordia , Perugia, Italy
| | - Sergio Masnaghetti
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS Tradate , Varese, Italy
| | - Gaetano Vaudo
- Department of Medicine, University of Perugia , Perugia, Italy
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Management of hypertension in the very old: an intensive reduction of blood pressure should be achieved in most patients. J Hum Hypertens 2020; 34:551-556. [PMID: 32398768 DOI: 10.1038/s41371-020-0345-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/23/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023]
Abstract
There is large evidence that treatment of hypertension significantly reduces the risk of morbidity and mortality in the elderly. Although it is generally accepted that the benefit of antihypertensive treatment is largely explained by the reduction in systolic blood pressure, the optimal blood pressure target in elderly patients is still a topic of debate. Unfortunately, the clinical trials which demonstrated the benefit of antihypertensive treatment in old and very old patients with hypertension included relatively fit patients since frail patients were generally excluded. Available data suggest that when treating older adults, and especially frail older hypertensive adults, extra caution is appropriate in the setting of significant adverse events. Nonetheless, recent observations demonstrated a similar benefit from a more intensive compared with a less intensive blood pressure lowering in both fit and frail older adults. Of note, the rate of serious adverse events appears not dissimilar in the two treatment strategies, and not associated to frailty. Taken together, these findings support the concept that an intensive therapeutic strategy appears reasonable even in elderly hypertensive patients, particularly when the treatment is well tolerated.
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Correa A, Rochlani Y, Khan MH, Aronow WS. Pharmacological management of hypertension in the elderly and frail populations. Expert Rev Clin Pharmacol 2018; 11:805-817. [PMID: 30004797 DOI: 10.1080/17512433.2018.1500896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Cardiovascular disease is a leading cause of mortality in the elderly. Hypertension is an important modifiable risk factor that contributes to cardiovascular morbidity and mortality. The prevalence of hypertension is known to increase with age, and hypertension has been associated with an increase in risk for cardiovascular disease in the elderly. There is a wealth of evidence that supports aggressive control of blood pressure to lower cardiovascular risk in the general population. However, there are limited data to guide management of hypertension in the elderly and frail patient subgroups. These subgroups are inadequately treated due to lack of clarity regarding blood pressure thresholds, treatment targets, comorbidities, frailty, drug interactions from polypharmacy, and high cost of care. Areas covered: We review the current evidence behind the definition, goals, and treatments for hypertension in the elderly and frail and outline a strategy that can be used to guide antihypertensive pharmacotherapy in this population. Expert commentary: Lower blood pressure to < 130/80 mm Hg in elderly patients if tolerated and promote use of combination therapy if the blood pressure is > 20/10 mm Hg over the goal blood pressure. Antihypertensive treatment regimens must be tailored to each individual based on their comorbidities, risk for adverse effects, and potential drug interactions ( Figure 1 ).
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Affiliation(s)
- Ashish Correa
- a Department of Medicine , Mount Sinai St. Luke's - West Hospital/Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - Yogita Rochlani
- b Cardiology Division, Department of Medicine , Westchester Medical Center/New York Medical College , Valhalla , NY , USA
| | - Mohammed Hassan Khan
- b Cardiology Division, Department of Medicine , Westchester Medical Center/New York Medical College , Valhalla , NY , USA
| | - Wilbert S Aronow
- b Cardiology Division, Department of Medicine , Westchester Medical Center/New York Medical College , Valhalla , NY , USA
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Gentile G, Mastroluca D, Ruggenenti P, Remuzzi G. Novel effective drugs for diabetic kidney disease? or not? Expert Opin Emerg Drugs 2014; 19:571-601. [PMID: 25376947 DOI: 10.1517/14728214.2014.979151] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Diabetes mellitus is increasingly common worldwide and is expected to affect 592 million people by 2035. The kidney is often involved. A key goal in treating diabetes is to reduce the risk of development of kidney disease and, if kidney disease is already present, to delay the progression to end-stage renal disease (ESRD). This represents a social and ethical issue, as a significant proportion of patients reaching ESRD in developing countries do not have access to renal replacement therapy. AREAS COVERED The present review focuses on novel therapeutic approaches for diabetic nephropathy (DN), implemented on the basis of recent insights on its pathophysiology, which might complement the effects of single inhibition of the renin-angiotensin-aldosterone system (RAAS), the cornerstone of renoprotective interventions in diabetes, along with glycemic and blood pressure control. EXPERT OPINION Although a plethora of new treatment options has arisen from experimental studies, the number of novel renoprotective molecules successfully implemented in clinical practice over the last two decades is disappointingly low. Thus, new investigational strategies and diagnostic tools - including the appropriate choice of relevant renal end points and the study of urinary proteome of patients - will be as important as new therapeutic interventions to fight DN. Finally, in spite of huge financial interests in replacing the less expensive ACE inhibitors and angiotensin II receptor blockers with newer drugs, any future therapeutic approach has to be tested on top of - rather than instead of - optimal RAAS blockade.
