Hypertension management in older adults

A practical guide for assessing and managing cardiovascular risk during androgen-deprivation therapy in patients with prostate cancer

Prostate cancer is the most common malignancy among men worldwide, and androgen-deprivation therapy (ADT) is a mainstay of treatment. There are observational data demonstrating an increased risk of cardiovascular events in patients who receive ADT, particularly those who have an elevated baseline cardiovascular risk. Because, for most patients with prostate cancer, death is predominantly from noncancer-related causes, cardiovascular disease and its risk factors should be optimized during cancer treatment. This review provides an overview of the landscape of ADT treatment and serves as a guide for appropriate cardiovascular screening and risk-mitigation strategies. The authors emphasize the importance of shared communication between the multidisciplinary cancer team and primary care to improve baseline cardiovascular screening and treatment of modifiable risk factors within this higher risk population.

Effects of different types of carotid endarterectomy on the course of resistant arterial hypertension

OBJECTIVE

Analysis of the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (СЕЕ) (classical with plasty of the reconstruction zone with a patch, eversion, formation of a new bifurcation, autoarterial reconstruction, glomus-saving techniques) in patients with resistant arterial hypertension (RAH).

MATERIALS AND METHODS

The actual cohort, comparative, retrospective, open research for the period from January 2013 to December 2021 includes 1577 patients with significant hemodynamic stenosis of the internal carotid artery Depending on revascularization strategy five groups were formed: Group 1: 18.3% (n = 289) - classical Carotid endarterectomy with plasty of the reconstruction zone with a patch (from diepoxy-treated xenopericardium or synthetic); Group 2: 29.9% (n = 472) - eversional CEE with cut-off of carotid gloomus (CG); Group 3: 6.9% (n = 109) - the formation of a new bifurcation; Group 4: 7.4% (n = 117) - autoarterial reconstruction; Group 5: 37.4% (n = 590) - glomus-saving CEE (1 technique - according to A.N. Kazantsev; two technicians - according to R.A. Vinogradov; three technicians - according to K.A.Antsupov). According to the 24-h blood pressure monitor in the preoperative period, the following degrees of AH were identified: 1° - 5.7% (n = 89); 2° - 64.2% (n = 1013); and 3° - 30.1% (n = 475).

RESULTS

In the postoperative period, no significant differences were obtained in the frequency of deaths, myocardial infarction, stroke, hemorrhagic transformation. However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (group 1: 1.03% (n = 3); group 2: 3.6% (n = 17); group 3: 3.67% (n = 4); group 4: 2.56% (n = 3); group 5: 0.5% (n = 3); p = 0.10). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG.

CONCLUSION

Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE, accompanied by the lowest incidence of adverse cardiovascular events caused by postoperative hypertensive crisis and hyperperfusion syndrome.

Interaction between hypertension and frailty and their impact on death risk in older adults: a follow-up study

BACKGROUND

Hypertension and frailty often occur concurrently, exhibiting increasing prevalence in the older population. In this study, we analyzed the frailty status among older adults with hypertension and the impact of their interaction on death risk.

METHOD

This prospective cohort survey study included data from older people in an urban community in Beijing collected between 2009 and 2020 using the cluster random sampling method. The participants were older adults who were ≥ 60 years old at the time of investigation and had lived at the place of investigation for > 1 year. The survey variables comprised those related to health and frailty status assessed during the 2009 baseline survey, along with death-related information as outcome variables in 2020. Additionally, a frailty index (FI) model was used to examine the frailty status among the older adults at baseline. The effects of hypertension prevalence on the age-related frailty changes as well as on mortality for varying degrees of frailty were further analyzed. Lastly, Cox regression and Kaplan-Meier curves were applied to evaluate the impact of the interaction between hypertension and frailty on death risk.

