chapter 1 yang jadi
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INTRODUCTION
The antihypertensive are a class of drugs that are used to treat hypertension (high blood
pressure). Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the
risk of stroke by 34%, of ischemic heart disease by 21%, and reduce the likelihood of dementia,
heart failure, and mortality from cardiovascular disease. There are many classes of
antihypertensive, which lower blood pressure by different means; among the most important and
most widely used are the thiazide diuretics, the ACE inhibitors, the calcium channel blockers, the
beta blockers, and the angiotensin II receptor antagonists or ARBs.
Which type of medication to use initially for hypertension has been the subject of several large
studies and resulting National Guidelines. The fundamental goal of treatment should be the
prevention of the important endpoints of hypertension, such as heart attack, stroke and heart
failure. Patient age, associated clinical conditions and end-organ damage also play a part in
determining dosage and type of medication administered. The several classes of antihypertensive
differ in side effect profiles, ability to prevent endpoints, and cost. The choice of more expensive
agents, where cheaper ones would be equally effective, may have negative impacts on national
healthcare budget.
Antihypertensive therapy has been shown to reduce morbidity and mortality in older patients
with elevated systolic or diastolic blood pressures. This benefit appears to persist in patients
older than 80 years, but less than one third of older patients have adequate blood pressure
control. Systolic blood pressure is the most important predictor of cardiovascular disease. Blood
pressure measurement in older persons should include an evaluation for orthostatic hypotension.
Low-dose thiazide diuretics remain first-line therapy for older patients. Beta-blockers,
angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, and calcium channel
blockers are second-line medications that should be selected based on comorbidities and risk
factors.
Multiple studies have demonstrated that isolated elevated systolic blood pressure is more
prevalent in older persons because of increased large-artery stiffness. Systolic blood pressure
should be the primary target for the diagnosis and care of older persons with hypertension. Blood
pressure should be based on the average of two or more properly measured readings, in the
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sitting position, on two or more office visits. Accurate measurement of blood pressure in older
persons can be challenging because of cardiovascular changes associated with aging.
Age-related may lead to orthostatic hypotension, so blood pressure should be monitored in the
sitting and standing positions.
Measurements may be inaccurate because of pseudo hypertension, in which the blood pressure
cuff fails to compress a calcified artery. This should be considered in patients with resistant
hypertension (i.e., patients with inadequate blood pressure control despite treatment with an
appropriate three drug regimen), especially if these patients have symptoms of orthostatic
hypotension. Resistant hypertension may be caused by white-coat hypertension, and therefore
may be transient. Ambulatory blood pressure monitoring may be useful in documenting white-
coat hypertension and verifying hypotensive symptoms in patients receiving antihypertensive
agents. One study found that ambulatory blood pressure monitoring was a better predictor of
cardiovascular risk than conventional measurements in an older population with isolated systolic
hypertension.
The goal blood pressure recommended for hypertensive patient is less than 140/90 mm Hg (less
than 130/80 mm Hg in patients with diabetes mellitus or chronic kidney disease), because
achieving these values has been associated with a decrease in cardiovascular disease
complications. Although most data support the treatment of older patients with stage 2 isolated
systolic hypertension (systolic blood pressure higher than 160 mm Hg), recommending in
treating older patients with stage 1 isolated systolic hypertension (systolic blood pressure 140 to
159 mm Hg) equally aggressively. Observational studies and secondary analyses of randomized
controlled trials have documented a relationship between a low diastolic blood pressure.
Measuring blood pressure: mercury sphygmomanometers
Use the correct size cuff. The cuff width should be >40% of the arm circumference. The bladder
should be centered over the brachial artery. And the cuff applied snugly. Support the arm in a
horizontal position at mid-sternal level.
Inflate the cuff while palpating the brachial artery, until the pulse disappears. This provides an
estimate of systolic pressure.
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Inflates the cuff until 30mmHg above systolic pressure, then place stethoscope over the brachial
artery. Deflate the cuff at 2 mmHg/second.
