|Year : 2022 | Volume
| Issue : 1 | Page : 32-36
Isolated systolic hypertension in very elderly
Department of Medicine, Government Medical College, Kota, Rajasthan, India
|Date of Submission||01-Mar-2022|
|Date of Decision||17-Mar-2022|
|Date of Acceptance||18-Mar-2022|
|Date of Web Publication||21-Apr-2022|
Dr. Meenaxi Sharda
Department of Medicine, Government Medical College, Kota, Rajasthan
Source of Support: None, Conflict of Interest: None
Globally, hypertension is a common problem in the elderly, and its prevalence increases with increasing age. Isolated systolic hypertension (ISH) subset is more common in the very elderly population, and as the population ages, its prevalence will rise more and more. In the past, treatment of hypertension (HT) in the very elderly was controversial and either no treatment or complications of treatment risk overweigh the benefits observed. The inclusion of elders in various clinical trials has demonstrated a better understanding and rational approach toward optimal management of HT. Systolic blood pressure (BP) is more important in predicting adverse cerebrovascular outcomes and decline in renal function in elderly patients with ISH. Early detection, protection of target organs, correction of high BP will develop, promote, and corroborate healthy aging.
Keywords: Diastolic blood pressure, isolated systolic hypertension, systolic blood pressure, very elderly
|How to cite this article:|
Sharda M. Isolated systolic hypertension in very elderly. J Indian Acad Geriatr 2022;18:32-6
| Introduction|| |
The elderly population is further designated into two groups: elderly (65+/60+) and oldest-old (80+). Worldwide, the proportion of the oldest old is projected to increase from 1.9% in 2000% to 4.2% by 2050. In earlier decades of life, there is a linear increase in both the systolic and diastolic blood pressure (BP). However, after the sixth decade, reduced compliance of the aorta during systole due to atherosclerotic stiffening leads to a continuous rise in systolic pressure. At the same time, diastolic BP (DBP) remains normal or decreases as smaller arterioles are not involved [Figure 1]. The risk of all-cause cardiovascular death is positively correlated to the increase in systolic blood pressure (SBP) and pulse pressure (PP) in elderly patients and is inversely related to DBP.
|Figure 1: Age-dependent changes in systolic and diastolic blood pressure|
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| Magnitude of Problem|| |
Hypertension is a common problem in older adults, with isolated systolic hypertension (ISH) being the most common type. Its prevalence increases with age, and two-third of persons aged >60 years and three-fourth of persons aged >75 years have ISH. As per data from the Framingham Heart Study, normotensive persons reaching age 65 years have a 90% lifetime risk of developing hypertension (predominantly of the systolic subtype) if they live a further 20–25 years.
| Definition and Grading|| |
As per the European Society of Cardiology and European Society of Hypertension (ESC/ESH) guidelines August 2018, ISH is defined as SBP higher than 140 mmHg and DBP <90 mmHg. Normal DBP separates patients with ISH from those with essential hypertension. SBP is responsible mainly for all complications attributable to hypertension. Therefore, even minor differences in SBP can dramatically impact cardiovascular outcomes. ISH can be categorized into three classes based on office BP measurement [Table 1].
|Table 1: Categories of isolated systolic hypertension based on office blood pressure measurement|
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| Etiology and Pathophysiology|| |
ISH in the elderly is secondary to modifiable and hereditary risk factors along with pathophysiological changes of aging. It can develop from burned-out diastolic hypertension in patients with long-term essential hypertension or from a de novo increase in SBP secondary to increased arterial stiffness in previously normotensive individuals. Secondary causes of de novo systolic hypertension include osteoporosis with vascular calcification, accelerated atherosclerosis from chronic kidney disease (CKD), peripheral vascular disease, thyrotoxicosis, repaired coarctation of the aorta, and aging of the proximal aorta.
With increasing age and progression of atherosclerosis, there is increased deposition of arterial calcium and collagen associated with fraying of arterial elastin. The resultant reduction in arterial elasticity and compliance leads to decreased lumen-to-wall ratio and increased arterial stiffness. The rennin‒angiotensin‒aldosterone system (RAAS) affects the elastin-collagen content of the arterial wall leading to vascular stiffening and loss of contractility, the proliferation of arterial smooth muscle cells, and fibrotic remodeling of vascular intima increases vascular thickening. These changes predominantly involve large arteries and the aorta. The noncompliant stiffed arterial tree leads to a fast rise in peak BP, whereas the limited recoil results in a greater decline of DBP [Figure 2]. In addition, these changes result in an increase in pulse wave velocity with faster propagation of cardiac contraction.
|Figure 2: Schematic representation of the relationship between aortic compliance and pulse pressure|
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| Concerns of Isolated Systolic Hypertension Treatment in the Elderly|| |
ISH in the very elderly requires to be identified and treated adequately because of the various concerns of this entity in the rising aging population worldwide.
