Managing Hypertension in Older Adults.

PURPOSE OF REVIEW: The population of older adults 60-79 years globally is projected to double from 800 million to 1.6 billion between 2015 and 2050, while adults ≥ 80 years were forecast to more than triple from 125 to 430 million. The risk for cardiovascular events doubles with each decade of aging and each 20 mmHg increase of systolic blood pressure. Thus, successful management of hypertension in older adults is critical in mitigating the projected global health and economic burden of cardiovascular disease. RECENT FINDINGS: Women live longer than men, yet with aging systolic blood pressure and prevalent hypertension increase more, and hypertension control decreases more than in men, i.e., hypertension in older adults is disproportionately a women's health issue. Among older adults who are healthy to mildly frail, the absolute benefit of hypertension control, including more intensive control, on cardiovascular events is greater in adults ≥ 80 than 60-79 years old. The absolute rate of serious adverse events during antihypertensive therapy is greater in adults ≥ 80 years older than 60-79 years, yet the excess adverse event rate with intensive versus standard care is only moderately increased. Among adults ≥ 80 years, benefits of more intensive therapy appear non-existent to reversed with moderate to marked frailty and when cognitive function is less than roughly the twenty-fifth percentile. Accordingly, assessment of functional and cognitive status is important in setting blood pressure targets in older adults. Given substantial absolute cardiovascular benefits of more intensive antihypertensive therapy in independent-living older adults, this group merits shared-decision making for hypertension targets.

Adherence in Hypertension.

The global epidemic of hypertension is largely uncontrolled and hypertension remains the leading cause of noncommunicable disease deaths worldwide. Suboptimal adherence, which includes failure to initiate pharmacotherapy, to take medications as often as prescribed, and to persist on therapy long-term, is a well-recognized factor contributing to the poor control of blood pressure in hypertension. Several categories of factors including demographic, socioeconomic, concomitant medical-behavioral conditions, therapy-related, healthcare team and system-related factors, and patient factors are associated with nonadherence. Understanding the categories of factors contributing to nonadherence is useful in managing nonadherence. In patients at high risk for major adverse cardiovascular outcomes, electronic and biochemical monitoring are useful for detecting nonadherence and for improving adherence. Increasing the availability and affordability of these more precise measures of adherence represent a future opportunity to realize more of the proven benefits of evidence-based medications. In the absence of new antihypertensive drugs, it is important that healthcare providers focus their attention on how to do better with the drugs they have. This is the reason why recent guidelines have emphasize the important need to address drug adherence as a major issue in hypertension management.

Hypertension in the United States, 1999 to 2012: progress toward Healthy People 2020 goals.

BACKGROUND: To reduce the cardiovascular disease burden, Healthy People 2020 established US hypertension goals for adults to (1) decrease the prevalence to 26.9% and (2) raise treatment to 69.5% and control to 61.2%, which requires controlling 88.1% on treatment. METHODS AND RESULTS: To assess the current status and progress toward these Healthy People 2020 goals, time trends in National Health and Nutrition Examination Surveys 1999 to 2012 data in 2-year blocks were assessed in adults ≥18 years of age age-adjusted to US 2010. From 1999 to 2000 to 2011 to 2012, prevalent hypertension was unchanged (30.1% versus 30.8%, P=0.32). Hypertension treatment (59.8% versus 74.7%, P<0.001) and proportion of treated adults controlled (53.3%-68.9%, P=0.0015) increased. Hypertension control to <140/<90 mm Hg rose every 2 years from 1999 to 2000 to 2009 to 2010 (32.2% versus 53.8%, P<0.001) before declining to 51.2% in 2011 to 2012. Modifiable factor(s) significant in multivariable logistic regression modeling include: (1) increasing body mass index with prevalent hypertension (odds ratio [OR], 1.44); (2) lack of health insurance (OR, 1.68) and <2 healthcare visits per year (OR, 4.24) with untreated hypertension; (3) healthcare insurance (OR, 1.69), ≥2 healthcare visits per year (OR, 3.23), and cholesterol treatment (OR, 1.90) with controlled hypertension. CONCLUSIONS: The National Health and Nutrition Examination Survey 1999 to 2012 analysis suggests that Healthy People 2020 goals for hypertension ([1] prevalence shows no progress, [2] treatment was exceeded, and [3] control) have flattened below target. Findings are consistent with evidence that (1) obesity prevention and treatment could reduce prevalent hypertension, and (2) healthcare insurance, ≥2 healthcare visits per year, and guideline-based cholesterol treatment could improve hypertension control.