Systolic pressure: appearance of sustained repetitive tapping sounds ( Korotkoff I).
Diastolic pressure: usually the disappearance of sounds (Korotkoff V). However in some
individual example like pregnant women sound are present until zero point. In this case, the
muffling of sound, Korotkoff IV, should be used.
There are a variety of drugs for antihypertensive treatment but which type of antihypertensive
that suitable in elderly for constant and longer period time of use. Some antihypertensive drugs
cannot be chose because of several side effects and their inefficacy for elderly. The correct
choice of drugs not just can treat older patient but also can prevent any further complication that
caused by uncontrolled blood pressure. Perhaps this research can achieve its target in deciding
the correct drugs for the treatment which not only can control the blood pressure level but also
can give the most comfort to the users especially in the elderly.
Special Considerations When Treating Hypertension
Recommendations for treating hypertension are similar in the general population and older
persons. The key points include:
(1) Treat isolated systolic blood pressure;
(2) Thiazide diuretics should be first line treatment
(3) Second-line treatment should be based on comorbidities and risk factors i.e; such as calcium
channel blocker or beta blocker.
(4) Patients with systolic blood pressure higher than 160 mm Hg or diastolic blood pressure
higher than 100 mm Hg usually will require two or more agents to reach goal.
(5) Treatment should be initiated with a low dose of the chosen antihypertensive agent, and
titrated slowly to minimize side effects such as orthostatic hypotension and weight loss and
sodium reduction have been shown to be feasible and effective interventions in older patients
with hypertension.
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STEPS Comparison of Antihypertensive Agents in Older Persons
Thiazide Diuretics :
Contra Indication: Electrolyte disturbance, especially hypokalemia Acute renal insufficiency
and dehydration. Drug interaction: digoxin and NSAIDS
Side Effect : Orthostatis and sexual dysfunction
Efficacy : Hypertension, isolated systolic hypertension, heart failure, diabetes, patients
at high risk for cardiovascular disease, recurrent stroke prevention
Simplicity : once daily
Calcium Channel Blocker :
Contraindication: Nondihydropyridines: atrioventricular block, bradycardia Dihydropyridines:
hypotension, reflex tachycardia,. Drug interactions: cyclosporine and grape fruit juice.
Side Effect : Peripheral edema, constipation, gingival hyperplasia.
Efficacy : Hypertension, diabetes, patients at high risk for cardiovascular disease.
Symptom control in chronic stable angina, ischemic heart disease, and atrial fibrillation
Simplicity : one to two times daily.
Beta Blockers:
Contra Indication : Bronchospasm Drug interactions: digoxin, diltiazem verapamil
Side Effect : Sedation, depression and sexual dysfunction
Efficacy : Hypertension, heart failure, post myocardial infarction, patients at high risk
for cardiovascular disease
Simplicity : one to two times daily
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Specific Agents
3.1 Thiazide Diuretics.
Several issues should be considered when using thiazide diuretics in older patients. Older
patients are more prone to thiazide-induced dehydration and orthostatic changes, so physicians
should check for orthostatic hypotension and suggest measures for preventing falls. Serum
electrolyte levels should be monitored frequently, and hypokalemia should be treated with
potassium administration, the addition of a potassium-sparing diuretic like spironolactone or the
use of a combination product such as triamterene/hydrochlorothiazide. This is important because
in the SHEP trial, older patients with potassium levels less than 3.5 mg per dL (0.9 mmol per L)
lost the cardiovascular protective benefit from the thiazide.
Although poorly studied, their efficacy may be decreased in patients with chronic kidney disease.
Uric acid and thiazides compete for excretion at the level of the renal tubule, so caution is
necessary in patients with a history of gout. Although thiazide diuretics have been reported to
affect serum glucose and lipid levels adversely, there is a decreased incidence of metabolic
abnormalities and associated clinical outcomes with low-dose therapy. Patients taking digoxin
and a thiazide diuretic may be at increased risk of digoxin toxicity because of diuretic induced
electrolyte disturbances. Non-steroidal anti-inflammatory drugs (NSAID) may reduce diuretic
and antihypertensive effects of thiazides.
