Guidelines for hypertension in the elderly--1999 revised version. Ministry of Health and Welfare of Japan

Understanding the decline of mean systolic blood pressure in Japan: an analysis of pooled data from the National Nutrition Survey, 1986-2002

OBJECTIVE

To assess the relationships between the observed drop in mean systolic blood pressure (SBP) in Japan in 1986-2002 and the use of antihypertensive treatment and lifestyle factors.

METHODS

A nationally representative sample of 90,554 men and 101,903 women aged 20 years and over was obtained from pooled data of annual cross-sectional surveys in Japan during 1986-2002. Using two-stage least squares with an instrumental variable, we examined the association between SBP and antihypertensive medication and lifestyle factors, including body mass index (BMI), physical activity, alcohol consumption, cigarette smoking and dietary salt intake. In the surveys, regular exercise was defined as exercise for more than 30 minutes at a time more than twice a week for over 1 year. Current smoking was defined as either daily or occasional cigarette use. Current drinking was defined as an intake of more than one standard cup of Japanese sake, one large bottle of regular beer, or one double measure of whisky at a time more than three times a week. Changes in mean predicted SBP in each sex and age group between 1986 and 2002 were decomposed into the respective contributions of these explanatory variables.

FINDINGS

Age-specific means of predicted SBP declined during this period by 1.8 (95% confidence interval, CI: 1.2-2.5) to 3.0 (95% CI: 2.4-3.6) mmHg in men and 3.7 (95% CI: 3.4-4.1) to 5.1 (95% CI: 4.5-5.7) mmHg in women. These reductions were partly explained by the increased use of medications across all sex and age groups and decreased mean BMI in women in their 30s and 40s. The contributions of treatment effects increased with age. Elevated mean BMI in men and elderly women offset part of the decline of their mean SBP.

CONCLUSION

Declining mean SBP in Japan between 1986 and 2002 was partly attributable to the increased use of antihypertensive medications, especially in the older population, and lowered mean BMI in young women. However, a substantial part of the decline was left unexplained and needs to be investigated further. A still greater decline in SBP would be expected through improvements in body weight management, salt and alcohol intake, and treatment and control of hypertension.

Hypertension in the Elderly

Elderly individuals with hypertension show specific characteristics as a result of advancing arteriosclerosis, a high frequency of isolated systolic hypertension, increased pulse pressure and orthostatic hypotension. The necessity to treat hypertension in the elderly, including isolated systolic hypertension, has been demonstrated in many large-scale intervention trials. Young-old (65-74 years of age) hypertensive patients should be treated the same as nonelderly hypertensive patients. In old-old (75-84 years of age) patients with mild hypertension (140-159/90-99 mm Hg), the recommended target blood pressure (BP) is <140/90 mm Hg. In old-old (75-84 years of age) and oldest-old (> or =85 years of age) patients with systolic BP > or =160 mm Hg, cautious treatment is required. An intermediate target BP of <150 mm Hg is appropriate, followed by a final target BP of <140 mm Hg, if tolerated. Nonmedical therapy, such as salt restriction, exercise and weight reduction, is useful in the elderly. However, individualised management of nonmedical therapy is necessary to avoid deterioration of quality of life resulting from strict management of the patient's lifestyle. Diuretics, calcium channel antagonists, ACE inhibitors and angiotensin II type 1 receptor antagonists have been established as first-line antihypertensive drugs in the elderly. Use of combination therapy helps to achieve target BPs. The starting dose of each drug should be half the usual dose for nonelderly patients, and may be increased at intervals of >4 weeks, with achievement of the target BP in 3-6 months or longer. In hypertensive patients with co-morbid diseases, the target BP should be determined individually and antihypertensive drugs selected bearing in mind the patient's clinical circumstances. Avoiding hypoperfusion of target organs is very important in elderly hypertensive patients. When treating hypertension in elderly patients, the approach should be to identify individual pathophysiological characteristics and lower the BP cautiously and slowly.