RESULTS

Ultimately, 1197 older individuals aged between 60 and 101 years(average age at baseline: 74.8 ± 8.6 years) were included .Among them, 475 individuals were men (mean age:74.8 ± 8.8 years), and 722 were women (mean age:74.8 ± 8.4 years).Frailty was identified in 151 individuals, leading to a prevalence rate of 12.6%(151/1197),while hypertension was detected in 593 (prevalence rate:49.5% [593/1197]).A total of 443 deaths were recorded by 2020, resulting in a mortality rate of 37.0% (443/1197).Moreover, FI values and mortality rates were higher at any age in older adults with hypertension compared with those without hypertension. Survival time analysis showed that the median survival time of older adults with hypertension and frailty was the shortest (39.0[95%CI: 35.6-42.3] months)when compared with that of older adults without hypertension but with frailty (52.9 [95%CI: 46.6-59.3] months), those with hypertension but without frailty (102.7 [95%CI: 98.7-106.8] months), and those without hypertension and frailty (127.9 [95%CI: 113.5-134.7] months),with log-rank x2 = 999.686 and P < 0.001. Furthermore, Cox regression results demonstrated that older adults with hypertension and frailty had the highest death risk when compared with that of older adults without hypertension and frailty (HR = 1.792, P < 0.001), those without hypertension but with frailty (HR = 1.484, P < 0.001), and those with hypertension but without frailty (HR = 1.406, P = 0.005).

CONCLUSION

Frailty is prevalent among older adults with hypertension; however, older adults with both hypertension and frailty have a relatively higher mortality risk. Therefore, screening and assessment of frailty in the older population with hypertension are crucial for its early identification, thereby enabling timely and appropriate interventions to prevent or delay the adverse effects of this concurrent condition.

The Problems and Needs of Self-Management Among Indonesian Older Adults With Hypertension: A Qualitative Study

Introduction

Hypertension is the most common older adults' health problem in Indonesia. Older adults experience various changes in their life that often contribute to their ability to manage health problems, especially in chronic diseases.

Objectives

This study aimed to understand the problems and needs of self-management of older adults with hypertension.

Methods

This was a qualitative exploratory descriptive design. Data collection was conducted among 62 participants. Participants were 15 older adults with hypertension and 11 older adults' families, 12 primary care nurses, seven medical doctors, 11 health volunteers, three heads of primary care, and three district health officials selected by purposeful sampling. Data were collected using semistructured, face-to-face interviews (older adults and their families) and focus group discussion (healthcare workers). Data analysis was carried out qualitatively descriptively using an inductive thinking process; Colaizzi's measures were used for analysis.

Results

This study identified eight main themes: (1) complaints related to aging and hypertension, (2) knowledge and beliefs about hypertension, (3) behavior changes after hypertension, (4) disease management support; access to health services for older adults, (5) the need to manage hypertension for older adults, (6) disease management support, (7) hypertension self-management behavior, and (8) compliance with medication.

Conclusion

This study provided evidence regarding older adults' problems and needs in managing hypertension. These findings should be considered while providing nursing care at the community level to initiate the self-management of hypertension in older adults.

Analysis of older adult blood pressure readings and hypertension treatment rates among the unsheltered population of Miami-Dade County

Objective

To assess prevalence of elevated blood pressure readings, rates of established hypertension diagnosis, and blood pressure control medication prescription rates in a cohort of older people experiencing unsheltered homelessness presenting to a Street Medicine clinic in Miami-Dade County, Florida. In addition, we will compare outcomes found in the study cohort to that of the general population.

Methods

Demographic information, clinical history, blood pressure control medication prescription, and blood pressure measurements were taken by a Street Medicine team of medical providers. The team routinely provides medical evaluations and care for people experiencing unsheltered homelessness who reside in rough sleeper tent encampments located on the street. Clinical information and vitals were recorded in REDCap. De-identified data from patients 65 years and above were downloaded and compared to a general population data set-the Centers for Disease Control National Health and Nutrition Examination Survey (CDC NHANES) 2017-2020 Pre-pandemic cohort. Data analysis was performed using R Studio version 4.3.2.

