Continuum of Care for the Vulnerable Elderly Population



|Quality Outpatient Care of Older Persons |

|Department of Family Medicine and Program on Aging – University of North Carolina at Chapel Hill |

|Evidence-Based Geriatric Module: Hypertension |

Rationale

Hypertension is one of the most common medical diagnoses in persons over the age of 65. At least two-thirds of people in the US aged 70+ have hypertension (defined as a systolic BP ≥ 140 mm Hg and/or a diastolic BP ≥ 90 mmHg), and the prevalence of hypertension increases further with advancing age. (1-3) Among elderly hypertensives, 60-87% have isolated systolic hypertension (ISH), and ISH has been found to be associated with mortality, cardiovascular disease, and stroke. (4-9) Unfortunately, ISH is the least likely form of hypertension to be treated. (4, 10,11) Diastolic hypertension is also a risk factor for cardiovascular disease in the elderly, but between ages 50 and 60, systolic hypertension assumes a superior role over diastolic blood pressure as a predictor of adverse cardiovascular outcomes. (5, 12-16) A widened pulse pressure (>50 mm Hg) is often seen in the setting of ISH, and thus may be a marker of increased cardiovascular risk and the need for hypertension treatment. (1) (See “III. Treatment: …J-Curve Hypothesis” for information regarding management of another cause of a widened pulse pressure: a low diastolic blood pressure.)

In the US, the elderly account for the group with the largest relative risk of uncontrolled hypertension, despite having the most frequent contact with the medical system. (1) One study suggests this may be because of lack of awareness of the issue and lack of adequate control with current treatment strategies. (17). Aside from the burden of morbidity and mortality, the financial costs of untreated hypertension can be staggering. In 1999 alone the estimated direct and indirect cost of hypertensive disease was above $33.3 billion. (1)

Numerous large-scale placebo-controlled trials of hypertension treatment in elderly patients have shown that successful reductions in blood pressure are associated with significant reductions in cardiovascular events and mortality. (18-23) The evidence is most compelling for patients aged 65-79, since this population figured prominently in the trials. It is more difficult to extrapolate benefit to patients aged 80+, since not as many people in this age group were featured in each trial. In fact, no large scale trials of hypertension treatment in octo- or nonagenarians have been completed as yet, although the Hypertension in the Very Elderly Trial (HYVET) is ongoing. (24) Therefore, for now, we must rely on secondary analyses of data from existing trials: one meta-analysis of 1670 octogenarians involved in several large-scale placebo-controlled trials of antihypertensive treatment showed a relative risk reduction in stroke, cardiovascular events, and heart failure of 34%, 22%, and 39% respectively. However, there was a non-significant 6% increase in all-cause mortality. (25) It is hoped that the results of the HYVET trial will more directly address benefits vs. risks of hypertension treatment in the very elderly. For now, however, given the cardiovascular risks associated with age and with hypertension, and given the evidence of cardiovascular event reduction with hypertension treatment, limits on attempts at treatment should not be based upon age alone. Conversely, it is acceptable to individualize treatment decisions for very elderly hypertensives based upon the assessment of risk vs. benefit of treatment in the person.

Any decision to treat an asymptomatic condition must consider the impact of treatment on quality of life. In most cases quality of life is enhanced by measures that maintain activities of daily living and cognitive function – i.e. by measures which prevent strokes and heart attacks. Hence, hypertensive therapy in older persons is usually worthwhile. However, for some individuals, particularly the very frail or the very old, the adverse effects of medication may outweigh the benefits. Setting a goal blood pressure of 160 mmHg, or if there are multiple cardiac risk factors or |A review of 36 studies of hypertension treatment in the elderly found that the strongest evidence for treatment |39 |

|evidence of target organ damage. |effect occurred with an initial SBP > 160 mmHg, with weaker data to guide therapy if the SBP was lower than this.| |

