Elderly patients with hypertension often have multiple risk factors and more target organ damage and coexisting diseases, and their treatment and control rates are low. For elderly hypertensive patients of different age groups, it is too simplistic to use a “one-size-fits-all” index to achieve the target blood pressure.
The pharmacological treatment of elderly patients with hypertension should emphasize individualization, diversification, optimization, simplification and safety. To make the treatment more targeted, home self-measurement of blood pressure should be advocated, and necessary ambulatory blood pressure monitoring should be performed during the treatment process for special individuals.
Treatment of hypertension in the elderly should be early intervention and comprehensive management
Diversification means early intervention, comprehensive management, intervention of various risk factors, combined with anti-atherosclerosis treatment. It is advisable to lower the blood pressure of elderly patients with hypertension gently, usually within 2-3 months to bring the blood pressure to the target. The target blood pressure value is <140/90 mmHg or 150/90 mmHg, and can be lower for some patients. Stroke guidelines in Europe and the United States recommend that blood pressure should be lowered and monitored over time in patients after stroke or transient ischemic attack, with an average benefit of 10/5 mmHg, but not too low if hemodynamic stroke or bilateral carotid stenosis is suspected.
Combination of medications should be used in the treatment of hypertension in the elderly
There is a “J” shaped curve between blood pressure levels and cardiovascular risk during antihypertensive therapy, especially diastolic blood pressure. Combination therapy is an important strategy for optimizing the treatment pattern of hypertension, and should be used for grade 2 or higher hypertension or for those exceeding the target value of 20/10 mm Hg. Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor antagonists (ARBs) and diuretics, ACEIs and calcium antagonists (CCBs), and combinations of ARBs and CCBs can be the preferred regimen for combination therapy and are more appropriate for older patients with hypertension, but should be treated differently. The clinical decision to initiate monotherapy or combination therapy depends on the patient’s basal blood pressure level and clinical symptoms, and moreover on the patient’s individual tolerance to a rapid decrease in blood pressure. In elderly patients with hypertension, starting monotherapy may be safer.
Medication safety is particularly important in elderly patients
The incidence of adverse drug reactions in people ≥65 years of age is twice as high as in people 16 to 64 years of age. Changes in pharmacokinetics and effect kinetics are age-related, liver and kidney function usually decreases with age, and frequent use of multiple drugs may increase drug-drug interactions. Therefore, elderly people should pay attention to adjusting drug doses and be alert to adverse drug reactions. For the elderly and the thin elderly, the treatment principle of “start with small amount and increase gradually” should be followed, and the monitoring should be strengthened, and the follow-up should be done every 1-2 weeks when the treatment is started.
The level of blood pressure reduction is more important than the class of drugs used
Five classes of antihypertensive drugs, diuretics, CCB, ACEI, ARB and B-blockers, are commonly used in the treatment of hypertension in the elderly. Antihypertensive drugs suitable for the treatment of elderly patients with hypertension should be able to reduce blood pressure gently, smoothly, effectively for 24 hours, be safe, have few adverse effects, be easy to take and have high compliance. Low-dose diuretics and long-acting CCBs are more suitable for the initial treatment of elderly patients with hypertension.
1.Diuretics
Elderly hypertensive patients with high salt sensitivity and increased volume load are more suitable for treatment with diuretics. The adverse effects of diuretics on the metabolism of sugar, uric acid, and blood potassium are closely related to the species, dose, duration of therapy, and the baseline status of the patient.
Long-term use of indapamide regular tablets (2.5 mg/day) can lead to a significant increase in blood creatinine and uric acid and a significant decrease in blood potassium. Clinical use of indapamide (2.5 mg/day) and hydrochlorothiazide (>25 mg/day) should be monitored intensively, and low doses, or combination with potassium-preserving diuretics/aldosterone receptor antagonists may reduce the incidence of hypokalemia and new-onset diabetes. Thiazide diuretics are mostly used at low doses in combination with ACEI or ARB, and tab diuretics are chosen if the glomerular filtration rate (GFR) is <30 ml/min?1.73 m-2.
2.CCB
Long-acting formulations of dihydropyridine CCB are more suitable for elderly hypertension, and their effect on stroke reduction is better than other antihypertensive drugs.CCB can be used for hypertensive patients with combined atherosclerosis, coronary artery disease, peripheral artery disease and diabetes mellitus, but should not be used to treat patients with combined heart failure.
A small number of long-acting CCB preparations may cause adverse reactions such as headache, flushing and palpitations at the beginning of dosing, which last less than 24 hours and do not provide good control of morning peak blood pressure. a common adverse reaction associated with CCB is edema, mostly in the ankle, which can be prevented by combining with ACEI or ARB.
