CURRICULUM VITAE

Nama
: Dr. H.Hadi Hartono,SpPD,K-Ger
Tempat/Tgl Lahir : Yogyakarta/17 Maret 1945
Alamat
: Jl. Senjoyo Dlm. 3, Semarang
Jabatan
: Konsultan Klinik Intalasi Geriatri RSUP DR.KARIADI
Hp
: 0811298414
Pendidikan
:
S1 Kedokteran FK UNDIP (1975)
Sp-1 I.P. Dalam FK UNDIP(1985)
Konsultan Tumor Geriatri, South Australia (1988)
Konsultan Geriatri, PB-PAPDI (1996)
Organisasi :
Ketua PERGEMI
Wakil Ketua PEROSI Semarang
Penasehat PERWATUSI, Jawa Tengah
IDI Jawa Tengah
PERGEMI JATENG

HYPERTENSION
In the elderly

Dr.Hadi-Martono SpPD,K-Ger
Geriatric Division/Dept.of Medicine
Dr. Kariadi HOSPITAL
Medical Faculty Diponegoro Univ.
Semarang

Elderly Hypertension

Different pathogenesis than that of from the younger counterpart

Usually in the form of isolated systolic hypertension(ISH)

Give different response to therapy from that of the young

Comorbidity/ies are oftenly found

Issues of white coat and Pseudo-hypertension

Difficulties in change the way of life

Limited datas to pts over 80 years old

Limited socio-economic resources

Differences of cardiovascular parameters in the young and old pts

Parameters
Cardiac output(lt/mnt)
Stroke volume(cc)
Total Periph.resistance(u)
Total blood volume(lt)
Renal blood flow(cc/mnt)

Young
6,22 1,20

Elderly
4,7 1,4

88,323,2

70,718,3

18,8 4,4

25,8 7,3

4,641,01

4,1 0,8

1,154 0,87

0,454 0,38

Significant incidence along the

elderly age line
Relative incidence decrease as age
increase but absolute incidence
increasing
Even in western countries the
percentage of patient being treated
are not optimal

Some devastating complication of hypertension

The Pathophysiology of Hypertension in the

elderly
Stiffness of big arterial wall
Plasma renin concentration
Response to sodium
Simpathetic control on circulation system
Imbalance response on alpha and beta receptor
The effect of atheromatous change on vascular endothel
result in endothelial disfunction
increase in peripheral resistance

autoregulation

BLOOD PRESSURE =CARDIAC OUTPUT X PERIPHERAL

RESISTANCE
Hypertension
= Increased CO and/or increased PR
Preload
Structural

Contractility

Constriction

Hypertrophy
Fluid
Volume
Renal
sodium
insulinemia
retention

Functional

Volume
redistribution
Decreased
Filtration
Surface

Sympathetic Renin
cell mem Hypernervous
angiotensin brane aloveractivity

Excess
Genetic
stress
Endothelium
CONTRIBUTING
FACTORS LEADS
sodium
alteration
derived

excess

teration

Genetic

obesity

TO HYPERTENSION
alteration

Low renal blood flow e.g :

blood volume
blood pressure
_
blood sodium
Kidneys
_

RENIN ANGIOTENSIN
ALDOSTERON
SYSTEM

Secretion of renin
Angiotensinogen

Increased blood
pressure

Angiotensin 1

High blood
potassium

ACE

Angiotensin 2

Vasoconstriction

Adrenal cortex

Inhibition

Secretion of Aldosteron

Bradyjkinin/kinins

Inhibition

Angiotensin 2

Degradation

Kidney tubules
Reabsorption of sodium and water
Excersion of potassium
Blood sodium levels
Blood volume
Blood pressure

AT1 receptors

AT2 receptor

Reactive oxygen species

Pro-inflammatory process
Vaso-constriction
Cellular growth/proliferation
Apoptosis
Neurohumoral actiovation

B1/B2 receptors

NO
Vasodilation
Growth inhibition
Apoptosis

Type of Hypertension in the Elderly

Systolic Hypertension: 6-12 %at age > 60 yrs. Women > men
Incidence increase with age
Diastolic Hypertension: 12-14% more > 60 yrs. Men > women
incidence decrease with age
Systolic-Diastolic Hypertension : 6-8% more > 60 th. Women > men
Incidence increase with age
Classification of hypertension ( JNC-VI )
Category

Systolic

Optimal

<120

and

<80

Normal

<130

and

<85

High-Normal

Diastolic

130-139

or

85-89

Hipertension Stg. 1

140-159

or

90-99

Stg. 2

160-179

or

100-109

Stg. 3

>180

or

>110

The etiology of Secondary Hipertension in the

elderly
Drugs : corticosteroid, estrogen, NSAID, alcohol, ergotamine,
antihistamine, simpatomimetic decongestant
Renal : renal artery stenosis, pyelonephritis, glomerulonephritis
obstructive uropathy, analgesic nephropathy,polycystic
kidney,Connective tissue disorders
Endocrine : Conns syndrome, Cushings syndrome,
pheochromocytoma, acromegaly, hyperparathyroidism
Neurol: diseases of the spinal cord,incr.of intracranial pressure
Others: coarctatio of the aorta, pseudo-hypertension