III. Treatment: Goal Blood Pressure Reduction

|Recommendation |Rationale |References |

|Non-diabetic and non-proteinuric elders: |Numerous large-scale placebo-controlled trials of hypertension treatment in elderly patients have shown that | |

|< 140/90 mmHg and no orthostasis or significant |successful reductions in blood pressure are associated with significant reductions in cardiovascular events and |1, 18-23, |

|side-effects. |mortality. More aggressive blood pressure reduction in diabetics and in those with renal disease is associated |32, 33 |

| |with more favorable outcomes. | |

| | | |

|diabetics: < 130/80 mm Hg. |Expert opinion has not established a less aggressive treatment goal in older patients, but orthostasis and other | |

|proteinuric patients: < 125/75 mmHg |harmful side-effects of treatment should be minimized. Therefore, it is mandatory to check for orthostasis and to | |

|(and no orthostasis or significant side-effects for either |alter treatment means/goals if this is occurring. | |

|group) | | |

| |A meta-analysis of 15, 693 older patients with ISH showed that just a 10 point reduction in systolic blood | |

| |pressure, even if SBP remained greater than 140 mmHg, was associated with a 30% reduction in strokes, 26% |8 |

|If these goals cannot be achieved, a sustained reduction in |reduction in cardiovascular event-related deaths, 23% reduction in myocardial infarctions, and a 13% reduction in | |

|systolic blood pressure should still be made, especially if |all-cause deaths. | |

|initial systolic blood pressure is > 160 mmHg. | | |

III. Treatment: Age-based Recommendations and Rationale

|Type of Hypertension |Age 65-79 |Age ≥ 80 |

| | | |

|Isolated Diastolic |RCT’s suggest that treatment lowers risk of stroke, cardiac |Insufficient evidence, due to lack of large numbers of octogenarians in each RCT.(19,21,23) |

|(DBP ≥ 90 mm Hg) |events, and death. |Expert opinion suggests treatment.(1) Decision must be individualized to the patient, assessing|

| |(1, 19, 21,23) |expected life span, comorbidities, and risks vs. benefits of treatment. |

| | | |

|Isolated Systolic |RCT’s show that treatment significantly lowers risk of stroke, |RCT's involving broad age ranges (6th-9th decades) support treatment, but extrapolation should |

|( SBP ≥ 140 mm Hg) |cardiac events, congestive heart failure, and cardiovascular |be done carefully as there are fewer numbers of patients aged 80+ in these trials. (18-23) |

| |mortality. (1, 18-23) |Expert opinion and secondary analyses of trials suggests treatment. (1, 41,42) Benefit of |

| |Benefit is more conclusive in patients with SBP >160 mmHg. (39) |treatment is more conclusive in patients with SBP >160 mmHg. (39) |

| | | |

| | |A dedicated double-blinded RCT is needed to conclusively address mortality effect of treatment.|

| | |Therefore, decision to treat must be individualized to the patient, assessing expected life |

| | |span, comorbidities, and risks vs. benefits of treatment. |

| | | |

| | | |

| | |Notes: |

| |Notes: |One meta-analysis of 7 RCT’s suggested caution with treatment: (25) |

| |Range of event reduction in 3 large trials: (18-20) |Subjects: 1,670 patients, age 80+, most with ISH |

| |36-47% ( in stroke, 13-30% ( in MI's, 29-51%, |Results: Among treated group, 33% ( in strokes (NNT = 30), 23% ( in cardiovascular events |

| |( in CHF. |(NNT = 21), and a 40% ( in CHF (NNT = 48). No reduction in all-cause or cardiovascular |

| | |mortality. However, restricting analysis to double-blind trials would have produced a |

| |Meta-analysis of 8 ISH trials: (40) |non-significant 6% increase in all-cause mortality. |

| |30% ( in stroke, 26% ( in cardiac events, 13% ( in total | |

| |mortality |Hypertension in the Very Elderly Trial (HYVET): (24) |

| | |RCT specifically designed to evaluate the benefit of HTN treatment in age 80+. Primary |

| | |endpoint: stroke incidence. Secondary endpoints: cardiovascular events and mortality. Results |

| | |not available yet. |

| | | |

|Systolic/Diastolic |RCT's: treatment significantly lowers risk of stroke, cardiac |Insufficient evidence, but expert opinion suggests treatment.(1) Decision must be |

|(BP ≥ 140/90 mmHg) |events, and cardiovascular mortality. (19,21,23) |individualized to the patient, assessing expected life span, comorbidities, and risks vs. |

