The goal of treatment for hypertension in the elderly is to minimize the overall risk of cardiovascular disease, but there are discrepancies in the recommendations for antihypertensive goals for hypertension in the elderly in previous national and international guidelines. How exactly should hypertension in the elderly be managed? Professor Dang Aimin of Fu Wai Hospital, Chinese Academy of Medical Sciences, answered this question at the 27th International Society of Hypertension Scientific Meeting (ISH 2018).
Clinical features of hypertension in the elderly
Increased systolic blood pressure is predominant: simple systolic hypertension (ISH) accounts for 60% of hypertension Higher blood pressure fluctuations, an increase in the "morning peak" phenomenon (early-morning hypertension), and an increase in the combination of hypertension with postural and postprandial hypotension Abnormal circadian and nocturnal rhythms Increase in non-arteritic or hyperarteritic types Increase in white coat hypertension: increase in pseudohypertension Hypertension in the elderly often coexists with a variety of diseases, such as cerebrovascular disease (cerebral hemorrhage, ischemic stroke, transient ischemic attack), cardiac disease (history of myocardial infarction, angina pectoris, history of coronary artery revascularization, chronic heart failure), and renal disease (diabetic nephropathy, impaired renal function)Principles of multidisease ****survival treatment of hypertension in the elderly
Combined with heart failure: if there are no contraindications, ACEI/ARB, β-blockers and diuretics can be used. Try to avoid the use of CCB, for those who are difficult to control blood pressure, can use the vascular selective dihydropyridine CCB (felodipine or amlodipine).
Combined with coronary artery disease: β-blockers and ACEIs should be preferred, and if there is no contraindication, they should be used at an early stage; CCB plus nitrate can be used in elderly coronary artery disease whose blood pressure is difficult to control or in concomitant vasospastic angina pectoris;
Combined with atrial fibrillation: meta-analysis showed that ACEI/ARB can significantly reduce the recurrence of atrial fibrillation in patients with atrial fibrillation and heart failure, and it can be preferred; for persistent rapid atrial fibrillation, β-blockers can be used, but it can be preferred. persistent rapid atrial fibrillation can be controlled by β-blockers or non-dihydropyridine CCBs to control the ventricular rate.
Combined stroke: acute stroke blood pressure should be lowered smoothly, for chronic cerebrovascular disease in elderly hypertensive patients, the key is to maintain cerebral blood flow; blood pressure target 140/90 mmHg; can be preferred to long-acting CCBs, ACEI/ARBs, diuretics and so on.
Combined with diabetes mellitus: the application of ACEI/ARB can improve glucose metabolism and endothelial function while lowering blood pressure, reduce urinary microalbumin, and delay the onset of diabetic nephropathy, especially ARB has a better renal protection, so it should be preferred.
Combined with renal insufficiency: ACEI/ARB can reduce urinary protein, reduce the occurrence of end-stage renal disease, can be preferred, but should monitor the blood creatinine and electrolyte levels; when the antihypertensive efficacy does not reach the standard, can be added to long-acting dihydropyridine CCB, with a tendency to fluid retention, can be combined with a small dose of loop diuretics.
Antihypertensive therapy in the debilitated elderly
There is a lack of evidence on whether antihypertensive therapy is beneficial in elderly patients with grade 1 hypertension (systolic blood pressure 140-150 mmHg), and therefore a systolic blood pressure ≥160 mmHg is recommended as the cutoff for initiating antihypertensive therapy.
The goal of systolic blood pressure control in frail elderly patients of advanced age is <150 mmHg, but not less than 130 mmHg; blood pressure below this value should be considered for a reduction in the dose of antihypertensive medication, or even discontinuation.
Emphasizing the application of home self-measurement of blood pressure and ambulatory blood pressure monitoring in elderly patients.
Calcium channel blockers, thiazide diuretics, and angiotensin-converting enzyme inhibitors should be used as the preferred antihypertensive drugs in elderly patients.
Summary
Professor Dang Aimin concluded that achieving blood pressure lowering is the key to reducing cardiovascular events in elderly hypertensive patients. In general, blood pressure reduction in the elderly should be <140/90 mmHg; in "young" elderly patients in good health, it can be reduced to <130/80 mmHg. Intensive blood pressure management should be careful to monitor for adverse effects such as renal damage.
Blood pressure patterns and clinical conditions in elderly hypertensive patients are complex and variable, and should be managed individually and comprehensively in accordance with the guidelines.