An Angiotensin Receptor Blocker Reduces the Risk of Congestive Heart Failure in Elderly Hypertensive Patients with Renal Insufficiency

We examined the efficacy of candesartan in reducing cardiovascular events in hypertensive patients with coexisting chronic kidney disease and cardiovascular diseases. This open-label, prospective study was conducted from 1999 to 2002, and 141 hypertensive subjects 60 to 75 years old with non-diabetic chronic renal insufficiency were enrolled. Before randomization of the patients, we examined their past medical history and found that 69 patients had been hospitalized due to myocardial infarction (MI) or stroke. Therefore, the patients were divided into 2 groups, one with previous histories of MI or stroke and the other with no previous history of Ml or stroke. The patients were randomized to receive either the angiotensin receptor blocker candesartan or conventional treatment. The mean duration of follow-up was 3.1 +/- 0.4 years. The primary outcome was a primary cardiovascular event (MI, stroke, or heart failure) verified by hospitalization. At the end of the study, in the patients with past history of cardiovascular diseases, blood pressure was reduced from 146.4 +/- 7.2/79.2 +/- 5.1 to 34.4 +/- 6.1/72.3 +/- 4.0 mmHg in the candesartan group and from 145.3 +/- 5.1/80.1 +/- 3.8 to 133.4 +/- 5.8/73.8 +/- 4.2 mmHg in the conventional treatment group. In the patients without past history of cardiovascular diseases, blood pressure was reduced from 143.2 +/- 4.3/78.3 +/- 4.8 to 133.8 +/- 5.3/ 73.1 +/- 3.8 mmHg in the candesartan group and from 143.9 +/- 6.8/78.1 +/- 4.2 to 132.6 +/- 5.4/74.5 +/- 4.4 mmHg in the conventional treatment group at the end of the study. There were no significant differences between the candesartan group and the conventional treatment group in the reduction of blood pressures. Among patients with a past history of cardiovascular disease, the serum creatinine concentration increased from 1.49 +/- 0.38 to 1.58 +/- 0.42 by candesartan treatment and from 1.50 +/- 0.32 to 1.89 +/- 0.37 by conventional treatment. On the other hand, in patients with no past history of cardiovascular disease, the serum creatinine concentration increased from 1.44 +/- 0.42 to 1.46 +/- 0.40 by candesartan treatment and from 1.46 +/- 0.44 to 1.51 +/- 0.38 by conventional treatment. Although, there was no significant difference in the incidence of cardiovascular events between the 2 groups with the candesartan-based and conventional-based antihypertensive treatment, in patients without cardiovascular events (12/36 vs. 7/34: these figures indicate events per total participated persons per 3 years; following figures are the same as this), treatment with candesartan reduced the incidence of cardiovascular events in the patients with past history of cardiovascular diseases (20/33 vs. 32/ 38). In particular, candesartan-based treatment reduced the incidence of congestive heart failure by 66.4% in these patients. In conclusion, this prospective, open-labeled randomized study suggests that 1) previous history of cardiovascular diseases is a major risk factor for cardiovascular events; and 2) candesartan is effective for reduction of cardiovascular events in hypertensive patients with coexisting chronic kidney disease and cardiovascular diseases, especially for prevention of congestive heart failure.

Treated hypertensives with good medication compliance are still in a state of uncontrolled blood pressure in the Japanese elderly

OBJECTIVES

Blood pressure (BP) is poorly controlled in many countries. Poor compliance was suggested as the main cause for poor BP control. The purpose of this study was to examine the association between compliance and the control of both casual blood pressure (BP) and 24-hr ambulatory BP in a Japanese elderly population.

METHODS

The study was a cross-sectional survey. Casual BP and 24-hr ambulatory BP were measured at home. Hypertension was defined as casual systolic BP (SBP)≧140 and/or diastolic BP (DBP)≧90 mmHg, or as treated hypertension. A compliance rate of greater than 80% by the pill count method was defined as good compliance.