Closing the gap in hypertension control between younger and older adults: National Health and Nutrition Examination Survey (NHANES) 1988 to 2010.

BACKGROUND: Joint National Committee goal blood pressure for all adults was <140/<90 mm Hg or lower from 1984 to 2013. Adults aged ≥60 years (older) have mainly isolated systolic hypertension, with major trials attaining systolic blood pressure <150 but not <140 mm Hg. The main objective was to assess changes in hypertension control to <140/<90 mm Hg in younger (aged <60 years) and older adults and <150/<90 mm Hg in the latter. METHODS AND RESULTS: National Health and Nutrition Examination Surveys (NHANES) 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed in adults aged ≥18 years. From 1988 to 1994 to 2005 to 2010, hypertension control to <140/<90 mm Hg improved in older (31.6% to 53.1%; P<0.001) and younger (45.7% to 55.9%; P<0.001) patients. The age gap in control declined from 14.1% (P<0.01) in 1988 to 1994 to 2.8% (P=0.13) in 2005 to 2010. Better hypertension control reflected increased percentages of older (55.6% to 77.5%) and younger (34.6% to 54.7%) patients on treatment and treated older (45.7% to 64.9%) and younger (56.8% to 73.4%) patients controlled (all P<0.001). Control to <150/<90 mm Hg rose from 48.8% to 69.9% in older adults. Antihypertensive medication number and percentages on ≥3 medications increased in both age groups but increased more in older patients (P<0.01). Blood pressure control was higher in both age groups with ≥2 healthcare visits per year and on statin therapy. CONCLUSIONS: The age gap in hypertension control to <140/<90 mm Hg was virtually eliminated in 2005 to 2010 as clinicians intensified therapy, especially in older patients in whom isolated systolic hypertension predominates, controlling 70% to <150/<90 mm Hg. More frequent healthcare visits and the use of statin therapy may improve hypertension control in all adults.

The Results of the "Positive Action for Today's Health" (PATH) Trial for Increasing Walking and Physical Activity in Underserved African-American Communities.

BACKGROUND: The "Positive Action for Today's Health" (PATH) trial tested an environmental intervention to increase walking in underserved communities. METHODS: Three matched communities were randomized to a police-patrolled walking plus social marketing, a police-patrolled walking-only, or a no-walking intervention. The 24-month intervention addressed safety and access for physical activity (PA) and utilized social marketing to enhance environmental supports for PA. African-Americans (N=434; 62% females; aged 51±16 years) provided accelerometry and psychosocial measures at baseline and 12, 18, and 24 months. Walking attendance and trail use were obtained over 24 months. RESULTS: There were no significant differences across communities over 24 months for moderate-to-vigorous PA. Walking attendance in the social marketing community showed an increase from 40 to 400 walkers per month at 9 months and sustained ~200 walkers per month through 24 months. No change in attendance was observed in the walking-only community. CONCLUSIONS: Findings support integrating social marketing strategies to increase walking in underserved African-Americans (ClinicalTrials.gov #NCT01025726).

Treatment Resistant Hypertension.

Treatment resistant hypertension (TRH) is defined by office blood pressure (BP) uncontrolled on ≥ 3 or controlled on ≥ 4 antihypertensive medications, preferably at optimal doses and including a diuretic. Apparent (a)TRH is used when optimal therapy, adherence, and measurement artifacts are unknown. Among treated hypertensives, ~30% of uncontrolled and 10% of controlled individuals have aTRH, with a higher prevalence in Blacks than other race-ethnicity groups. In ≥ 50% of aTRH patients, BP measurement artifacts ('office' TRH), suboptimal regimens, or suboptimal adherence are present, ie, pseudo-resistance. While patients with 'office' TRH have fewer cardiovascular events than those with 'true' TRH, no evidence confirms that patients with suboptimal regimens or adherence are spared. Averaging several office BPs obtained with an automated monitor can reduce 'office' TRH. Home or ambulatory BP monitoring can identify office resistance. Prescribing ≥ 3 different antihypertensive medication classes, eg, thiazide-type diuretic, renin-angiotensin blocker and calcium antagonist at ≥ 50% of maximum recommended doses reasonably defines optimal therapy. Intensifying diuretic therapy, eg, adding an aldosterone antagonist, is effective for many TRH patients who are volume expanded. Clinical information, hemodynamic and renin-guided therapeutics can inform other treatment options. Attention to adverse effects, medication costs, and pill burden can improve adherence and control. Patients with aTRH and suspected secondary hypertension should be evaluated. Interfering substances or medications should be discontinued. These approaches will identify or correct the problem in ~80% of aTRH patients. Referral to a hypertension specialist and newer therapeutic approaches are options for TRH patients who cannot take or do not respond to optimal therapy.

