American Society of Hypertension (ASH) 26th Annual Scientific Meeting and Exposition

May 21-24, 2011 New York, NY

Orthostatic Hypotension a Common Concern for Very Elderly Persons With Hypertension

The high risk of hypertension in geriatric patients has long been recognized. Less commonly discussed is the prevalence of orthostatic hypotension among the elderly, despite its close relationship with antihypertensive medications. Orthostatic hypotension, which is sometimes called postural hypotension, refers to a sudden drop in blood pressure (BP) that occurs when an individual rises from a reclining or sitting position. Individuals experiencing orthostatic hypotension typically report feeling dizzy or light-headed and may be prone to falls.

According to a poster presented at the ASH 2011 annual meeting, orthostatic hypotension may occur more frequently among very elderly people with hypertension than previously estimated. Elaine Ku, MD, Division of Nephrology, Keck School of Medicine, Los Angeles, and colleagues found that more than half of the elderly residents screened at the Los Angeles Jewish Home for the Aging experienced orthostatic hypotension. This represents a sharp increase over the prevalence of orthostatic hypotension observed among elderly participants in the Cardiovascular Health Study, who had rates ranging from 14.8% to 26%, which correlated positively with advancing age.

Ku and associates screened 94 of the facility’s residents, all of whom were taking medication to treat hypertension. The average age of the patients was 89.8 ± 6.2 years, and the majority (70%) were women. The researchers measured the BP of the patients before and after standing to identify those who experienced a >20 mm Hg drop in systolic BP or a >10 mm Hg drop in diastolic BP within 1 to 3 minutes of getting to their feet. Orthostatic hypotension was observed in 48 (51%) of the 94 patients. It occurred more commonly in patients who had a history of stroke, transient ischemic attack, or hypothyroidism, or in patients currently taking antipsychotic medications. In the Cardiovascular Health Study, 26% of persons in the ≥85-year demographic were found to experience orthostatic hypotension; however, this study was restricted to community-dwelling adults free of cardiovascular disease.

According to the investigators, use of antihypertensive medications is likely the most common cause of orthostatic hypotension, but the mechanism of this condition in elderly patients is complex and may involve multiple factors. Other known risk factors are volume depletion, autonomic dysfunction, arterial stiffness, cardiac disease, central nervous system disorders, dementia, venous diseases, and amyloidosis.

Orthostatic hypotension places patients at tremendous risk of falls, the consequences of which can be life-threatening in elderly individuals. Despite the prevalence and possible consequences of orthostatic hypotension, the condition’s effects on the morbidity and mortality of very elderly individuals (age >80 years) has not received sufficient scrutiny, according to the poster’s authors. Given the significant use of antihypertensive medication in the very elderly, the researchers recommend that future studies seek to provide additional data on the important questions remaining about orthostatic hypotension.

Elderly Patients With Comorbidities Less Likely to Achieve Blood Pressure Control

A review of medical records for elderly patients with hypertension found that most were prescribed antihypertensive medications in accordance with guideline recommendations for their relevant comorbid diseases and risk factors. Individuals with the greatest number of relevant conditions and compelling indications (RCCIs) for antihypertensive treatments, however, were less likely to achieve reductions in blood pressure (BP) that met therapeutic goals. Investigators from the Analysis Group Inc., Boston, MA, and Novartis Pharmaceuticals Corporation, East Hanover, NJ, presented data from the retrospective study in a poster session at the ASH annual meeting.

The research team examined medical records from four primary care centers in the United States for community-dwelling patients ≥65 years of age whose diagnosis of hypertension was established with ≥1 BP reading at a clinic visit on or after January 1, 2007, and confirmed during ≥1 follow-up visit. Patients found to have received care for a hypertensive emergency or terminal illness were ineligible. Investigators randomly selected 357 patients (mean age, 78.3+7.0 years) from among the list of individuals who met eligibility criteria and analyzed records from the patient’s first clinic visit to his or her last clinic visit.

Patients were stratified according to number of RCCIs, which were assessed using guidelines from “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure” (JNC-7). Only 68 patients had no RCCIs (0-RCCI), 132 were categorized as 1-RCCI, and 157 were classified as ≥2-RCCI. Overall, 72.8% of patients were at high risk of coronary artery disease. Records showed that at the first visit, median systolic BP was significantly higher among patients in the ≥2-RCCI group, at 141.2 mm Hg, compared with 131.4 mm Hg for the 0-RCCI group and 137.4 mm Hg for the 1-RCCI arm (P <.001).

JNC-7 guidelines outline treatment recommendations for patients with uncomplicated hypertension and for those with a high risk of coronary disease or who have conditions (eg, diabetes, chronic kidney disease) considered compelling indicators for starting therapy with medication from a specific class of antihypertensive drugs. During the initial visit, 96.1% of patients were prescribed an antihypertensive medication, and 66.5% of these patients received more than one drug. Therapeutics were typically prescribed in accordance with JNC-7 guidelines, although less commonly for patients who had a history of stroke or diabetes.

Follow-up visits were recorded every 3 months and showed that treatment regimens were modified for 61.8% of patients in the ≥2-RCCI group, 57.6% in the 1-RCCI arm, and 55.9% in the 0-RCCI group. Patients with ≥2 RCCIs were least likely to attain BP goals, with only 15% of patients in this group demonstrating satisfactory BP levels during the 75% to 100% of clinic visits where BP was measured. The proportion of patients who attained BP goals over time increased significantly in the 1-RCCI group and the 0-RCCI arm (33% and 50%, respectively). The authors concluded that their review indicates “the need for more aggressive hypertension management in elderly patients.”