RESULTS

Of the 178 treated hypertensives, 82.6% showed good compliance. Between the treated hypertensives with good compliance and those with poor compliance, no significant difference was found in either casual BP or ambulatory BP. Of the treated hypertensives with good compliance, the prevalence of achieved target ambulatory BP, i.e., daytime BP<135/85 mmHg, nighttime BP<120/75 mmHg, and 24-hr BP<125/80 mmHg, was, respectively, 35.4%, 43.5%, and 20.4%.

CONCLUSIONS

Casual BP and 24-hr ambulatory BP were poorly controlled in the community-living elderly although many of the treated hypertensives showed good compliance. It is unlikely that this inadequate control of hypertension is due to poor compliance on the part of the subjects.

Trends in pharmacologic management of hypertension in Japan one year after the publication of the JSH 2000 guidelines. First Japanese Society of Hypertension

Hypertension, a major risk factor for cerebrovascular disease and heart disease, often requires drug therapy. The First Japanese Society of Hypertension Guidelines for the Management of Hypertension were published in June 2000. In the present work, we surveyed 447 doctors who attended continuing medical education meetings between March and July 2001 to elucidate national antihypertensive treatment patterns. A minimum level of 150/95 mmHg was selected by 60% and 140/90 mmHg by 19% of respondents as thresholds for initiating drug treatment, while 130/85 mmHg was selected by 26% of respondents as the goal blood pressure in middle-aged uncomplicated male patients. Sixty-nine percent of respondents selected a calcium antagonist as their previous drug of the first choice and 22% selected an ACE inhibitor. For their future first choice, 55% would prescribe an angiotensin II receptor antagonist (AIIA); 19% an ACE inhibitor; and 16% a calcium antagonist. Seventy-two percent selected a calcium antagonist + an ACE inhibitor and 17% selected a calcium antagonist + AIIA as their previous first-choice drug combinations. For their future drug combinations, 56% would select an AIIA + a calcium antagonist and 25% a calcium antagonist + an ACE inhibitor. Four weeks or less was selected by 69% of respondents as the period intended to reach the goal blood pressure. Eight weeks or more was selected by 28%. Overall, our data suggest that doctors in Japan are still cautious and conservative in controlling blood pressure levels but want rapid achievement of the goal blood pressure. Their first choice drug is shifting from calcium antagonists to AIIAs. These findings indicate the need for continued effort to evaluate the diversity of clinical practice and assess the appropriateness of continuing medical education.

A case of metastatic extra-adrenal pheochromocytoma 12 years after surgery

At the age of 53, a 65-year-old man had been diagnosed with extra-adrenal pheochromocytoma in the retroperitoneum and underwent total tumorectomy. Afterward, he had his serum catecholamine periodically measured in an outpatient clinic. In February 1999, 12 years after surgery, he complained of lower left abdominal pain. Computed tomography and magnetic resonance imaging revealed an osteolytic lesion in thoracic vertebrae 11Th (Th 11). Although his basal serum and urine catecholamines were at normal levels, glucagon injection increased blood pressure and plasma catecholamine levels. 131I-metaiodobenzylguanidine (MIBG) scintigraphy was specifically taken up to Th 11. By bone biopsy, the osteolytic lesion in Th 11 was finally diagnosed with metastasis of pheochromocytoma. For post-operative pheochromocytoma, long-term follow-up involving biochemical tests, including serum catecholamines, and MIBG is needed.