Weight Loss Pharmacotherapy: Brief Summary of the Clinical Literature and Comments on Racial Differences.

The disparity in obesity rates between White, Black, and Hispanic individuals, especially women, is striking. Moreover, at any given body mass index or abdominal girth, incident diabetes is greater in Black, Hispanic and other racial-ethnic minorities than Whites. In addition to the growing health burden, the total costs of obesity in 2030 could exceed $500 billion (USD). Weight loss of 5%-15% from baseline can be attained with anti-obesity pharmacotherapy approved for long-term use in combination with lifestyle change. Weight loss of ≥ 5% is associated with medical benefits including reduction of incident diabetes and cardiovascular risk. While medical weight loss after one year or more in the US population is better than previously seen in many clinical trials, >60% of adults fail to sustain a 5% weight loss. Drug therapies approved for long-term weight loss may permit even more subjects to sustain healthful weight reduction.

Social and Medical Determinants of Cardiometabolic Health: The Big Picture.

Cardiometabolic diseases, including diabetes and heart disease, account for >12 million years of life lost annually among Black adults in the United States. Health disparities are geographically localized, with ~80% of health disparities occurring within ~6000 (16%) of all 38,000 US ZIP codes. Socio-economic status (SES), behavioral and environmental factors (social determinants) account for ~80% of variance in health outcomes and cluster geographically. Neighborhood SES is inversely associated with prevalent diabetes and hypertension, and Blacks are four times more likely than Whites to live in lowest SES neighborhoods. In ZIP code 48235 (Detroit, 97% Black, 16.2% unemployed, income/capita $18,343, 23.6% poverty), 1082 Medicare fee-for service (FFS) beneficiaries received care for type 2 diabetes (T2D) and coronary artery disease (CAD) in 2012. Collectively, these beneficiaries had 1082 inpatient admissions and 839 emergency department visits, mean cost $27,759/beneficiary and mortality 2.7%. Nationally in 2011, 236,222 Black Medicare FFS beneficiaries had 213,715 inpatient admissions, 191,346 emergency department visits, mean cost $25,580/beneficiary and 2.4% mortality. In addition to more prevalent hypertension and T2D, Blacks appear more susceptible to clinical complications of risk factors than Whites, including hypertension as a contributor to stroke. Cardiometabolic health equity in African Americans requires interventions on social determinants to reduce excess risk prevalence of risk factors. Social-medical interventions to promote timely access to, delivery of and adherence with evidence-based medicine are needed to counterbalance greater disease susceptibility. Place-based interventions on social and medical determinants of health could reduce the burden of life lost to cardiometabolic diseases in Blacks.

Blood pressure and cholesterol control in hypertensive hypercholesterolemic patients: national health and nutrition examination surveys 1988-2010.