| | |benefits of treatment. |

III. Treatment: Considerations Regarding Blood Pressure Reduction: J-Curve Hypothesis

|Recommendation |Rationale |References |

|The presence of a “J curve phenomenon” (higher cardiovascular |Some clinical trials have shown a J-shaped relationship between DBP and risk of coronary events. It is | |

|morbidity and mortality associated with lower DBP’s) is not |hypothesized that lowering DBP excessively may affect coronary perfusion, thus leading to an increased risk of |21, 43-47 |

|well-established: it is not clear that there is a cause and |myocardial events and death. | |

|effect relationship between low DBP’s and mortality. |However, a J-shaped relationship between DBP and morbidity/mortality is not well-established, as some studies have|18, 48 |

| |failed to demonstrate this phenomenon. | |

| | | |

|Therefore, a low DBP is not a contra-indication to trying to | | |

|treat isolated systolic hypertension. However, during | | |

|treatment, it is advisable to monitor the degree of DBP |Other studies have suggested that the increased risk of coronary events seen in people with lower DBP’s may be |49, 50 |

|reduction in patients with existing cardiovascular disease. |due to the presence of underlying existing cardiac disease or chronic disease (i.e. the low DBP is a proxy measure| |

| |for higher risk). | |

| | | |

| | | |

| |One meta-analysis of seven RCT’s involving hypertension treatment of 40, 233 patients found a J-shaped |51 |

| |relationship between diastolic blood pressure and risk for total and cardiovascular deaths for both treated and | |

| |untreated patients, suggesting that the increased death risk was not related to hypertension treatment, but | |

| |perhaps was related to underlying health conditions causing a low DBP. | |

III. Treatment: Nonpharmacologic Interventions

|Intervention |Recommendation |Rationale |References |

|Reduction in Sodium Intake |Limit sodium to less than 2.4 gm/day. |RCT's and well-designed clinical studies support effect of sodium intake|1, 40, 52, 53 |

| | |limitations on clinically significant BP reductions. Although individuals | |

| | |vary in their sodium sensitivity, older patients tend to be more | |

| | |salt-sensitive than younger hypertensives. Limitations should be modified | |

| | |per patient’s overall nutritional status or quality of life issues. | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|Increased Intake of |Diet should be rich in grains, fruits and vegetables, and |Trials involving the use of the DASH diet in treating hypertension showed |54-56 |

|Calcium/Potassium |low-fat dairy products. |moderate reductions in BP in older hypertensives. | |

| | | | |

|(“Dietary Approaches to Stopping | | | |

|Hypertension” Diet: DASH Diet) | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|Weight Loss |If overweight (BMI > 25), reduce weight to at least within 10% |Excess weight is correlated with elevated BP's, and a weight loss of only |1, 52, 57 |

| |of ideal body weight. For starters, encourage at least 10 kg of|10 kg can lower systolic BP by 5-20 mmHg. | |

| |weight loss. Individualize recommendations to patient’s other | | |

| |health concerns, as well. | | |

| | | | |

III. Treatment: Guidelines on Selection of Therapeutic Agents, per Compelling Indication

|Compelling Indication |Recommendation |Rationale |References |

|Obesity |All older obese persons should be educated about the benefits |Trial of Antihypertensive Interventions and Management (TAIM) suggests |1, 52, 57 |

| |of weight loss and decreasing sodium intake |that effective weight loss of 4.5 kg or more lowers blood pressure | |

| | |similarly to low-dose drug therapy and potentiates drug effects. | |

| | | | |

| | |Trial of Nonpharmacologic Interventions in the Elderly (TONE) suggests | |

| | |that weight loss and reduced sodium intake was a feasible, effective, and | |

| | |safe nonpharmacologic therapy of hypertension in older persons. | |

| | | | |

| | |Note: Neither of these trials demonstrated a reduction in cardiovascular | |

| | |morbidity/mortality. | |

| | | | |

|Isolated Systolic Hypertension |Consider using a thiazide diuretic as first line agent. |Predominance of ISH RCT’s showing treatment benefit used thiazide |1, 18-20, 23, 58 |

| | |diuretics (usually chlorthalidone). A meta-analysis of 42 trials involving| |

| | |192,478 adults with all forms of hypertension showed that low-dose | |

| | |diuretics, compared to multiple other classes of anti-hypertensives, were | |