Results

Blood pressure was reported in 120 distinct interactions with older people experiencing homelessness. Compared to the age-matched NHANES data, older people experiencing unsheltered homelessness were at significantly increased relative risk for elevated blood pressure within the range of Stage 1 Hypertension (RR: 3.914, 95% CI: 2.560-5.892, P < 0.001), and within range of Stage 2 Hypertension (RR: 5.550, 95% CI: 4.272-7.210, P < 0.001). According to NHANES, 49.6% of adults over 60 with diagnosed hypertension receive treatment. Of study participants, 69% of those with elevated blood pressure had previously received a diagnosis of hypertension and 15.9% on medication to control blood pressure.

Conclusion

Our cohort of older people experiencing unsheltered homelessness had higher rates of elevated blood pressure and reduced rates of hypertension diagnosis and treatment as compared to the general population. Older people experiencing unsheltered homelessness are a growing population, and future research should seek to evaluate and understand older adult care vulnerabilities, including chronic disease management, to improve health outcomes for those who are aging, hypertensive, and unhoused.

Prevalence of non-communicable chronic diseases: arterial hypertension, diabetes mellitus, and associated risk factors in long-lived elderly people

OBJECTIVE

To identify the prevalence of non-communicable chronic diseases: arterial hypertension, diabetes mellitus, and associated risk factors in long-lived elderly people from three Brazilian regions.

METHODS

This is a multicenter, cross-sectional, and comparative study conducted with elderly people aged 80 years or older.

RESULTS

Higher prevalence of arterial hypertension were observed among those who use polypharmacy (75.7%), among elderly people aged between 80 and 84 years (33.9%), as well as in elderly people who are overweight (78.2%). The prevalence of diabetes was 24% (RP: 0.76; 95% CI: 0.59-0.98) lower among women compared to men and 2.15 times higher among those who use five or more medications (RP: 2.15; 95% CI: 1.63-2.85).

CONCLUSIONS

In our sample, polypharmacy, body weight, and gender determine the prevalence of non-communicable chronic diseases: arterial hypertension and diabetes mellitus in long-lived elderly people.

The therapeutic concordance approach reduces adverse drug reactions in patients with resistant hypertension

Background

Adverse drug reactions (ADRs) remain among the leading causes of therapy-resistant hypertension (TRH) and uncontrolled blood pressure (BP). We have recently reported beneficial results in BP control in patients with TRH adopting an innovative approach, defined as therapeutic concordance, in which trained physicians and pharmacists reach a concordance with patients to make them more involved in the therapeutic decision-making process.

Methods

The main scope of this study was to investigate whether the therapeutic concordance approach could lead to a reduction in ADR occurrence in TRH patients. The study was performed in a large population of hypertensive subjects of the Campania Salute Network in Italy (ClinicalTrials.gov Identifier: NCT02211365).

Results

We enrolled 4,943 patients who were firstly followed-up for 77.64 ± 34.44 months, allowing us to identify 564 subjects with TRH. Then, 282 of these patients agreed to participate in an investigation to test the impact of the therapeutic concordance approach on ADRs. At the end of this investigation, which had a follow-up of 91.91 ± 54.7 months, 213 patients (75.5%) remained uncontrolled while 69 patients (24.5%, p < 0.0001) reached an optimal BP control. Strikingly, during the first follow-up, patients had complained of a total of 194 ADRs, with an occurrence rate of 68.1% and the therapeutic concordance approach significantly reduced ADRs to 72 (25.5%).

Conclusion

Our findings indicate that the therapeutic concordance approach significantly reduces ADRs in TRH patients.

Antihypertensive treatment changes and related clinical outcomes in older hospitalized patients

BACKGROUND

Hypertension management in older patients represents a challenge, particularly when hospitalized.

OBJECTIVE

The objective of this study is to investigate the determinants and related outcomes of antihypertensive drug prescription in a cohort of older hospitalized patients.

METHODS

A total of 5671 patients from REPOSI (a prospective multicentre observational register of older Italian in-patients from internal medicine or geriatric wards) were considered; 4377 (77.2%) were hypertensive. Minimum treatment (MT) for hypertension was defined according to the 2018 ESC guidelines [an angiotensin-converting-enzyme-inhibitor (ACE-I) or an angiotensin-receptor-blocker (ARB) with a calcium-channel-blocker (CCB) and/or a thiazide diuretic; if >80 years old, an ACE-I or ARB or CCB or thiazide diuretic]. Determinants of MT discontinuation at discharge were assessed. Study outcomes were any cause rehospitalization/all cause death, all-cause death, cardiovascular (CV) hospitalization/death, CV death, non-CV death, evaluated according to the presence of MT at discharge.

