michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
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individuals. 2, 5 The risk <strong>of</strong> AD increases with increasing age. 6, 7 Clinically, this is manifest as orthostatic<br />
blood pressures (SBP drops > 10 mmHg or DBP > 5 mmHg going from sitting to standing), which can<br />
complicate management. The effect <strong>of</strong> orthostatic BP drops is that individuals under treatment are at<br />
increased risk <strong>of</strong> symptomatic hypotension, increased medication side effects and a not insignificant<br />
increase in risk <strong>of</strong> falling. Appropriate management requires first that seated and standing measures<br />
<strong>of</strong> BP are done and second that recommendations for home monitoring specify standing BP’s and third<br />
that the target BP goal is focused on control <strong>of</strong> the standing BP. For many patients this may translate<br />
into the need for larger doses <strong>of</strong> anti-hypertensive medications in the evening (when the person will be<br />
supine for several hours) compared to the morning doses.<br />
Elderly patients are far more likely than younger individuals to have isolated systolic HTN (ISH). 8<br />
Isolated systolic HTN may account for as much as 80% <strong>of</strong> the HTN seen in the elderly population. As<br />
a consequence, the particular choices <strong>of</strong> medication may need to be specialized. A practitioner must<br />
also keep in mind the relatively low control rates found in the elderly. Part <strong>of</strong> the issue is the relative<br />
unawareness many patients have about their diagnoses, with only about 50% <strong>of</strong> individuals aware they<br />
are hypertensive. Despite awareness <strong>of</strong> the high frequency <strong>of</strong> multiple cardiovascular co-morbidities<br />
in the elderly population, HTN is frequently uncontrolled. In fact, elderly patients are up to five times<br />
more likely to have uncontrolled blood pressure than their younger counterparts. 9 A major reason for<br />
the lack <strong>of</strong> SBP control in the elderly has to do with the magnitude <strong>of</strong> the SBP elevation that is <strong>of</strong>ten far<br />
above goal levels. Also, co-morbidities such as obesity, diabetes mellitus, CKD (both depressed GFR<br />
and albuminuria), and the presence <strong>of</strong> pressure-related target-organ injury are more common in elderly<br />
than non-elderly hypertensives. All <strong>of</strong> these conditions have been shown to confer resistance to the BP<br />
lowering effect to anti-hypertensive agents.<br />
Co-morbid illnesses increase the difficulty <strong>of</strong> appropriately treating elderly individuals with HTN.<br />
A significant number <strong>of</strong> individuals will have DM, coronary heart disease (CHD), congestive heart<br />
failure (CHF) or be on chronic anticoagulation therapy. Each <strong>of</strong> these conditions requires sensitivity<br />
to the recommended medication classes for each disease. Elderly individuals may have physical<br />
limitations to home BP monitoring, such as poor vision or difficulty standing for prolonged periods <strong>of</strong><br />
time. In addition, individuals may be particularly sensitive to the effects <strong>of</strong> BP lowering or not tolerate<br />
NKFM & MDCH 51