| | |the most effective first-line agents for preventing the occurrence of | |

| | |cardiovascular disease morbidity and mortality. | |

| | | | |

|Diabetes mellitus |ACE Inhibitors or angiotensin receptor blockers (ARB’s) should |Due to renoprotective effects and neutral effects on glucose and lipids, |1, 26, 28, 59, 60 |

| |be considered as first line agents. Watch serum glucose if |ACE Inhibitors and ARB’s are preferred agents. Cost must be considered | |

| |using thiazide diuretics. |when choosing which agent to use among these categories. | |

| | | | |

| | |First line treatment with chlorthalidone is not associated with any | |

| | |adverse effects on quality of life, including cognitive performance. | |

| | |However, one may see mild elevations in serum glucose with thiazide | |

| | |diuretics, so glucose monitoring is encouraged. | |

III. Treatment: Guidelines on Selection of Therapeutic Agents, per Compelling indication

|Compelling Indication |Recommendation |Rationale |References |

| | | | |

|Congestive Heart Failure |Use ACE Inhibitors or ARB’s as first-line agents. B-blockers |ACE Inhibitors and ARB’s have been found to have benefits on left |1, 32 , |

| |are also beneficial. |ventricular remodeling and systolic function in patients with CHF. These |61-64 |

| | |agents and B-blockers have a positive effect on reducing mortality in | |

| | |patients with CHF. | |

| | | | |

|Myocardial Infarction |Beta-blockers and/or ACE inhibitors (or ARB’s) should be |B-blockers and ACE Inhibitor’s are associated with decreased mortality |1, 32, |

| |considered as first-line agents. If an anti-anginal is |after myocardial infarctions. |65-67 |

| |necessary, the use of calcium channel blockers can be | | |

| |considered. | | |

| | | |1, 68 |

|Nephropathy |Use ACE inhibitors ( or ARB’s) when the serum creatinine is |Meta-analyses have shown that in “non-vulnerable elders,” ACE inhibitors | |

| |greater than 1.5 mg/dL or the 24-hour urine protein is greater |slow the progression toward end stage renal disease and dialysis in the | |

| |than 1 gram. |setting of hypertensive nephropathy. | |

| | | | |

| | | | |

|Gout |Avoid thiazide diuretics in patients with gout. |Patients predisposed to acute attacks of gout may be susceptible to the |1, 60 |

| | |increased resorption or decreased secretion of serum uric acid when taking| |

| | |thiazide diuretics. | |

| | | | |

|Hyperlipidemia |Use calcium channel blockers or ACE inhibitors |Effects of calcium channel blockers or ACE inhibitors tend to be neutral |59, 69 |

| | |on blood glucose and lipids; therefore, there may be an advantage over the| |

| | |use of thiazide diuretics or B-blockers. | |

| | | | |

|Erectile dysfunction |Use chlorthalidone with caution. |Chlorthalidone is associated with erectile dysfunction in 10-15% of middle|26, 28 |

| | |aged men. | |

IV. Treatment: Therapies Not Recommended

|Recommendation |Rationale |References |

|Short-acting calcium channel blockers should be avoided. |Short-acting calcium channel blockers (sublingual nifedipine) have been |32, 70-72 |

| |associated with rapid and excessive drops in blood pressure. Expert | |

| |opinion does not advocate use of these agents, as observational studies | |

| |and meta-analyses have shown higher mortality in groups receiving these | |

| |agents. | |

IV. Treatment: Additional Information Regarding Treatment Strategies

| |

|See Teaching Card and Slide Shows which accompany this module. (Evidence-Based Geriatric Module: Hypertension) |

V. Quality of Care Indicators for Continuous Quality Improvement Activities

-

| |

|See Quicksheet and Audit form which accompany this module. (Evidence-Based Geriatric Module: Hypertension) |

References

1. Chobanian A, Bakris G, Black H, et al. The seventh report of the Joint National Committee on prevention,

detection, evaluation and treatment of high blood pressure, JAMA 289:2560-2572, 2003.

2. Wolz M, Cutler J, Roccella E, et al. Statement from the National High Blood Pressure Education Program:

prevalence of hypertension, Am J Hypertens 13:103-104, 2000.

3. National Center for Health Statistics: Health United States 2003. Available at , accessed

5/2/05.