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Affiliation(s)
- Giorgio Gentile
- IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Clinical Research Center for Rare Diseases "Aldo e Cele Daccò" , Villa Camozzi, Via Giambattista Camozzi 3, 24020, Ranica, Bergamo , Italy +39 03545351 ; +39 0354535371 ;
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Kaiser EA, Lotze U, Schäfer HH. Increasing complexity: which drug class to choose for treatment of hypertension in the elderly? Clin Interv Aging 2014; 9:459-75. [PMID: 24711696 PMCID: PMC3969251 DOI: 10.2147/cia.s40154] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Treatment of hypertension in the elderly is expected to become more complex in the coming decades. Based on the current landscape of clinical trials, guideline recommendations remain inconclusive. The present review discusses the latest evidence derived from studies available in 2013 and investigates optimal blood pressure (BP) and preferred treatment substances. Three common archetypes are discussed that hamper the treatment of hypertension in the very elderly. In addition, this paper presents the current recommendations of the NICE 2011, JNC7 2013-update, ESH/ESC 2013, CHEP 2013, JNC8 and ASH/ISH guidelines for elderly patients. Advantages of the six main substance classes, namely diuretics, beta-blockers (BBs), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and direct renin inhibitors (DRIs) are discussed. Medical and economic implications of drug administration in the very elderly are presented. Avoidance of treatment-related adverse effects has become increasingly relevant. Current substance classes are equally effective, with similar effects on cardiovascular outcomes. Selection of substances should therefore also be based on collateral advantages of drugs that extend beyond BP reduction. The combination of ACEIs and diuretics appears to be favorable in managing systolic/diastolic hypertension. Diuretics are a preferred and cheap combination drug, and the combination with CCBs is recommended for patients with isolated systolic hypertension. ACEIs and CCBs are favorable for patients with dementia, while CCBs and ARBs imply substantial cost savings due to high adherence.
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Affiliation(s)
| | - Ulrich Lotze
- Department of Internal Medicine, DRK-Manniske-Krankenhaus Bad Frankenhausen, Bad Frankenhausen, Germany
| | - Hans Hendrik Schäfer
- Roche Diagnostics International AG, Rotkreuz, Switzerland ; Institute of Anatomy II, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
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Somma C, Trillini M, Kasa M, Gentile G. Managing end-stage renal disease in the elderly: state-of-the-art, challenges and opportunities. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ahe.13.52] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Jacobs JM, Stessman J, Ein-Mor E, Bursztyn M. Hypertension and 5-Year Mortality among 85-Year-Olds: The Jerusalem Longitudinal Study. J Am Med Dir Assoc 2012; 13:759.e1-6. [DOI: 10.1016/j.jamda.2012.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 05/03/2012] [Accepted: 05/07/2012] [Indexed: 11/15/2022]
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Sodium Consumption: An Individual's Choice? Int J Hypertens 2012; 2012:860954. [PMID: 22263106 PMCID: PMC3259482 DOI: 10.1155/2012/860954] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 11/14/2011] [Indexed: 02/06/2023] Open
Abstract
Excess intake of dietary salt is estimated to be one of the leading risks to health worldwide. Major national and international health organizations, along with many governments around the world, have called for reductions in the consumption of dietary salt. This paper discusses behavioural and population interventions as mechanisms to reduce dietary salt. In developed countries, salt added during food processing is the dominant source of salt and largely outside of the direct control of individuals. Population-based interventions have the potential to improve health and to be cost saving for these countries. In developing economies, where salt added in cooking and at the table is the dominant source, interventions based on education and behaviour change have been estimated to be highly cost effective. Regardless, countries with either developed or developing economies can benefit from the integration of both population and behavioural change interventions.
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Abstract
The occurrence of additional cardiovascular events when the diastolic blood pressure is lowered below a critical level is referred to as "the diastolic J curve." Although the critical level of diastolic blood pressure where the J curve begins is not certain, increasingly strong evidence from prospective, controlled studies has confirmed the existence of such a J curve. With the likely addition of more patients who will be treated more vigorously, in particular, elderly subjects with isolated systolic hypertension, the potential for an increase in the number of adverse cardiovascular events must be considered and caution used to avoid too low a diastolic blood pressure.
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Kaplan NM. Can treating the diastolic blood pressure below a certain value increase cardiovascular risk? Curr Cardiol Rep 2011; 13:517-9. [PMID: 21845442 DOI: 10.1007/s11886-011-0213-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The appearance of cardiovascular events when the diastolic blood pressure is lowered to some critical level is referred to as a "J-curve." Extensive data document the presence of a J-curve appearing when the diastolic blood pressure is lowered by antihypertensive medication to a level below 65 mm Hg, particularly in patients with underlying coronary heart disease even if such disease has not been clinically evident. Caution is needed in the more intensive and widespread treatment of hypertensive patients to avoid a J-curve.
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Affiliation(s)
- Norman M Kaplan
- University of Texas Southwestern Medical School, Dallas, TX 75390-8586, USA.
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Blood pressure lowering in the oldest old: a step toward abandoning arbitrary blood pressure targets. J Hypertens 2011. [DOI: 10.1097/hjh.0b013e328341af1e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Blood pressure lowering in the oldest old: a step toward abandoning arbitrary blood pressure targets. J Hypertens 2011; 29:171-3; author reply 173-5. [DOI: 10.1097/hjh.0b013e3283409240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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