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Newsletters August 2011 - Jefferson Cardiology Happenings

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Drug Management Hypertension in Elderly

In July, this newsletter evaluated lifestyle measures to assist in manage-ment of hypertension, high blood pressure in persons over 65. This month will focus on drug therapy guidelines from the American College of Cardiology and American Heart Association published in April 2011. It is now recognized that clinical research has shown benefit of treatment of hypertension in older persons and even in persons over age 80. The goal of therapy is to maintain blood pressure under 140/90.

Drug therapy is recommended to start at the lowest level and increased as needed to attain target blood pressure to the maximum tolerated dose. If ade-quate blood pressure control is not achieved with the initial medication then a second medication from another class of medication should be added. Medica-tions that are not tolerated can be re-placed by other medications. If target values are not attained with a second drug then a third drug should be added.

If the initial pressure reading is greater than 20 mm mercury above the target value, the initial therapy should include two medications. When new medications are added, precautions are needed to avoid drug interactions.

Thiazide diuretics including hydrochlorothiazide and chlorthalidone are recommended for initial therapy. These agents may reduce blood pressure by reducing fluid volume in blood vessels and reducing blood vessel resistance. Multiple studies with these agents have shown benefit with reduced cardiac events, stroke and kidney damage. Care must be taken to avoid dehydration and mineral imbalance with these drugs. Indapamide is a commonly used non-thiazide diuretic. Furosemide and bumetanide can be used with heart failure or chronic kidney disease. Spironolactone is useful when combined with other agents and may raise potassium.

Beta blockers have been used in treatment of hypertension but research has shown less benefit in treatment of the elderly. These may be used in com-bination with diuretics. Beta blockers may have benefit in older patients with angina, heart failure, migraine, fast rhythm abnormalities and senile tremor.
Calcium channel drugs include several classes and may have effect on heart rate, heart muscle, and electrical impulse conduction in the heart as well as arterial tone. These may include verapamil, diltiazem, nifedipine and amlodipine. Research has shown these drugs to be effective in hypertensive eld-erly persons. These are helpful in patients with stiff arteries. These drugs may have a variety of side effects includ-ing ankle swelling, headache and excessive blood pressure drop when standing. Some of these may aggravate heart failure and cause excessive slowing of heart rate.

ACE inhibitors block the production in the body of a chemical angiotension that constricts blood ves-sels. These agents include lisinopril, ramipril, captopril and enalapril and act to dilate blood vessels. Related agents which act downstream in the same system are called ARBs and include losartan, olmesartan and valsartan. These groups have similar benefit in lowering blood pressure, benefitting heart failure and treating kidney protein loss. These agents may raise potassium and ACE inhibitors frequently cause a cough.

Because of side effects other agents have been relegated to fourth line agents. Hydralazine and minoxidil both raise heart rate while minoxidil may cause accumulation and fast rhythm abnormalities. Clonidine may cause sedation and reduced heart rate. These agents may be used in combination with other agents.

Combination therapy may offer increased benefit with limited side effects and better compliance. A research study evaluated the relative benefit of the combination of an ACE inhibitor and diuretic with an ACE inhibitor with a calcium channel blocker. The combination of the ACE inhibitor and calcium channel blocker demonstrated better protection against cardiovascular events.

In patients with hypertension and coronary artery disease, the first choice is a beta blocker. If blood pressure remains high or if angina persists then a calcium channel blocker should be added. If the heart muscle is thickened by hypertension then research has shown that ACE inhibitors are most effective in reducing the excessive muscle mass though most other blood pressure medi-cations reduce excessive mass. Heart failure patients with weakened muscle may be benefitted by either an ACE inhibitor or ARB agent. African Ameri-can patients have been shown to benefit from the combination of hydralazine and a long-acting nitroglycerin preparation. If blood pressure is not well controlled by multiple medications then blockage of one or both kidney arteries may be present. This condition may respond to balloon angioplasty and stenting.

Stroke reduction is more related to improved blood pressure control rather than a particular medication. Patients with an aortic aneurysm require intense blood pressure control and should receive an ACE inhibitor or ARB as well as a beta blocker. A recommendation has been made that diabetics maintain a blood pressure under 130/80. However, a recent research study demonstrated no difference in outcomes of systolic blood pressure under 120 compared to systolic blood pressure under 140. Also thiazide diuretics may increase risk of diabetes in potentially susceptible persons.

This is a limited overview of the recent guideline. If questions arise, ask your doctor.

A publication of Jefferson Cardiology Association
Alan D. Bramowitz, M.D. | Michael S. Nathanson, M.D. | Gennady Geskin, M.D.

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