BACKGROUND: Hypertension doubles coronary heart disease (CHD) risk. Treating hypertension only reduces CHD risk ≈25%. Treating hypercholesterolemia in hypertensive patients reduces residual CHD risk >35%. METHODS AND RESULTS: To assess progress in concurrent hypertension and hypercholesterolemia control, National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2004, and 2005 to 2010 were analyzed. Hypertension was defined by blood pressure ≥140/≥90 mm Hg, current medication treatment, and 2-told hypertension status; blood pressure <140/<90 defined control. Hypercholesterolemia was defined by ATP III criteria based on 10-year CHD risk, low-density lipoprotein cholesterol (LDL-C), and non-high-density lipoprotein cholesterol; values below diagnostic thresholds defined control. Across surveys, 60.7% to 64.3% of hypertensives were hypercholesterolemic. From 1988 to 1994 to 2005 to 2010, control of LDL-C rose (9.2% [95% confidence interval (CI), 6.6%-11.9%] to 45.4% [95% CI, 42.6%-48.3%]), concomitant hypertension and LDL-C (5.0% [95% CI, 3.3%-6.7%] to 30.7% [95% CI, 27.9%-33.4%]), and combined hypertension, LDL-C, and non-high-density lipoprotein cholesterol (1.8% [95% CI, 0.4%-3.2%] to 26.9% [95% CI, 24.4%-29.5%]). By multivariable logistic regression, factors associated with concomitant hypertension, LDL-C, and non-high-density lipoprotein cholesterol control (odds ratio [95% CI]) were statin (10.7 [8.1-14.3]) and antihypertensive (3.32 [2.45-4.50]) medications, age (0.77 [0.69-0.88]/10-year increase), ≥2 healthcare visits/yr (1.90 [1.26-2.87]), black race (0.59 [0.44-0.80]), Hispanic ethnicity (0.62 [0.43-0.90]), cardiovascular disease (0.44 [0.34-0.56]), and diabetes mellitus (0.54 [0.42-0.70]). CONCLUSIONS: Despite progress, opportunities for improving concomitant hypertension and hypercholesterolemia control persist. Prescribing antihypertensive and antihyperlipidemic medications to achieve treatment goals, especially for older, minority, diabetic, and cardiovascular disease patients, and accessing healthcare at least biannually could improve concurrent risk factor control and CHD prevention.

The efficacy and safety of intravenous hydralazine for the treatment of hypertension in the hospitalized child.

BACKGROUND: Intravenous (IV) hydralazine is frequently used for the treatment of elevated blood pressure (BP) in hospitalized children. Its safety and efficacy have not been examined. METHODS: This is a retrospective chart review of IV hydralazine use in hospitalized children (birth to 17 years) over a 3-year period. Demographic data and data on adverse effects (AE), BP, and heart rate (HR) prior to and after each first dose were collected. RESULTS: The patient cohort comprised 110 children admitted to the hospital during the study period, of whom 77 received the recommended dose. Mean age of the children was 8.5 ± 5.4 years; 33 % were male, and 32.5 % were white. Pre-dose systolic and diastolic BP indexes were 1.3 and 1.2, respectively. The median reduction in systolic and diastolic BP was 8.5 and 11.5 %, respectively. Sixteen (21 %) children achieved a 25 % reduction in systolic or diastolic BP, and BP increased in 30 % of patients; 10 % of children had a BP of <95th percentile for age, sex, and height after one dose. Seven (9 %) children had a documented AE. HR increased by a median of 3.5 %. In the multivariable models examining percentage change in systolic and diastolic BP, male gender was significantly associated with a change in systolic BP. CONCLUSIONS: In hospitalized children, IV hydralazine was well tolerated, BP response was variable, and 21 % of the patients achieved a ≥25 % reduction of systolic or diastolic BP. Further studies are needed to compare the safety and efficacy of IV hydralazine to other short-acting antihypertensive agents.

Decreased heart rate variability is associated with increased transcranial Doppler velocities in children with sickle cell disease.

OBJECTIVE: To explore the relationship between 24-hour blood pressure (BP) variability, heart rate (HR) variability, and transcranial Doppler velocity (TCDV) in a cohort of pediatric sickle cell disease (SCD) patients. DESIGN, SETTING, AND PARTICIPANTS: This is a retrospective study of 11 children aged 8-18 years with SCD who previously underwent 24-hour ambulatory BP monitoring and TCDV measurements. INTERVENTIONS: Medical records were reviewed for TCDV and 24-hour ABP data. TCDV in the right and left middle cerebral artery were examined, and the highest velocity was recorded. HR and BP standard deviations were used as markers of variability. The relationships between daytime, nighttime, and 24-hour blood pressures and heart rate variability were determined. RESULTS: Mean age, body mass index and hemoglobin levels were 11.2 ± 3.0 years, 18.7 ± 3.4 kg/m2, and 9.1 ± 1.7 g/dL, respectively. Median transcranial Doppler velocity was 136cm/s (125-142). Decreased day, night, and 24-hour heart rate variability were significantly associated with increased transcranial Doppler velocity (R = -.69, P = .02; R = -.82 P =.002; R = -.66, P = .03, respectively). BP variability did not correlate with TCDV. Nighttime BP indexes were higher than daytime. CONCLUSIONS: In this small cohort, decreased heart rate variability assessed by the standard deviation of HR was associated with increased transcranial Doppler velocities in children with SCD. No correlation between measurements of BP variability and TCDV was found. Our study provides new information on heart rate and blood pressure variability and TCDV; a surrogate marker of stroke risk in sickle cell disease. Larger multicenter studies are needed to confirm our findings.