4. Franklin S, Jacobs M, Wong N, et al. Predominance of isolated systolic hypertension among middle-aged and

elderly US hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES)

III,Hypertension 37:869-874, 2001.

5. Kannel W. Prevalence and implications of uncontrolled systolic hypertension, Drugs & Aging 20(4):277-286, 2003.

6. Wilking S, Belanger A, Kannel W, et al. Determinants of isolated systolic hypertension, JAMA 260:3451-3455,

1988.

7. Lewington S, Clarke R, Qizilbasch N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a

metaanalysis of individual date for one million adults in 61 prospective studies. Lancet 360:1903-1913, 2002.

8. Staessen J, Gasowski J, Wang J, et al. Risk of untreated and treated isolated systolic hypertension in the elderly:

meta-analysis of outcome trials, Lancet 355: 865-872, 2000.

9. Fried L, Kronmal R, Newman A, et al. Risk factors for 5-year mortality in older adults. The Cardiovascular Health

Study, JAMA 279:585-592, 1998.

10. Coppola W, Whincup P, Walker M, et al. Identification and management of stroke risk in older people: a national

survey of current practice in primary care. J Hum Hypertens 11:185-191, 1997.

11. Fagard R, Van den Enden M. Treatment and blood pressure control in isolated systolic hypertension vs. diastolic

hypertension in primary care. J Hum Hypertens 17:681-687, 2003.

12. Franklin S, Larson M, Khan S, et al. Does the relation of blood pressure to coronary heart disease change with

aging? The Framingham Heart Study, Circ 103:1245-1249, 2001.

13. Staessen J, Wang J, Bianchi G, et al. Essential hypertension, Lancet 361:1629-41, 2003.

14. Staessen J, Wang J, Thijs L. Cardiovascular prevention and blood pressure reduction: a quantitative overview

updated until 01 March 2003, J Hypertens 21:1055-1076, 2003.

15. Elliott W. Management of hypertension in the very elderly patient, Hypertension 44:800-804, 2004.

16. Benetos A, Thomas F, Bean K, et al. Prognostic value of systolic and diastolic blood pressure in treated

hypertensive men, Arch Intern Med 162:577-581, 2002.

17. Hyman D, Pavlik V. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med 345: 479-486, 2001.

18. SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with

isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP), JAMA 265:3255-3264, 1991.

19. Dahlof B, Lindholm L, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with

hypertension (STOP-Hypertension), Lancet 338:1281-1285, 1991.

20. Staessen J, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older

Patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 350: 757-764, 1997.

21. Staessen J, Bulpitt C, Clement D, et al. Relation between mortality and treated blood pressure in elderly patients

with hypertension: report of the European Working Party on High Blood Pressure in the Elderly. BMJ 298:1552-1556, 1989.

22. Liu L, Wang J, Gong L, et al. Comparison of active treatment and placebo in older Chinese patients with isolated

systolic hypertension. Systolic Hypertension in China (Syst-China) Collaborative Group. J Hypertens 16:1823-1829, 1998.

23. Peart S, Brennan P, Broughton P, et al. Medical Research Council trial of treatment of hypertension in older adults:

principal results. BMJ 304:405-412, 1992.

24. Bulpitt C, Fletcher A, Beckett N, et al. Hypertension in the Very Elderly Trial (HYVET): Protocol for the main

trial, Drugs & Aging 18(3): 151-164, 2001.

25. Gueyffier F, Bulpitt C, Boissel J-P, et al. Antihypertensive drugs in very old people: a subgroup meta-analysis of

randomized controlled trials, Lancet 353: 793-796, 1999.

26. Fletcher A. Quality of life in the management of hypertension [Review]. Clin and Exper Hypertens 21 (5-6): 961-72, 1999.

27. Forette F, et al. Does the benefit of antihypertensive treatment outweigh the risk in very elderly hypertensive patients? J Hypertens 18

(suppl 3): S9-S12, 2000.

28. Fogari R, Zoppi A. Effect of antihypertensive agents on quality of life in the elderly. Drugs Aging 21(6):377-393, 2004.

29. US Preventive Services Task Force, Screening for hypertension. In: U.S. Preventive Services Task Force. Guide to Clinical Preventive

Services, 2nd ed. Alexandria, Virginia, 1996.