Percentage of end point of 7 big study on elderly

hypertension
AUSTRALIA EWPHE
Non-fatal:events
Stroke
\Myocardial infarct.
All cardiac endpoint
All cardio-vasc. Events
Fatal Events
Stroke
Cardiac
All cardiovas.events
ALL non Cardiovasc.
Total mortality
All events:
Stroke
Cardiac
All Cardio-vasc.
* p<0,05

nr :not reported

Coope SHEP STOP MRC Syst-Eur

and Warender

-37
+18
-10
-26

-35
nr
-9
-36*

-27
+11
-26
-26 --

-37*
-33
-40

-38*
-16
nr

--36

nr

-1
-75*

-32
-38*

-70
+1

-29
-20a

-61
+13
-23

-27
+21
-9

-22
-nr
-3

-34
-19

-36*
-20

-24

-34*

a. ischemic heart disease

--38*
-30
nr
-13

-30 -44* -20

-33

-25

nr

-73*
-25b

-12
-22a

-27
-27

-20
+5
-13

nr
nr
43

-89
+5
-3

-27
-1
-14

-42
-15

-36*
-27*

-47*
-13b

-25
-19

-41*
-26*

-23*

-32 *

-40*

-17

-31*

b : myocardial infarction

The Hypertension in The Very Elderly Trial (HY-VET)

The Trial:
International, multi-centre, randomised double-blind placebo
controlled
Inclusion Criteria:
Aged 80 or more,
Systolic BP; 160 -199mmHg
+ diastolic BP; <110 mmHg,
Informed consent

Exclusion Criteria:
Standing SBP < 140mmHg
Stroke in last 6 months
Dementia
Need daily nursing care

Primary Endpoint:
All strokes (fatal and non-fatal)

Target blood
pressure
150/80 mmHg

ANTIHYPERTENSIVE THERAPY BENEFITS PEOPLE OF ALL

AGES,EVEN TO THOSE OVER 80S
(Moser,M 2003)

0
-10
-16

-20
-21
-30
-35

-40
-38

-50
-60

-52

CHF

STROKES

LVH

Fatal/non fatal

CVD

CHD events

Deaths

Fatal/non fatal

CHF Decreased by 52%

Strokes decreased by 38%
LVH decreased by 35%
CVD death decreased by 21 %
CVD events decreased by 16 %

Four Reasons why Hypertension may

be Different in the Elderly

Hypertension in the Very Old

(Bulpitt J Hum Hyp 1994; 8:603)

1. They are survivors

2. Many have taken years to
become hypertensive
3. Some have atheromatous renal
artery stenosis
4. Diastolic pressure falls in the
elderly

JNC 7: New Features and Key Messages

For persons over age 50, SBP is a more important than DBP as CVD risk factor.

Starting at 115/75 mmHg, CVD risk doubles with each increment of

20/10 mmHg throughout the BP range.

* Persons who are normotensive at age 55 have a 90% lifetime risk for developing
HTN.
Those with SBP 120139 mmHg or DBP 8089 mmHg should be considered
prehypertensive who require health-promoting lifestyle modifications to prevent CVD.

Thiazide-talone or combined with other drug classes are drug of first choice
Certain high-risk conditions are compelling indications for other drug classes.

Most patients will require two or more antihypertensive drugs to achieve goal BP.

If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually
should be a thiazide-type diuretic.

NO SPECIFIC SYMPTOMS AND SIGNS

Management of elderly hypertension need specific approach

GERIATRIC ASSESSMENT including:

Evaluation :- socioeconomic/psychocognitive
- IHD risk factor
- complication
- the etiology of
hypertension
-comorbidity
-nutrition
Education
Therapy
Follow Up

Anamnesis
Physical
Examination
Lab

PROB
LEM
LIST

Chest X-ray
ECG,etc

Blood pressure measurement : standing,(sitting )and lying down.