Greater use of antihypertensive medications explains lower blood pressures and better control in statin-treated than statin-eligible untreated adults.

OBJECTIVE: Statins appear to have greater antihypertensive effects in observational studies than in randomized controlled trials. This study assessed whether more frequent treatment of hypertension contributed to better blood pressure (BP, mmHg) control in statin-treated than statin-eligible untreated adults in observational studies. METHODS: National Health and Nutrition Examination Surveys 2009-2020 data were analyzed for adults 21-75 years ( N  = 3814) with hypertension (BP ≥140/≥90 or treatment). The 2013 American College of Cardiology/American Heart Association Cholesterol Guideline defined statin eligibility. The main analysis compared BP values and hypertension awareness, treatment, and control in statin-treated and statin-eligible but untreated adults. Multivariable logistic regression was used to assess the association of statin therapy to hypertension control and the contribution of antihypertensive therapy to that relationship. RESULTS: Among adults with hypertension in 2009-2020, 30.3% were not statin-eligible, 36.9% were on statins, and 32.8% were statin-eligible but not on statins. Statin-treated adults were more likely to be aware of (93.4 vs. 80.6%) and treated (91.4 vs. 70.7%) for hypertension than statin-eligible adults not on statins. The statin-treated group had 8.3 mmHg lower SBP (130.3 vs. 138.6), and 22.8% greater control (<140/<90: 69.0 vs. 46.2%; all P values <0.001). The association between statin therapy and hypertension control [odds ratio 1.94 (95% confidence interval 1.53-2.47)] in multivariable logistic regression was not significant after also controlling for antihypertensive therapy [1.29 (0.96-1.73)]. CONCLUSION: Among adults with hypertension, statin-treated adults have lower BP and better control than statin-eligible untreated adults, which largely reflects differences in antihypertensive therapy.

Age and sex disparities in blood pressure control and therapeutic inertia: Impact of a quality improvement program.

Objective: Hypertension quality improvement programs reduce uncontrolled blood pressure (BP) but impact may differ by sex and age. Methods: This study examined uncontrolled BP, defined as a BP ≥ 140/90 mmHg, and therapeutic inertia, defined as absence of medication initiation or escalation during visits with uncontrolled BP, by sex and by age group (19-40, 41-65, 66-75, and 76+ years) during a 12 month follow-up period among 21, 861 patients with hypertension and ≥ two visits in primary care clinics enrolled in the American Medical Association (AMA) Measure Accurately, Act Rapidly, and Partner with Patients (MAP) BP hypertension quality improvement program. Results: The mean age was 64.8 years (standard deviation [SD 12.8]) and ranged from 19 to 87 years; 53.6% were female. In age groups 19-40, 41-65, 66-75, 76-87 years, uncontrolled BP at the first clinic visit was present in 51.5%, 42.5%, 37.5% and 36.6% of males, respectively, and in 40.0%, 38.0%, 36.0% and 39.6% of females, respectively. Based on vital signs at the first vs. last clinic visit, the proportion of patients with uncontrolled BP in age groups 19-40, 41-65, 66-75 years declined by 19.4%, 13.5%, 10.1% and 8.7% in males, respectively, and 14.4%, 12.5%, 9.3%, and 8.4%, among females, respectively. Therapeutic inertia ranged from 66.5% and 75.9% of clinic visits among males and females age 19-40 years, to 85.6% and 84.9% of clinic visits among males and females age 76-87 years, respectively. The proportion of clinic visits with therapeutic inertia was lower among males vs. females across all age groups until age 76-87 years. Conclusion: A quality improvement program improves BP control but declines in uncontrolled BP are larger and therapeutic inertia is lower for younger vs. older age groups and for males vs. females. More interventions are needed to reduce sex and age disparities in hypertension management.