30. Canadian Task Force on the Periodic Health Examination. Hypertension in the elderly: case-finding and treatment to prevent vascular disease.

Health Canada: 944-951, 1994.

31. Cardiovascular Steering Committee: Hypertension diagnosis and treatment.

Bloomington [MN]: Institute for Clinical Systems Improvement (ICSI); 2002 Jan.

32. Hypertension in older people. A national clinical guideline. Scottish Intercollegiate Guidelines Network (SIGN),

2001. , accessed 5/24/05

33. Feldman R, Campbell N, Larochelle P, et al. 1999 Canadian recommendations for the management of

hypertension.CMAJ 161(suppl 12):1-17, 1999.

34. The Hypertension Working Group. Diagnosis and management of hypertension in the primary care setting.

Department of Veterans Affairs (US); 1999 May.

35. National High Blood Pressure Education Program Working Group. National High Blood Pressure Education

Program Working Group Report on Hypertension in the Elderly. Hypertension 23:275-285, 1994.

36. Report of a WHO Expert Committee. Hypertension Control. WHO technical report series; 1996.

37. Stamler J, Stamler R, Neaton J. Blood pressure, systolic and diastolic, and cardiovascular risks. US population data.

Arch Intern Med 153:598-615, 1993.

38. Stokes J, Kannel W, Wolf P, et al. Blood pressure as a risk factor for cardiovascular disease. The Framingham

Study- 30 years of follow-up. Hypertension 13 (5 suppl):113-118, 1989.

39. Chaudhry S, Krumholz H, Foody J. Systolic hypertension in older persons. JAMA 292(9):1074-1080, 2004.

40. Sander G. High blood pressure in the geriatric population: treatment considerations. American Journal of Geriatric

Cardiology 11(4): 223-232, 2002.

41. Insua JT, Sacks HS, Lau T-S, et al. Drug treatment of hypertension in the elderly: a meta-analysis. Ann Intern

Med 121:355-362, 1994.14.

42. MacMahon S, Rodgers, A. The effects of blood pressure reduction in older patients: an overview of five

randomized controlled trials in elderly hypertensives. Clin and Exper Hypertension 15:967-978, 1993.

43. Fletcher A, Beevers D, Bulpitt C, et al. The relationship between a low treated blood pressure and IHD mortality: a

report from the DHSS Hypertension Care Computing Project (DHCCP). J Hum Hypertens 2:11-15, 1988.

44. McCloskey L, Psaty B, Koepsell T, et al. Level of blood pressure and risk for myocardial infarction among treated

hypertensive patients. Arch Intern Med 152:513-20, 1992.

45. Alderman M, Ooi W, Madhavan S, et al. Treatment-induced blood pressure reduction and the risk for myocardial

infarction. JAMA 262:920-4, 1989.

46. Samuelsson O, Wilhelmsen L, Pennert K, etal. The J-shaped relationship between coronary heart disease and

achieved blood pressure level in treated hypertension: further analyses of 12 years of follow-up of treated hypertensives in the Primary Prevention Trial in Gothenburg, Sweden. J Hypertens 8:547-555, 1990.

47. Cooper S, Hardy R, Labarthe D, et al. The relationship between degree of blood pressure reduction and mortality

among hypertensives in the Hypertension Detection and Follow-Up Program. Am J Epidemiol 127:387-403, 1988.

48. Hansson L. The BBB Study: the effect of intensified antihypertensive treatment on the level of blood pressure, side

effects, mortality, and morbidity in “well treated” hypertensive patients. Behandla Blodtryck Battre. Blood Press 3(4):248-254, 1994.

49. Aromaa A. Blood pressure level, hypertension and five-year mortality in Finland. Acta Med Scand Suppl. 646:43-

50, 1981.

50. Lindholm L, Lanke J, Bengtsson B, et al. Both high and low blood pressures risk indicators of death in middle-

aged males. Isotonic regression of blood pressure on age applied to data from a 13-year prospective study. Acta Med Scand 218(5):473-480, 1985.

51. Boutitie F, Gueyffier F, Pocock S, et al. J-shaped relationship between blood pressure and mortality in hypertensive

patients: new insights from a meta-analysis of individual–patient data. Ann Intern Med 136:438-448, 2002.

