EYE ON THE ELDERLY—Hypertension care: Striking the proper balance
How aggressive should treatment be? Which drug combinations should raise red flags? Which drugs should you avoid entirely? Here’s how to safely customize your care.
Elderly patients who take NSAIDs while on ACE inhibitors are at particular risk for acute renal failure; reviews of iatrogenic acute renal failure in the elderly have shown that most cases are related to the concurrent use of these medications.36,37 This is yet another reason to avoid giving NSAIDs to elderly patients with hypertension, particularly if they’re taking diuretics or ACE inhibitors.
Beware of ACE inhibitor-ARB combinations. The American College of Cardiology and the American Heart Association recommend substituting an ARB if side effects from an ACE inhibitor occur in patients with heart failure, but extreme caution is required if the patient experienced ACE inhibitor-associated angioedema.38 TRANSCEND, a randomized controlled trial of almost 6000 patients, specifically studied the use of ARBs in patients unable to tolerate ACE inhibitors and concluded that they can be safely given to patients who had side effects from ACE inhibitors.39
Since ACE inhibitors and ARBs affect the renin-angiotensin-aldosterone pathway at different points, there has been interest in the effectiveness of combining these agents. The CHARM-Added trial found that the combination of these agents reduced both cardiovascular events and mortality in patients with heart failure.40
Combining ACE inhibitors and ARBs in patients without heart failure was evaluated in the ONTARGET trial. While the combination treatment group had a greater reduction in blood pressure, there was no significant cardiovascular benefit over patients who were on ACE inhibitors alone. But there was an increase in hypotension, syncope, and renal dysfunction among those in the combination treatment group, all of which are significant concerns in the elderly. The authors concluded that the ACE inhibitor-ARB combination should not be used in patients who do not have heart failure.41
Calcium channel blockers. CCBs block the entrance of calcium into vascular cells, producing dilation in the coronary arteries and peripheral vasculature, and are effective in the treatment of hypertension in elderly patients.42 Nondihydropyridine CCBs (diltiazem and verapamil) are useful in patients with atrial fibrillation and supraventricular tachycardia because of their negative chronotropic effects.2 And African American patients respond better to CCBs—with a greater reduction in blood pressure and cardiovascular complications—than to ACE inhibitors.2,25
Dihydropyridine CCBs (amlodipine and long-acting felodipine and nifedipine) are safe in patients with heart failure or chronic stable angina,43 but short-acting nifedipine has been found to increase the risk of mortality.44
Dihydropyridine CCBs have been reported to cause peripheral edema in 7% to 8% of patients taking long-acting nifedipine and up to 16% of elderly patient taking amlodipine.45 Verapamil has the highest incidence of constipation, and should be avoided in elderly patients.2
TABLE
Which drugs, for which patients?2
| DRUG CLASS* | INDICATIONS | CONSIDERATIONS |
|---|---|---|
| ACE inhibitors | Heart failure, post-MI, diabetes, high risk for CAD, chronic kidney disease, recurrent stroke prevention | Avoid concurrent use of ARBs in patients without heart failure. Avoid concurrent use of NSAIDs. If a second drug is needed, add a thiazide diuretic or CCB. |
| ARBs | Heart failure, diabetes, chronic kidney disease | Avoid concurrent use of ACE inhibitors in patients who don’t have heart failure. |
| Beta-blockers | Heart failure, post-MI, high risk for CAD, diabetes | Not recommended as first-line therapy for uncomplicated hypertension. |
| CCBs | High risk for CAD, diabetes | Avoid prescribing verapamil for elderly patients. |
| Thiazide diuretics | Heart failure, high risk for CAD, diabetes, recurrent stroke prevention | Avoid concurrent use of NSAIDs. Will not work with reduced GFR or hypokalemia. Use with caution in patients prone to orthostatic hypotension. |
| *Peripheral alpha-blockers, centrally acting alpha-agonists, and vasodilators should not be routinely used to treat hypertension in elderly patients. | ||
| ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CAD, coronary artery disease; CCB, calcium channel blocker; GFR, glomerular filtration rate; MI, myocardial infarction; NSAIDs, nonsteroidal anti-inflammatory drugs. | ||
Steer clear of these drugs
Significant side effects, including hypotension, sedation, depression, and dry mouth, limit the use of other antihypertensives, such as peripheral alpha blockers, centrally acting agents, and vasodilators, in elderly patients.2 In the ALLHAT trial, the alpha-blocker arm was stopped prematurely because of an increased rate of cardiovascular events and heart failure compared with the thiazide diuretic arm.25 That finding led to the recommendation that alpha-blockers not be used as first-line agents for treating hypertension.
Centrally acting alpha-agonists (clonidine, methyldopa, and reserpine) have a high incidence of sedation, dry mouth, and depression, and elderly patients are more likely to experience orthostatic hypotension and rebound hypertension if these agents are discontinued abruptly or doses are missed.2 Vasodilators, including minoxidil and hydralazine, cause sodium and fluid retention and reflex tachycardia.2 Because of their unfavorable side effects and lack of outcomes data, alpha-blockers, centrally acting alpha-agonists, and vasodilators should not be used routinely for the treatment of hypertension in elderly patients.