Treatment of hypertension in the elderly

Hypertension is a common condition among older people in most developed countries, and is a very important, if not the most important, risk factor for all subtypes of vascular disease and death. Many clinical trials in older people have demonstrated significant reductions in myocardial infarctions and strokes when antihypertensive drugs are provided. Lifestyle modifications are still recommended because they can lower a surrogate end point--blood pressure--but there are no data showing they reduce event rates. It is not appropriate to limit the choice of initial drug for hypertensive older individuals to a single class of agents, since so many older people have other medical problems that affect this decision. Monotherapy with an alpha blocker, however, is no longer recommended, even for men with hypertension and benign prostatic hypertrophy, as doxazosin was associated with a higher rate of cardiovascular events in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. The classic strategy of an initial diuretic (for at least 1 month) will likely be verified by the final results of ongoing randomized trials, expected in 2003. Until then, this strategy is effective, inexpensive, and unlikely to cause many adverse effects. Probably the most important exhortation, however, should be to achieve the blood pressure goal appropriate for the patient's risk status. Numerous clinical trials in older hypertensive patients have shown that more benefits accrue when the goal blood pressure is achieved than if a specific antihypertensive agent is chosen as initial therapy. Future cardiovascular risk may be related directly to the blood pressure attained, rather than to how it was attained.

Questionnaire survey on the Japanese guidelines for treatment of hypertension in the elderly: 1999 revised version

A questionnaire survey was administered to Japanese clinical specialists in hypertension in order to gauge their opinions on the 1999 revised version of the Guidelines for Hypertension in the Elderly prepared by the Comprehensive Research Project on Aging and Health of the Ministry of Health and Welfare. Out of 162 council members of the Japanese Society of Hypertension, 122 (75%) replied. The majority (93%) of respondents approved of the guidelines in general, and 72% of them approved of the age-related setting of a therapeutic goal for blood pressure. Sixty-five percent of respondents selected long-acting Ca antagonists, ACE inhibitors and low-dose diuretics as first-line agents for hypertension without complications in the elderly. The results of the questionnaire survey should be reflected in the next version of the guidelines.

Association of body mass index with blood pressure in 80-year-old subjects

OBJECTIVE

Little data are available on the association between obesity and high blood pressure in elderly individuals, particularly in subjects over 80 years of age. The aim of the present study was to determine the association between body mass index (BMI) and blood pressure in 80-year-old subjects.

METHODS

This study was part of the 8020 Data Bank Survey, which was designed to collect the baseline data of systemic and dental health conditions in 80-year-old subjects. We studied the cross-sectional association of BMI with blood pressures in 645 Japanese (258 men and 387 women), who were 80 years old.

RESULTS

Mean systolic blood pressure rose from 146.6 mmHg in the first quintile of BMI to 147.5 mmHg in the second, 150.3 mmHg in the third, 151.6 mmHg in the fourth, and 156.4 mmHg in the fifth quintiles (test for trend, P = 0.006). Mean diastolic blood pressure rose from 75.8 mmHg in the lowest quintile of BMI to 81.8 mmHg in the highest (test for trend, P = 0.002). We performed multiple regression analysis, controlling for factors known to influence blood pressure values, such as sex, alcohol intake, current smoking status and serum glucose, total cholesterol and creatinine concentrations. The association between BMI and systolic and diastolic blood pressure, respectively, was highly statistically significant in all analyses.

CONCLUSION

These results show that a close relationship is present between obesity and high blood pressure, even in very old subjects.

Altered diurnal variation of blood pressure in elderly subjects with decreased activity of daily living and impaired cognitive function

Activity of daily living (ADL) and cognitive are indices of physical and psychological activity in elderly subjects. The present study was performed to clarify the relationship among ADL, cognitive function, and ambulatory blood pressure (ABP) in the elderly. Study subjects were 77 females and 22 males (aged 60 to 101 years) with various levels of ADL and cognition, who were in nursing homes or geriatric hospitals. ABP was recorded every 30 min for 24 h by a noninvasive device. Mini-mental state examination (MMSE) and Barthel index measurement were used to evaluate cognitive function and ADL, respectively. Both the MMSE and Barthel index values showed a significant positive correlation with daytime ABP but not with nighttime ABP. The dip in nighttime BP correlated negatively with age, and positively with MMSE and Barthel index. In the multiple regression analysis, age and Barthel index values remained significant determinants of the dip in nighttime BP. Presence of stroke and MMSE became significant when the Barthel index values were removed from the analyses. When subjects were classified by tertiles of MMSE or Barthel index, subjects in the lowest MMSE group and those in the lowest Barthel index group had both lower daytime ABP and smaller nighttime BP dip than those of the other groups. A low BP level during the daytime was associated with altered diurnal variation of BP in elderly subjects with greater age, impaired cognitive function, and/or decreased ADL. ADL had a greater influence on diurnal BP variation than did cognitive function.

