2024-03-01 08:12:08
In an aging population, the management of high blood pressure can be complex. Should we prioritize achieving functional goals or quality of life in a person whose functioning is very impaired? This is the question discussed in the pages of Medscape.com by Dr. Eugene Yang, president of the Cardiovascular Disease Prevention Council of the American College of Cardiology (ACC).
United States – Dr. Eugene Yang is often faced with the complexity of evaluating the management of high blood pressure, particularly when it comes to knowing when to reduce antihypertensive medications or stop them altogether.
It takes into account the patient’s comorbidities, symptom severity, and risk factors for heart attack and stroke, among other variables. Recognizing age as a determinant of quality of life is at the heart of this calculation, according to Dr. Yang, chair of the Cardiovascular Disease Prevention Council of the American College of Cardiology.
In older adults, for example, differences in functional status can be striking. An octogenarian may be bedridden due to severe dementia, while another may play pickleball three times a week [le pickelball est un sport de raquette qui combine des éléments du tennis, du badminton et du tennis de table, NDLR].
“This happens to me all the time in my office. I have patients with reduced mobility and severe memory loss: their functionality is very low,” said Dr. Yang. “In the case of a patient whose life expectancy is limited, whose functions or memory are limited, the objective is not to prolong life but for them to be able to live more comfortably. »
Knowing when to prescribe blood pressure medications is essential. For some, lifestyle changes may be enough. For others, especially older patients, their comorbidities and medication regimen must be considered.
“It is recognized that we need to move to a new paradigm in which we need to decide when to be aggressive and when to be less aggressive,” Yang said.
The American Heart Association and the American College of Cardiology have published their latest recommendations in 2017, changing the diagnostic threshold from 140/90 to 130/80 mmHg. These scholarly societies have not published any updates since then, leaving primary care physicians and their colleagues to navigate this territory cautiously, balancing the benefits of reducing hypertension and the potential harms of insufficient treatment. .
However, it seems necessary to update these recommendations by taking into account the age of patients, a factor absent from current guidelines on the management of hypertension from American government and medical organizations. And this, while the European Society of Hypertension guidelines updated June 2023, recommends that adults over 80 or those classified as frail be treated when their systolic blood pressure exceeds 160.
High blood pressure does not always manifest itself with visible symptoms and patients do not always come to the office in time to benefit from early intervention. It can pave the way for serious health complications, including heart failure, stroke, kidney disease, heart attacks and, ultimately, death.
Gloomy statistics reveal its results: in 2021, hypertension was the primary or contributing cause of nearly 700,000 deaths in the United States, and nearly half of adults are affected. Only about one in four adults controls their hypertension.
New study sheds light
A recent study may provide much-needed clarity to primary care clinicians: tapering of blood pressure medications may not have the feared swinging effects on blood pressure as previously feared.
Researchers in Seoul, South Korea, analyzed the blood pressure of 83 patients with hypertension – average age 66 – who reduced their medication use. They found that reducing medication use was associated with an increase in blood pressure readings taken at home, but not in the office, and did not appear to influence blood pressure variability.
Research shows that variability in Systolic blood pressure is an important predictor of cardiovascular outcomesas well as risk of dementia.
Personalized approaches
When developing the treatment plan for a given patient, clinicians must consider the various factors at play, including other health conditions.
Obesity, diabetes and hyperlipidemia are among the common comorbidities often associated with hypertension. Because these additional conditions come with more symptoms to consider and various medications, these health profiles require personalized approaches to hypertension treatment.
Clinicians can recommend lifestyle changes, such as a change in diet and regular physical activity, as a first step for patients diagnosed with grade 1 hypertension, but who do not suffer from cardiovascular disease, chronic renal failure, diabetes or organ damage. However, in cases where comorbidities are present or hypertension is grade 2, clinicians should turn to medications for management, according to the International Hypertension Society.
Patients with heart failure and reduced ejection fraction face unique challenges, according to Dr. Keith C. Ferdinand, Gereld S. Berenson Professor of Preventive Cardiology at Tulane School of Medicine (News -Orléans, United States).
“Patients with heart disease are given a device to measure their blood pressure, but medication is often needed to prevent heart failure from getting worse,” said Dr. Ferdinand.
The latter insisted on the importance of continued treatment to avoid further cardiac deterioration. It advocates a cautious approach, emphasizing the continued use of medications such as sacubitril/valsartan, beta-blockers or sodium glucose co-transporter 2 (SGLT2) inhibitors, to prevent progression of the disease. heart failure.
Patients should also self-monitor their blood pressure at home and learn how to properly adjust a cuff to get accurate readings. This approach allows patients to actively engage in managing their health and detect any fluctuations that warrant special attention, he added.
The different medications for hypertension
The use of any of the five major classes of medications – angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, beta blockers, calcium channel blockers, and thiazide or thiazide-like diuretics – and their combinations is recommended as a basis for antihypertensive treatment strategies.
According to Dr. Yang, primary care clinicians should be careful to taper doses slowly. Centrally acting medications such as clonidine and beta blockers ultimately reduce heart rate and dilate blood vessels.
Decreasing the dose too quickly can create a rebound effect, and medications should be reduced gradually and monitored closely over several weeks, Dr. Yang said.
“You can’t stop some medications abruptly, you have to wean them off slowly,” because patients risk getting high blood pressure again, Dr. Yang added.
This article was translated from Medscape.com using multiple editorial tools, including AI, in the process. The content was reviewed by the editorial staff before publication.
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