Evaluate : white coat hypertension, pseudo-hypertension, orthostatic hypotension

MANAGEMENT : from the problem list

Address all the emergency problems(emergency encephalopathy etc)

then all the urgency :acute infection,CHF,acidosis
nutrition always been regarded as
urgency measures
Hypertension and all the cardiovascular risk should be
addressed as a compound
Although to prevent from polypharmacy is not always easy,
all attempt should be tried:
* dont give medication unless diagnosis is made
* familiarized with indication,contra-indication,
adverse event,dose etc of medication given
* not giving any medication to abate the adverse event
of others ( change to other medication with less/no
side effect )

THE NEW GUIDELINES:CLASSIFICATION

WHO-ISH,ESH-ESC

BP

BP

JNC VII

BP Classification
BSH-BPClassification

Optimal

<120/<80

<120/<80

Normal

Normal

120-129/80-84

120-129/80-84

Prehypertension

High normal

130-139/85-89

130-139/85-89

Stage-1 hypertension

Grade 1
hypertension
(mild)

140-159/90-99

140-159/90-99

Grade-2
hypertension
(moderate )

160-179/100-109

>160/>100

Grade-3
hypertension
(severe)

180/ 110

Isolated systolic
hypertension

140

90

Stage 2 hypertension

Isolated Systolic
Hyper-

STRATIFICATION OF RISK TO QUALIFY PROGNOSIS

BLOOD PRESSURES
Other risk factors
and disease history

Normal
SBP 120-129
DBP 80-84

High normal
SBP 130-139
DBP 85-89

Grade 1
SBP 140-159
DBP 90-99

Grade 2
SBP 160-179
DBP 100-110

Grade 3
SBP 180

No other risk factors

Average risk

Average risk

Low added
risk

Moderate
added risk

High added
risk

1-2 risk factors

Low added
risk

Low added
risk

Moderarte
added risk

Moderate
added risk

Very high
added risk

3 or more risk factors

or TOD or Diabetes

Moderate
added risk

High added
risk

High added
risk

High added
risk

Very high
added risk

ACC

High added
risk

Very high
added risk

Very high
added risk

Very high
added risk

Very high
added risk

TOD : Target organ Damage

ACC : Assosiated clinical condition

DBP 110

ESH=ESC 2003

How far should BP be lowered in the elderly?

Trial
Starting BP Final BP
HOT
170
140-144
EWPHE
183
149
SHEP
170
144
Syst-Eur
174
151
Conclude: No evidence to support
lowering BP to<140 mmHg
Guidlines

Blood Presssure target in some situation( after2006)

Standard
Diabeticient
Elderly

JNC-VII
WHO-ISH

<140/90
<130/85

< 130/80
or lower

BHS
Australia
New Zealand

<140/85
<130/85
<140/80

<140/80
or lower
or lower

AMBP

<140/90
<130/75-80

JNC-VII=Join National Committee on Prevention,Detection,Evaluation and Treatment of High Blood Pressure,WHO-ISH=

World Health Organisation-International Society on Hypertension,BHS=British Hypertension Society,AMBP=ambulatory
blood pressure measurement

THERAPY

after all other comorbidity sorted

out
I. Non Pharmacological
Stop smoking
Body weight (if overweight)
salt diet
alcohol
physical excercise
Fat & cholesterol
II. Pharmacological :
Always kept in mind : Compelling indication
Starting with low dose
1x / daily dosage
Beware of drug interaction, adverse drug reaction,
and of comorbid diseases
Orthostatic hypotension

HYPERTENSION DRUGS ACCORDING TO COMPELLING INDICATION

Co-existing pathology

Diuretik
-bloker Inhib.
Dosis rendah
ACE
Asthma/COPD
++
CI
+
CHF
+
C
++
Angina pectoris
+
+
+
SickSinus Syndrome
+
++
++
PeriferalVasc.Dis.
+
CI
+
Aortic Stenosis
+
CI
+
Renal Failure-RAS
+
+
CI
Renal Failure-non
RAS
+
+
CI
BenignProstaticHyptr
+
+
C
Diabetes mellitus
+
C
++
Dyslipidemia
+
C
+
Impotence
C
C
+
Gout
Constipation
C
+
+
+
+
+
C =caution

c.i =contra indication

Antag. Blocker CCB

CCB
AT2
dihidrop benz.
++
+
+
+
+
+
C
C/CI
+
C
++
++
+
C
C
C
+
+
+
CI
+
++
++
++
C
+
CI
+
C
C
+
+
+

+
+
+
+(++)
+

+
+
+
+
+

+
+
+
+
+

+
+

+
+

+
+

+
+

NORVASK

Original Amlodipine besylate

OLMETEC
Olmesartan medoxomil

OLMETEC PLUS
lmesartan medoxomil+ hydrochlorothiazide

ARB (Olmesartan ) as antihypertensive agents and prevent

progressive CKD through combination effect : haemodynamic,
antiproteinuric and pleiotropic mechanisms
Combination therapy : Olmesartan +HCT or
Olmesartan + CCB

Possible combination of different classes of antihypertensives

agents.The most rationale
combinations are represents as
DIURETICS
thick lines
BB

AlfaB
Or with the
Birmingham
hypertension
score

ARB

CCB

ACEI

ACEI or ARB

ESH-2003

Thizide diuretics
Non pharmacologic advice:
salt,bodyweight,Alcohol,smoking,exercise,

Dihydropiri
dine ccb

-Blockers
Harvey and Woodward,2001