Mechanism of action:
Thiazides inhibit NaCl reabsorption from the luminal side of epithelial cells in the DCT by
blocking the Na+/Cl- transporter (NCC). Thiazides lowering blood pressure primarily by
depleting body sodium stores. Initially, thiazides reduce blood pressure by reducing blood
volume and cardiac output; peripheral vascular resistance may increase. After 6-8 weeks, cardiac
output return toward normal while peripheral vascular resistance declines. Sodium is believed to
contribute to vascular resistance by increasing vessel stiffness and neural reactivity, possibly
related to increase sodium-calcium exchange with a resultant increase in intracellular calcium.
These effects are reversed by thiazides or sodium restriction.
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3.2 Calcium Channel Blockers
Calcium channel blockers prevent calcium from entering the cells of the arterial vasculature and
cause dilation in the coronary arteries and periphery. There are two classes of calcium channel
blockersdihydropyridines and nondihydropyridinesand both are effective treatments for
hypertension in older patients. As a group, calcium channel blockers have compelling indications
for use in patients at high risk for coronary disease and those with diabetes mellitus
.Nondihydropyridines (e.g., diltiazem, verapamil) exhibit negative inotropic and chronotropic
effects, making them beneficial in atrial fibrillation and supraventricular tachyarrythmias.
Dihydropyridines (i.e., amlodipine) are safe for use in patients with heart failure, hypertension,
or chronic stable angina.
Short-acting agents are not recommended in clinical practice. In comparison with other
antihypertensives, systematic reviews generally have found calcium channel blockers to be
equivalent or inferior to other antihypertensive agents. In the Antihypertensive and Lipid-
Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), amlodipine was found to be
inferior to chlorthalidone in preventing heart failurerelated events. Calcium channel blockers
have been found to be effective in salt sensitive hypertensive patients, such as blacks and older
persons. Interactions with other drugs and food are reported with some calcium channel blockers.
In particular, grapefruit juice may increase the bioavailability of felodipine significantly leading
to profound hypotension, and diltiazem can inhibit the metabolism of cyclosporine in transplant
patients leading to cyclosporine toxicity. The dihydropyridines, especially nifedipine, can cause
orthostatic hypotension, peripheral edema, and gingival hyperplasia. These are particularly
problematic in older patients. Verapamil often is a cause of constipation in older persons.
Mechanism of action:
Calcium channel blocker can reduce peripheral resistance and blood pressure. The mechanism of
action in hypertension is inhibition of calcium influx into arterial smooth muscle cells. These
drugs like verapamil, diltiazem and dihydropyridine family are equally effective in lowering
blood pressure. Doses of calcium channel blocker used in treating hypertension are similar to
those used in treating angina. However short acting dihydropyridines not recommended to be
used in hypertension because of the cardiac effect that can lead to myocardial infarction.
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3.3 Beta Blockers.
Beta blockers reduce mortality and morbidity in older patients with hypertension. Additional
indications for use of beta blockers in older persons include high risk for coronary disease and
prevention of a second myocardial infarction and heart failure. Despite the pharmacokinetic and
pharmacodynamics differences among various beta blockers, they have similar clinical
antihypertensive efficacy. Beta blockers that are lipophilic (e.g., propranolol) cross the blood-
brain barrier, possibly causing more sedation, depression, and sexual dysfunction in older
patients. Beta blockers are contraindicated in patients with severe reactive airway disease,
especially the nonselective agents (i.e., propranolol).
Particularly in older patients, beta blockers as a class can cause bradycardia, conduction
abnormalities, and development of heart failure if started too aggressively in patients with
preexisting left ventricular dysfunction. Beta blockers should be tapered before discontinuation
to minimize the risk of reflex tachycardia. The effects of beta blockers on lipid profiles are
transient and of little clinical significance. Beta blockers should be used with caution in
combination with other negative chronotropes, such as diltiazem, verapamil, or digoxin.