Cilnidipine is as effective as benazepril for control of blood pressure and proteinuria in hypertensive patients with benign nephrosclerosis

To investigate the beneficial effects of cilnidipine, a calcium channel blocker that shows high selectivity for N-type receptors, on the progression of chronic renal insufficiency, we compared the efficacy of cilnidipine to that of benazepril, an angiotensin-converting enzyme (ACE) inhibitor with known renal protective effects, in a one-year trial evaluating hypertensive control, serum creatinine, and albuminuria in a cohort of patients. Given the seeming importance of the etiology of chronic renal insufficiency in determining drug efficacy, we limited our study to 20 patients with a single common condition, benign nephrosclerosis. The average age of the patients was 62+/-4 years old. The changes in systolic and diastolic blood pressure over the course of the study year revealed a similar reduction with cilnidipine and benazepril. Both cilnidipine and benazepril induced similar reductions in systolic and diastolic blood pressure over the course of the study year. The baseline levels of serum creatinine were 1.40+/-0.2 mg/dl and urinary excretion of albumin was 168+/-10 mg daily. The levels of serum creatinine were not significantly changed throughout the study in either group, although the levels of urinary excretion of albumin were significantly decreased in both groups. There were no significant differences in either of these values between the two groups. In conclusion, both cilnidipine and benazepril equally and effectively reduced blood pressure and albuminuria in hypertensive patients with benign nephrosclerosis in a one-year trial.

Trandolaprilat, an angiotensin-converting enzyme inhibitor, is not excreted in bile via an ATP-dependent active transporter (cMOAT)

Trandolapril is the prodrug of an angiotensin-converting enzyme (ACE) inhibitor. It has been proposed that its active metabolite, trandolaprilat, is mainly excreted in bile, but this has not been clearly demonstrated. Recently it has been reported that temocaprilat, an active metabolite of the ACE inhibitor temocapril, is effectively excreted in bile via an ATP-dependent active transporter (canalicular multispecific organic anion transporter: cMOAT). To investigate whether trandolaprilat has the pharmacological ability to affect the cMOAT system in a manner similar to temocaprilat. The lipophilicity of trandolaprilat and temocaprilat was measured to determine the n-octanol-water partition coefficients. The dose-dependent inhibition of the up-take of [3H]-estradiol-17beta-D-glucuronide and [3H]-2,4-dinitrophenyl-S-glutathione, which are good substrates for cMOAT, in canalicular membrane vesicles (CMVs) prepared from Sprague-Dawley rats was determined in the presence of trandolaprilat and temocaprilat. The partition coefficient of trandolaprilat (log Po/w - 1.1) was about 30 times higher than that of temocaprilat (log Po/w - 2.5). The uptake of [3H]-estradiol-17beta-D-glucuronide and [3H]-2,4-dinitrophenyl-S-glutathione was dose-dependently inhibited by the presence of temocaprilat, but trandolaprilat had no effect on the transport of [3H]-estradiol-17beta-D-glucuronide or [3H]-2,4-dinitrophenyl-S-glutathione into CMVs even at concentrations as high as 200 microM. It could be concluded that trandolaprilat has a higher lipophilicity than temocaprilat. But the hepatobiliary excretion system via cMOAT may not contribute to the excretion of trandolaprilat in bile.