Isolated systolic hypertension as a risk factor
- ISH is a common, independent, and important modifiable risk factor for end-stage renal disease, cardiac disease, and stroke
- Independent risk factor for cognitive impairment and dementia in elderly
- Increase in PP is a stronger predictor of cardiovascular risk than either SBP or DBP elevation.
Most elderly patients are resistant to treatment due to:
- Increased left ventricular hypertrophy
- Vascular hypertrophy and remodeling
- High levels of sympathetic tone
- Nonmodulation of RAAS.
Evidence base for treatment
From 1960 onward, landmark trials such as Hypertension Detection and Follow up Program, Systolic Hypertension in the Elderly Program, and Systolic Hypertension in Europe trial (Syst-Eur) have shown good evidence base for the treatment of HT in older adults irrespective of the drug used. However, the trend analysis from the European Working Party on High BP in the Elderly trial suggested that the treatment of HT may be less effective or even harmful in the very elderly.
This uncertainty led to the commission of hypertension in the very elderly trial (2003), where relative benefits and risks associated with antihypertensive treatment in patients >80 years old were addressed. Further inclusion of subjects with ISH in this trial concludes that treatment with indapamide +/-perindopril is safe, effective, and without significant orthostatic hypotension. Following benefits from treatment were observed.
- Significant reduction in all-cause and cardiovascular mortality 23%
- Statistically significant reduction in congestive heart failure 64%
- Reduction in rate of fatal or nonfatal stroke 30%
- Reduction in rate of death from stroke 39%
- Reduction in rate of death from any cause 21%
- Possible protection from incident fractures and dementia.
Threshold for treatment
SBP ≥160 mmHg in individuals >80 years of age.
Importance of diastolic blood pressure
DBP <65 mmHg has been associated with an increased risk of stroke and cardiovascular events. Recent guidelines warn against lowering DBP to below 60 or 65 when ISH and established coronary artery disease are present because of concern about myocardial ischemia since coronary artery blood flow occurs in the diastolic phase.
Optimum reduction level
BP targets in older adults should be individualized based on a person's frailty, comorbid conditions, tolerability, and adverse effects of drugs. Reduction in heart failure (HF), death from stroke, or any other cause have been shown even with a target SBP <150 mmHg.
According to the Canadian Hypertension Education Program guidelines, 2020 target SBP to <120 mmHg in high-risk patients (with clinical or subclinical cardiovascular disease (CVD) or CKD or age more than 75 years).
SBP Intervention Trial 2019 has observed that intensive SBP to a goal of 120 mmHg results in a reduction in CVD outcome by 34%, decrease in total mortality by 33%, and decrease in minimal cognitive impairement (MCI)/dementia as well.
ESH-ESC guidelines (2018) recommend a reduction of SBP to between 130 and 140 mmHg in elderly 65 years and older regardless of comorbidities.
| Clinical Evaluation|| |
Most elderly patients are asymptomatic. BP should be measured in sitting, supine, and standing positions. Standing BP should often be used to decide, initiate, or escalate the antihypertensive treatment in the elderly and avoid postural hypotension. Laboratory works up for target organ damage should be done in each case.
| Management of Isolated Systolic Hypertension in Very Elderly|| |
Management of ISH can be divided into two parts:
- Nonpharmacological treatment (lifestyle modification)
- Pharmacological therapy.
| Nonpharmacological treatment|| |
The Trial of Nonpharmacologic Interventions in Elderly demonstrates that nonpharmacologic interventions, especially reduced sodium intake and weight loss, result in a reduction in the number of drugs and doses.
The different aspects of lifestyle modifications are:
BP increases as weight increases. In addition, being overweight predisposes to sleep apnea which further raises BP. With each kilogram of weight loss, BP reduces by about 1 mmHg. In addition, it improves insulin sensitivity and sleep apnea and decreases the sensitivity to sodium. Hence, weight reduction is one of the most effective lifestyle changes for control of BP.