Mechanism of action:
Propranolols efficacy in treating hypertension as well as mast of its toxic effects result from
nonselective beta blockade. Propranolol decrease blood pressure primarily as a result of a
decrease in cardiac output. Other beta blocker drugs may decrease cardiac output or decrease
peripheral vascular resistance to various degrees, depending on cardioselectivity and partial
agonist activities. Beta blockade in brain, kidney and peripheral adrenergic neurons has been
proposed as contributing to the antihypertensive effect observed with Beta receptor blocker. In
spite of confliction, some of the drugs did not cross the blood brain barrier thus give ineffective
for the hypertensive treatment. Propranolol inhibits the stimulation of renin production by
catecholamine. It is likely that propranolols effect is due in part to depression of the renin-
angiotensin-aldosterone system. Although more effective in patient with high plasma renin level,
propranolol also reduces blood pressure in hypertensive patient with normal or lower renin
activity such as in elderly. Beta blocker also might act at the peripheral presynaptic beta
adrenoreceptors to reduce sympathetic vasoconstrictor nerve activity. In mild to moderate
hypertension, propranolol produces significant reduction in blood pressure without postural
hypotension.
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SUMMARY
As being discussed before, thiazide diuretics remain as the first line treatment in treating elderly
with hypertension, followed by calcium channel blocker or beta blocker. Most of the time ACE
inhibitor did not being chose because of inefficacy in treating elderly that having lower level of
renin activities, besides the side effect of ACE inhibitors that can affect the kidney function.
However thiazide diuretics, calcium channel blocker and beta blocker can give variety side effect
in long period of used. The most common adverse effect of diuretics is potassium depletion
except for potassium-sparing diuretics. Although mild degree of hypokalemia are tolerated well
by many patients, hypokalemia may be hazardous in person taking digitalis, those who have
chronic arrhythmias, or those with acute myocardial infarction or left ventricular dysfunction.
Diuretics may also cause magnesium depletion, impair glucose tolerance, and increase serum
lipid concentration. Diuretics can increase uric acid concentration and may precipitate gout. The
toxicity for calcium channel blocker are direct extension of their therapeutic action. Excessive
inhibition of calcium influx can cause serious cardiac depression, including cardiac arrest,
bradycardia, atrioventricular block, and heart failure. Minor toxicity includes flushing, dizziness,
nausea, constipation, and peripheral edema. The principal toxicities for beta blocker drugs results
from blockade of cardiac, vascular, or bronchial beta receptors especially propranolol. The most
important of these predictable extensions of the beta blocking action occur in patient with
bradycardia or cardiac conduction disease, asthma, peripheral vascular insufficiency, and
diabetes. For some beta blocker example like propranolol the discontinuation after prolonged
regular used can create a withdrawal syndrome, manifested by nervousness, tachycardia,
increased intensity of angina, or increase of blood pressure. Myocardial infarction has been
reported in a few patients.
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REFERENCES
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december 2004. 193-196
3) T W Auyeung, MB, Geriatri Unit. Tuen Mun Hospital, Tuen Muen, New Territories. HypertensionIn Geriatrics. December 1996. Pg 638- 644
4) Marvin Moser, MD; William C. Cushman, MD; Michael G. Ziegler, MD. The Treatment ofHypertensioninthe Elderly. The Journal of Clinical Hypertension. Vol. 10 no> 1 January 2008. Pg
58-68
5) Murray longmore, IanB. Wilkinson, Edward H. Davidson, Alexander Foulkes, Ahmad R. Mafi. 8edition. Oxford University Press. 2010. Pg 132- 135
6) Rene R. Wenzel. Renal Protection in Hypertensive Patients: Selection of AntihypertensiveTherapy. 2005. 66 suppl. 2:29-39.