Il geriatra commenta le linee guida sull ipertensione arteriosa. Niccolò Marchionni

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1 Il geriatra commenta le linee guida sull ipertensione arteriosa Niccolò Marchionni Cardiologia e Medicina Geriatrica Dipartimento del Cuore e dei Vasi Università di Firenze e Azienda Ospedaliero-Universitaria Careggi Firenze Presidente Società Italiana di Gerontologia e Geriatria Key points: Stratificazione del rischio nell anziano Criticità nella diagnosi nell anziano Trattamento nel molto anziano: quale target pressorio?

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3 Indipendentemente dall età

4 Pressione arteriosa ed età in Europa ed in Nord America. Dati da studi di popolazione condotti negli anni 90 Pressione arteriosa sistolica Pressione arteriosa diastolica Europa Nord America mmhg mmhg Età (anni) Età (anni) Wolf-Mayer K et al, JAMA 2003: 289:

5 Prevalenza di Ipertensione Arteriosa per età, in Europa e Nord America. Dati da studi di popolazione condotti negli anni (%) USA Canada Italia Inghilterra Anni Wolf-Mayer K et al, JAMA 2003: 289:

6 La stratificazione del rischio

7 As detailed in the 2007 ESH/ESC guidelines, several measures of renal, cardiac and vascular damage can be considered for total cardiovascular risk quantification. Because of their simplicity, wide availability and limited cost measures based on urinary protein excretion (including microalbuminuria), egfr (MDRD formula), and ECG are suitable for routine use. Cardiac and vascular ultrasounds are more and more easily available in Europe, and their use in the evaluation of the hypertensive patient can be encouraged.

8 AGE > 55 years in men and 65 years in women is a risk factor

9 Clearance della creatinina secondo la formula Modification of Diet in Renal Disease (MDRD) GFR = 186 X P cr X età x (se di etnia nera) x (se di sesso femminile) Hallan S et all. Am J Kidney Dis 2004, 44:84

10 Stage 3: GFR ml/min/1.73m 2

11 In pratica, non esistono anziani a basso rischio tutti gli anziani sono a rischio almeno medio-elevato

12 La diagnosi

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14 Vascular survival probability by diastolic orthostatic hypotension and by systolic orthostatic hypotension in older diabetic patients Lukkinen H. et al, Diabetes Res Clin Pract 67 (2005)

15 Causes of syncope in general population (EGSYS 2) and in geriatric departments (GIS) EGSYS 2* GIS** All (n=465) years (n=71) > 75 years (n=160) p* Cardiac Neuromediated Orthostatic Cerebrovascular Drug Induced Unexplained n (%) 74 (16) 309 (66) 46 (10) 0 (0) 2 (0) 11 (2) Orthostatic hypotension to be systematically assessed in older patients! n (%) 8 (11.3) 44 (62) 3 (4.2) 0 3 (4.2) 10 (14.1) n (%) 26 (16.3) 58 (36.3) 49 (30.5) 0 8 (5) 14 (8.8) ns 0,001 0,001 / ns ns * <75 years vs >75 years GIS * Brignole M et al, Eur Heart J. 2006; 27:76-82 ** Ungar A et al, JAGS 2006; 54:

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17 # Age >65 years #

18 Conclusions: ambulatory measurement of BP is superior to clinic measurement in predicting cardiovascular mortality in elderly subjects. Night-time (systolic) BP is the strongest predictor of outcome in this age group. Burr M.L. et all, Age and Ageing 2008

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21 Il trattamento

22 Box 7. Antihypertensive treatment in the elderly Since the publication of the last guidelines, evidence from large meta-analyses of published trials confirms that in the elderly antihypertensive treatment is highly beneficial. The proportional benefit in patients aged more than 65 years is no less than that in younger patients.

23 Trials of Antihypertensive Treatment in the Elderly Risk Reduction (%) Trial N Age Stroke CAD CHF All CVD Australian % 18% NA 31% EWPHE 840 > 60 36% 20% 22% 29% Coope % 3% 32% 24% STOP-HTN % 13% 51% 40% MRC % 19% NA 17% HDFP % 15% NA 16% SHEP 4736 > 60 33% 27% 55% 32% Syst-Eur 4695 > 60 42% 26% 36% 31% STONE % 6% 68% 60% Syst-China 2394 > 60 38% 33% 38% 37%

24 Mortalità e pressione arteriosa nell oldest old Probabilità di morte 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0, anni >85 anni + 85 anni anni Pressione arteriosa sistolica (mmhg) Studio di popolazione longitudinale (n=12802) 85 anni: n=1088 (368M/720 F) in men aged 85 and older, higher systolic blood pressure is associated with better survival. Satish S, JAGS 2001

25 Prevenzione del rischio CV nel molto anziano iperteso: metanalisi di RCT in doppio cieco Ictus Mortalità generale Mortalità CV Eventi CV Eventi coron. Insuff. card. Trattamento vs. Placebo RR (95% CI) Gueyffier F et al., Lancet 1999; 353:793 EWPHE SHEP-P SHEP STOP Syst-Eur Età >80 aa N=1566

26 The HYpertension in the Very Elderly Trial N. Beckett, R. Peters, A. Fletcher, C. Bulpitt on behalf of the HYVET committees and investigators ClinicalTrials.gov: NCT

27 Blood Pressure & The Very Elderly (aged 80 or more) Epidemiologic population studies suggest better survival with higher levels of blood pressure Clinical trials recruited too few Meta-analysis (n=1670) (Gueyffier et al. 1999) 36% reduction in the risk of stroke BENEFIT 14% (p=0.05) increase in total mortality RISK

28 Active treatment indapamide SR 1.5 mg +/- perindopril 2-4 mg

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30 Editorial Overcome Clinical Inertia to Control Systolic Blood Pressure Patrick J. O Connor, MD, PhD Healthpartners Research Foundation PO Box 1524 Minneapolis, MN, ( patrick.j.oconnor@healthpartners.com ARCH INTERN MED: VOL 163, DECEMBER 22, American medical Association. All Rights reserved Ma..

31 HYVET Population General Population Orthostatic Hypotension 8 % Diabetes 7 % ISH 32% 5-30 % 14 % % Low P.A., Clin Auton Res 2008; 18 [suppl 1]: 8-13 Wild S. et al., Diabetes Care 2004; 27: Di Bari M et al., J Hypert 1999; 17:1633

32 Achieved SBP in different trial and different population

33 Conclusions Treatment of SH in older patients with SBP of at least 160 mmhg is supported by strong evidences. The evidence available to support treatment of patients to the level of 140 mmhg or those with baseline SBP of 140 to 159 mmhg is less strong; thus, this treatment decisions should be more sensitive to patient preferences and tolerance of therapy.

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35 Box 7. Antihypertensive treatment in the elderly In the elderly, outcome trials have only addressed patients with an entry SBP at least 160 mmhg, and in no trial in which a benefit was shown achieved SBP averaged less than 140 mmhg. Evidence from outcome trials addressing lower entry and achieving lower on-treatment values are thus needed, but common sense considerations suggest that also in the elderly drug treatment can be initiated when SBP is higher than 140 mmhg, and that SBP can be brought to below 140 mmhg, provided treatment is conducted with particular attention to adverse responses, potentially more frequent in the elderly

36 Il geriatra commenta le linee guida sull ipertensione arteriosa Niccolò Marchionni Key points conclusivi: 1 L iperteso anziano è sempre a rischio almeno moderato: il trattamento va iniziato precocemente 2 Ricerca di ipotensione ortostatica e ABPM da effettuare in maniera sistematica 3 Target pressorio da scegliere in base alle condizioni generali del paziente