52. Whelton P, Appel L, Espeland M, et al. Sodium reduction and weight loss in the treatment of hypertension in older

persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). JAMA

279:839-846, 1998.

53. Kumanyika K. Weight reduction and sodium restriction in the management of hypertension. Clin Geriatr Med

5:770, 1989.

54. Sacks F, Svetkey L, Vollmer W, et al. Effects on blood pressure of reduced dietary sodium and the dietary

approaches to stop hypertension (DASH) diet. N Engl J Med 344:3-10, 2001.

55. Appel L, Moore T, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure: DASH

Collaborative Research Groups. N Engl J Med 336:1117-1124, 1997.

56. Labarthe D, Ayala C. Nondrug interventions in hypertension prevention and control. Cardiology Clinics 20(2): 249-

263, 2002.

57. Wassertheil-Smoller S, Blaufox M, Oberman A, et al. The Trial of Antihypertensive Interventions and Management (TAIM) study: adequate

weight loss, alone and combined with drug therapy in the treatment of mild hypertension. Arch Intern Med 152(1):131-6, 1992.

58. Psaty B, Lumley T, Furberg C, et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: a network

metaanalysis. JAMA 289: 2534-2544, 2003.

59. Gifford R. Antihypertensive therapy: Angiotensin-Converting Enzyme Inhibitors, Angiotensin II Receptor Antagonists, and Calcium

Antagonists. Medical Clinics of North America 81(6): 1319-33, 1997.

60. Weir M, Flack J, Applegate W. Tolerability, safety, and quality of life and hypertensive therapy: the case for low-dose diuretics. Am

J Med 101(3A): 83S-92S, 1996.

61. Hunt S, Baker D, Chin M, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult. J Am Coll

Cardiol 38:2101-2113, 2001.

62. Tepper D. Frontiers in congestive heart failure: effect of metoprolol CR/XL in chronic heart failure. Congest Heart Fail 5:184-185, 1999.

63. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart

failure. N Engl J Med 325:293-302, 1991.

64. Cohn J, Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med 345:1667-1675,

2001.

65. Pfeffer M, Braunwald E, Moye L, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after MI:

Results of the Survival and Ventricular Enlargement Trial (SAVE). N Engl J Med 327:669-677, 1992.

66. Psaty B, Heckbert S, Koepsell T, et al. The risk of MI associated with antihypertensive drug therapies. JAMA 74:620-625, 1995.

67. Heart Outcomes Prevention Evaluation Study investigators (HOPE): Effects of an angiotensin-converting inhibitor, ramipril, on cardiovascular

events in high-risk patients. N Engl J Med 342:145-153, 2000.

68. Bakris G, Williams M, Dworkin L, et al, for the National Kidney Foundation Hypertension and Diabetes Executive Committees Working

Group. Preserving renal function in adults with hypertension and diabetes. Am J Kidney Dis 36:646-661, 2003.

69. Singh V, Christiana J, Frishman W. How to use calcium antagonists in hypertension. Drugs 58(4): 579-87, 1999.

70. Harvey P, Woodward M. Management of hypertension in older people. Aust J Hosp Pharm 31:212-219, 2001.

71. Pahor M, Guralnik J, Corti M, et al. Long-term survival and use of antihypertensive medications in older persons. J Am Geriatr Soc 43:1191-

1197, 1995.

72. Furberg C, Psaty B, Meyer J. Nifedipine. Dose-related increase in mortality in patients with coronary heart disease. Circulation 92:1326-1331,

1995.

|Authorship |

| |

|These guidelines were developed by the Geriatric Education Guidelines development group of the Department of Family Medicine, University of North Carolina at Chapel Hill. Members of the |

|guidelines group include: Amrit Singh, MD (chair), John Harrington MD. Julie Price, MD; Bron Skinner, PhD; Philip Sloane, MD, MPH, and Sam Weir, MD, MPH. Primary author of this guideline was |

|Dr. Singh. |

| |

|This work was supported by funding from HRSA grant #5 D22 HP 00167-02 and from the Donald W. Reynolds Foundation. |

| |

| |

|© 2006 The University of North Carolina at Chapel Hill Program on Aging |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download