RESULTS

Hypertensive patients were older than normotensives, with a more impaired functional status, higher burden of comorbidity and polypharmacy. A total of 2233 patients were on MT at admission, 1766 were on MT at discharge. Discontinuation of MT was associated with the presence of comorbidities (lower odds for diabetes, higher odds for chronic kidney disease and dementia). An adjusted multivariable logistic regression analysis showed that MT for hypertension at discharge was associated with lower risk of all-cause death, all-cause death/hospitalization, CV death, CV death/hospitalization and non-CV death.

CONCLUSIONS

Guidelines-suggested MT for hypertension at discharge is associated with a lower risk of adverse clinical outcomes. Nevertheless, changes in antihypertensive treatment still occur in a significant proportion of older hospitalized patients.

Understanding perspectives on health-promoting behaviours among older adults with hypertension

Purpose

Health-promoting behaviours (HPBs) are considered the key to determining health among older adults with hypertension. Increasing our understanding of older adults’ views on HPBs could facilitate the development of interventions aimed at improving their quality of life. This study aims to describe the perceptions of older adults with high blood pressure concerning their HPBs and associated factors.

Methods

Semi-structured interviews with 40 individuals in Thailand were used to collect the data, which were analysed using thematic analysis.

Results

The results were categorized into five main themes related to personal, social, and environmental factors. Older adults explained that their experiences with HPBs involve taking responsibility for controlling blood pressure by following a doctor’s prescription, modifying their lifestyles to be healthier, sustaining social relationships, and experiencing spiritual growth through religious practices for inner peace. Older adults also identified environmental factors that influenced their engagement in HPBs depending on their residential areas.

Conclusions

The findings of this study highlight the importance of practices in which professionals support and encourage older adults to perform HPBs to maintain health and improve their well-being.

Chronological attenuation of NPRA/PKG/AMPK signaling promotes vascular aging and elevates blood pressure

Hypertension is common in elderly population. We designed to search comprehensively for genes that are chronologically shifted in their expressions and to define their contributions to vascular aging and hypertension. RNA sequencing was conducted to search for senescence-shifted transcripts in human umbilical vein endothelial cells (HUVECs). Small interfering RNA (siRNA), small-molecule drugs, CRISPR/Cas9 techniques, and imaging were used to determine genes' function and contributions to age-related phenotypes of the endothelial cell and blood vessel. Of 25 genes enriched in the term of "regulation of blood pressure," NPRA was changed most significantly. The decreased NPRA expression was replicated in aortas of aged mice. The knockdown of NPRA promoted HUVEC senescence and it decreased expressions of protein kinase cGMP-dependent 1 (PKG), sirtuin 1 (SIRT1), and endothelial nitric oxide synthase (eNOS). Suppression of NPRA also decreased the phosphorylation of AMP-activated protein kinase (AMPK) as well as the ratio of oxidized nicotinamide adenine dinucleotide (NAD⁺ )/reduced nicotinamide adenine dinucleotide (NADH) but increased the production of reactive oxygen species (ROS). 8-Br-cGMP (analog of cGMP), or AICAR (AMPK activator), counteracted the observed changes in HUVECs. The Npr1^+/- mice presented an elevated systolic blood pressure and their vessels became insensitive to endothelial-dependent vasodilators. Further, vessels from Npr1^+/- mice increased Cdkn1a but decreased eNos expressions. These phenotypes were rescued by intravenously administrated 8-Br-cGMP and viral overexpression of human PKG, respectively. In conclusion, we demonstrate NPRA/PKG/AMPK as a novel and critical signaling axis in the modulation of endothelial cell senescence, vascular aging, and hypertension.