If not contraindicated, regular physical activity is beneficial safe and should be encouraged in every elderly hypertensive patient. Any physical activity as per capacity, 30 min per day for most days of the weeks such as walking, jogging, cycling, swimming, or dancing, can lower BP by about 5–8 mmHg. Consistency is a must because stopping exercise again raises BP.
Dietary Approaches to Stop Hypertension (DASH) diet consisting of whole grains, fruits, and vegetables with a small amount of fish, poultry, legumes, nuts, and seeds a few times a week is recommended. The DASH diets have low saturated fat, trans fat, and total fat.
Moderation of alcohol
Less than one drink per day for women and <2/day for men can potentially lower BP by about 4 mmHg. However, drinking more than moderate amounts of alcohol raises BP and reduces the effectiveness of drugs.
Each cigarette smoked raises BP for many minutes.
| Pharmacological therapy|| |
Choice of drugs for monotherapy treatment of ISH in elderly includes:
- Calcium channel blockers (CCBs): The efficacy and safety of long-acting CCBs in treating elderly hypertensive patients have been proven and demonstrated in various clinical trials
- Diuretics: Thiazide diuretics are recommended as initial drug therapy for most patients with ISH due to their higher efficacy in reducing BP
- Angiotensin-converting enzyme inhibitors (ACEi)angiotensin receptor blockers (ARB): Many elderly hypertensive patients have specific indications for ACEi/ARB, such as heart failure, postmyocardial infarction, and diabetes
- Beta-blocker: in the absence of a specific indication of their use, beta-blockers should not be considered for initial therapy of hypertension, particularly in the elderly.
Antihypertensive is decided on an individual basis and should be based on the patient's comorbidities [Table 2]. The primary aim of pharmacotherapy is optimum BP control, with fewer medications or a regimen that has minimal adverse effects.
General guidelines of treatment:
- Antihypertensives should be started with lower initial doses (approximately one-half that in younger patients) to minimize the risk of side effects
- If a hypertensive emergency is not there, BP should be lowered gradually over 3–6 months rather than hours to days to minimize the risk of ischemic symptoms, particularly in patients with orthostatic hypotension since older adults may have sluggish baroreceptor and sympathetic neural responses along with impaired cerebral autoregulation
- When treating frail elderly hypertensive, extra caution is required in the setting of orthostatic hypotension to avoid overtreating them. Orthostatic hypotension is found in as many as 20% of elderly patients with ISH posing an increased risk of hip fracture during the initial months of therapy
- Reduction in cardiovascular risk is affected by BP reduction, not the choice of antihypertensive drugs. This principle of equivalent efficacy in cardiovascular outcomes applies to monotherapy, not to combined antihypertensive therapy. The combination of ACEi/ARB and a long-acting dihydropyridine CCB appears to significantly reduce cardiovascular events at the same attained BP as an ACEi/ARB and a thiazide diuretic. as observed in (ACCOMPLISH) trial of combination therapy.
The stepwise approach of ISH treatment is like any other case of hypertension [Table 3].
| Resistant Hypertension|| |
Hypertension is said to be resistant when BP is not controlled to an expected target level despite three different group of drugs in maximum tolerable doses. However, be cautious before labeling this in an older adult as this can be pseudo-resistance either because of a common occurrence of pseudo hypertension entity in elderly or faulty compliance of given treatment and nonadherence to lifestyle changes. In addition, drug interactions because of polypharmacy and rare causes of secondary ISH such as renal artery stenosis, obstructive sleep apnea, CKD, hyperthyroidism, and pheochromocytoma should be evaluated.
| Conclusion|| |
- ISH is common in the elderly population because of aging changes in conduit arteries
- SBP is a significant risk factor for cardiovascular and renal disease hence should be managed optimally on an individual basis
- Lifestyle modifications are the primary therapy and should be instilled and insisted on every visit of an elderly hypertensive individual
- Except in a situation of hypertensive emergency, start low, go slow, and gradual to achieve the best target BP level with maximum tolerable drugs and doses without side effects
- A potential limiting factor to the use of antihypertensive drugs is orthostatic hypotension which is common in the elderly
- If there is no indication for a specific antihypertensive drug, initial monotherapy with a long-acting CCB, low-dose thiazide diuretic, or ACEi/ARB in starting dose is recommended. If additional therapy is required, another group of drug/incremental doses can be added
- Sometimes, ISH is difficult to control.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]