Mr. RG is a 69-year-old asymptomatic black postal worker who walks four miles each day. He stopped smoking cigarettes one year ago. Because his fasting serum lipids six months ago showed a serum total cholesterol of 260 mg/dL, a serum low-density lipoprotein (LDL) cholesterol of 192 mg/dL, a serum high-density lipoprotein (HDL) cholesterol of 40 mg/dL, and serum triglycerides of 140 mg/dL, his physician prescribed rosuvastatin 40 mg daily as recommended by 2013 American College of Cardiology (ACC)/American Heart Association (AHA) lipid guidelines.1
His other laboratory data were normal, including a serum potassium of 4.5 meq/L, a fasting blood sugar of 86 mg/dL, and a serum creatinine of 1.0 mg/dL. His physical examination at that time was normal except for a blood pressure of 148/88 mm Hg and a left ventricular fourth heart sound. His body mass index was 24.5 kg/ m2. He was not on any medication that could cause hypertension. His father had died at age 54 years of a stroke associated with hypertension. His mother had died at age 62 years of a stroke associated with hypertension. A 12-lead electrocardiogram showed sinus rhythm and left ventricular hypertrophy. His physician did not prescribe antihypertensive medication consistent with recommendations in the 2013 Eighth Joint National Committee (JNC 8) guidelines.2
At this visit, his blood pressure was 148/88 mm Hg. His laboratory data were normal including a fasting serum total cholesterol of 166 mg/dL, a serum LDL cholesterol of 98 mg/dL, a serum HDL cholesterol of 44 mg/dL, and serum triglycerides of 120 mg/dL. A two-dimensional echocardiogram showed concentric left ventricular hypertrophy with a left ventricular mass index of 160 grams/m2.
Would this patient benefit from being treated with antihypertensive medication?
Show Answer
The correct answer is: B. Yes, this patient would benefit from antihypertensive medication.
The American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) 2011 expert consensus document on hypertension in the elderly developed in collaboration with the American Academy of Neurology, the American Geriatrics Society, the American Society for Preventive Cardiology, the American Society of Hypertension, the American Society of Nephrology, the Association of Black Cardiologists, and the European Society of Hypertension recommended that the systolic blood pressure (SBP) be lowered to <140 mm Hg in older persons younger than 80 years and to 140 to 145 mm Hg if tolerated in adults aged 80 years and older.3 These guidelines are strongly supported by clinical trial data, especially from the Systolic Hypertension in Elderly trial4-6 and from the Hypertension in the Very Elderly trial.7 The European Society of Hypertension/European Society of Cardiology 2013 guidelines for management of hypertension8 and the minority view from JNC 89 would also support a SBP of < 140 mm Hg in this person.
The REasons for Geographic and Racial Differences in Stroke (REGARDS) study is an observational study of stroke incidence of persons living in the stroke belt and stroke buckle regions of the United States.10 This study included 4,181 persons aged 55-64 years; 3,737 persons aged 65-74 years; and 1,839 patients aged 75 years and older (mean age 79.3 years) taking antihypertensive drugs. Median follow-up was 4.5 years for cardiovascular disease (coronary heart disease or stroke) and coronary heart disease, 5.7 years for stroke, and 6.0 years for all-cause mortality. We found that among older persons in this study taking antihypertensive medication, an SBP between 120 and 139 mm Hg was significantly associated with a lower risk for cardiovascular and all-cause mortality outcomes.10
Among 8,354 patients aged ≥60 years with coronary artery disease in the International Verapamil SR-Trandolapril Study (INVEST), a baseline SBP of ≥150 mm Hg, and 22,308 patient years of follow-up, 57% had an SBP <140 mm Hg, 21% had an SBP of 140 to 149 mm Hg, and 22% had an SBP of ≥150 mm Hg.11 The primary outcome of all-cause mortality, nonfatal myocardial infarction, or nonfatal stroke occurred in 9.36% of patients with an SBP <140 mm Hg, in 12.71% of patients with a SBP of 140-149 mm Hg, and in 21.3% of patients with an SBP ≥150 mm Hg (p<0.0001).11 Using propensity score analyses, compared with an SBP <140 mm Hg, an SBP of 140 to 149 mm Hg increased cardiovascular mortality 34% (p =0.04), total stroke 89% (p = 0.002), and nonfatal stroke 70% (p = 0.03).11 Compared with an SBP of <140 mm Hg, a SBP ≥150 mm Hg increased the primary outcome 82% (p <0.0001), all-cause mortality 60% (p<0.0001), cardiovascular mortality 218% (p<0.0001), and total stroke 283% (p<0.0001).11
Elderly persons are currently being undertreated for hypertension.3 If the JNC 8 panel recommendations are implemented, six million U.S. adults aged 60 years and older would not be eligible for antihypertensive drug therapy, and treatment intensity would be reduced for an additional 13.5 million older persons12, leading to the possibility of increased incidences of coronary events, stroke, heart failure, cardiovascular mortality, and other adverse events associated with poor control of hypertension.
References
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task force on Practice Guidelines. J Am Coll Cardiol 2014;63:2889-2934.
James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults. Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014;311:507-520.
Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol 2011;57:2037-2114.
SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991;265:3255-3264.
Perry HM Jr, Davis BR, Price TR, et al. Effect of treating isolated systolic hypertension on the risk of developing various types and subtypes of stroke. The Systolic Hypertension in the Elderly Program (SHEP). JAMA 2000;284:465-71.
Kostis JB, Davis BR, Cutler J, et al. Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA 1997;278:212-216.
Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Eng J Med 2008;358:1887-1898.
Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013;34:2159-2219.
Wright JT Jr, Fine LJ, Lackland DT, et al. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: the minority view. Ann Intern Med 2014;160:499-503.
Banach M, Bromfield S, Howard G, et al. Association of systolic blood pressure levels witcardiovascular events and all-cause mortality among older adults taking antihypertensive medication. Int J Cardiol 2014;176:219-226.
Bangalore S, Gong Y, Cooper-DeHoff RM, et al. 2014 Eighth Joint National Committee Panel recommendation for blood pressure targets revisited: results from the INVEST study. Am Coll Cardiol 2014;64:784-793.
Navar-Boggan AM, Pencina MJ, Williams K, et al. Proportion of US adults potentially affected by the 2014 hypertension guideline. JAMA 2014; 311:1424-1429.
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