Immunomodulatory properties of antihypertensive drugs and digitalis glycosides

INTRODUCTION

The role of chronic inflammatory process in the pathogenesis or exacerbation of hypertension has been already acknowledged.

AREAS COVERED

Therefore, one can speculate that hypotensive drugs may exert some of their therapeutic effects due to immunomodulatory properties. So far, this assumption has been tested in different studies, and the resulting knowledge is summarized in the current review article that is dedicated to different groups of antihypertensives, namely calcium channel blockers, beta blockers, as well as other less commonly used medications, such as hydralazine, agonists of alfa-2 receptor, diazoxide, doxazosin, aliskiren, and sodium nitroprusside. Articles were found in the Pubmed database by entering the name of a specific drug (or group of drugs) together with the words: immunology, cellular response, humoral response, inflammation, interleukin. The 2000-2021 range was used to search for all drugs except propranolol (1980-2021) and calcium blockers (1990-2021).

EXPERT OPINION

Observed decrease in serum/plasma concentration of proinflammatory cytokines, and CRP along with lower expression of adhesion molecules on immune cells strongly suggest that these drugs possess immunomodulatory properties, which seems to be crucial in the medical practice, especially in the therapy of hypertensive patients with other accompanying inflammatory-based diseases, such as type II diabetes, developed metabolic syndrome, allergies or autoimmunity.

[A multicenter study on the influence of different kinds of carotidal endarterectomy on the course of resistant arterial hypertension]

OBJECTIVE

To analyze the dynamics of systolic blood pressure (SBP) and the results of various types of carotid endarterectomy (CEE) in patients with resistant arterial hypertension (RAH).

MATERIALS AND METHODS

The study included 1577 patients with hemodynamically significant stenosis of the internal carotid artery (ICA) and RAH for more than 3 years. Patients were enrolled from January 2014 to December 2020. Depending on the implemented revascularization strategy, 5 groups were formed: group 1 (n=289 (18.3%)) with classical CEE with plasty of the reconstruction zone with a patch, group 2 (n=472 (29.9%)) with eversional CEE with cut-off of carotid glomus (CG); group 3 (n=109 (6.9%)) with the formation of a new bifurcation; group 4: (n=117 (7.4%)) with autoarterial reconstruction; group 5: (n=590 (37.4%)) with glomus-saving CEE.

RESULTS

In the postoperative period, no significant differences were obtained in the frequency of deaths (0.34% for group 1; 0.63% for group 2; 0% for groups 3, 4 and 5), myocardial infarction (0.34%, 0.84%, 1.83, 0.85%, 0.33%, respectively); ischemic stroke (0.34%, 1.27%, 0.91%, 0.85%, 0.17%, respectively), hemorrhagic transformation (0%, 0.84%, 0.91%, 0.85%, 0%, respectively). However, according to the frequency of the combined endpoint (death + myocardial infarction + ischemic stroke + hemorrhagic transformation), the lowest rates were observed in the group of classical carotid endarterectomy with plasty of the reconstruction zone with a patch and glomus-sparing CEE (1.03%, 3.6%, 3.67%, 2.56%, 0.5%, respectively). This is due to the absence of cases of labile AH and hypertensive crises among patients of groups 1 and 5, which was ensured by the preservation of carotid glomus (CG). As a result, the number of patients with 2 and 3 degrees of hypertension in these groups decreased statistically significantly. The vast majority of patients after these operations achieved a stable target SBP. In groups 2, 3, and 4, there was a statistically significant increase in the number of patients with 2 and 3 degrees of AH, which is associated with excision of the CG.

CONCLUSION

Classical CEE and glomus-sparing CEE techniques make it possible to achieve a stable target SBP level in patients with RAH as a result of CG preservation. Removal or traumatization of the latter during eversional CEE, the formation of a new bifurcation, autoarterial reconstruction is accompanied by the development of labile hypertension, an increase in the degree of hypertension and a high risk of hemorrhagic transformation in the brain. Thus, the most effective and safe types of CEE in the presence of RAH are classical CEE with plasty of the reconstruction zone with a patch and glomus-sparing CEE.