3.ACEI
The drug of choice for the treatment of hypertensive patients with combined heart failure, diabetes, coronary artery disease, and microproteinuria. The main adverse effect is cough. During the application of ACEI especially with captopril, care should be taken to monitor blood picture, serum potassium and renal function.
4.ARB
The effect is mild and the adverse effects are less than ACEI, especially cough is rare, more suitable for elderly hypertensive patients. Currently, it is mainly used as a preferable treatment for hypertension in those who are not adapted to ACEI and combined with proteinuria and diabetic nephropathy. Although many clinical trials emphasize the advantages of a particular ARB, its anti-hypertensive effects do not differ much, and Crosartan is the only anti-hypertensive agent that can mildly reduce blood uric acid levels.
5.β-blockers
Not recommended as the first-line treatment for elderly patients with hypertension, only in combination with heart failure, rapid arrhythmia, angina pectoris and other special circumstances. The effect of bisoprolol and metoprolol succinate extended-release tablets can last for 24 hours, and the half-life of metoprolol tartrate flat tablets is only 8 hours, and 2 times/day oral administration cannot achieve the purpose of 24-hour smooth blood pressure lowering.
6.α-blockers
It is easy to cause postural hypotension and is generally not used as the drug of choice for elderly hypertension. But for the combined benign prostatic hyperplasia hypertensive patients have a “two birds with one stone” effect. The dose should be small, and postural hypotension should be guarded against.
The choice of drugs for several special clinical conditions of elderly hypertension
1.Simple systolic hypertension (ISH)
ISH accounts for 60% to 80% of hypertension in the elderly. ccb and low-dose diuretics have some advantages in treating ISH. Some studies have proved that the magnitude of systolic blood pressure reduction of nitrate drugs is significantly greater than that of diastolic blood pressure reduction, but headache adverse reactions are common and very easy to produce drug resistance, its long-term efficacy is not reliable. Carvedilol has both α receptor and β receptor dual blocking effect, can significantly reduce systolic blood pressure, diastolic blood pressure impact is small, the dose of 10-25 mg, two times a day, most patients can tolerate.
2.Stubborn hypertension
Hypertension in 20% to 30% of patients with persistent hypertension, more common in elderly patients. The first step is to find the cause of recalcitrant to take targeted countermeasures.
① Advanced age, high baseline blood pressure levels, obesity, high salt diet, chronic kidney disease, diabetes mellitus, and left ventricular hypertrophy increase the risk of intractable hypertension;
(ii) Renal artery stenosis secondary to chronic kidney disease and renal atherosclerosis;
(iii) Sleep apnea syndrome is present in 83% of patients with recalcitrant hypertension, and attainment of hypertension can be greatly improved with positive airway pressure ventilation (CPAP) therapy;
④Poor medication compliance and inappropriate treatment regimens;
⑤ The influence of drugs, especially non-steroidal anti-inflammatory drugs.
Treatment measures for intractable hypertension include.
① Reducing body weight and a low-salt diet. Salt restriction can reduce systolic blood pressure by 5-10 mm Hg and diastolic blood pressure by 2-6 mm Hg;
② Among the commonly used antihypertensive drugs, long-acting or compounded preparations are used, and diuretics are often necessary;
③In the case of multidrug combination therapy, the choice of aldosterone receptor antagonists such as spironolactone and amiloride can further reduce the patient’s blood pressure;
④Antihypertensive drugs taken at night before bedtime can lower blood pressure more substantially than those taken during the day.
3. High blood pressure volatility
High blood pressure variability, morning peak of blood pressure, and non-arrythmic blood pressure are more common in elderly patients with hypertension, and are mostly associated with the inability to sustain stable blood pressure reduction for 24 hours with a single dose in the early morning. In a study of 1306 patients with intractable hypertension, the mean 24-hour systolic and diastolic blood pressures were lower in those who took at least one antihypertensive medication before bedtime, and the proportion of nonaspirates decreased from 83% to 40% (P<0.01). The timing of drug therapy should be selected according to each patient's routine and 24-hour blood pressure variability. Long-acting CCBs and most ACEI/ARBs are smooth, long-lasting, and improve blood pressure variability. Bedtime dosing provides better control of ambulatory blood pressure and reduces the incidence of non-arrythmic blood pressure and cardiovascular events. However, in the elderly and in patients with established cerebrovascular disease, cerebrovascular autoregulation is impaired, and bedtime dosing in these patients may do more harm than good.