Angiotensin-converting enzyme inhibitors This class of medication (eg, lisinopril 10–40 mg/day or equivalent), shown to be effective in the lowering of BP in the elderly, is also generally well tolerated and represents an acceptable alternative first-line therapy or in combination with a thiazide-type diuretic. These agents possess a favorable safety profile and lack significant CNS or metabolic side effects. In particular, the ACEIs have shown significant benefits in patients with diabetes (particularly with coexistent microalbuminuria) and those with left ventricular systolic dysfunction. In several clinical conditions, this class is associated with preservation of renal function. Generalized side effects include cough, angioedema, hyperkalemia (particularly in the setting of renal insufficiency or in combination with nonsteroidal anti-inflammatory drugs or potassiumsparing diuretics), and acute renal failure in patients with significant bilateral renal artery stenosis. These agents are contraindicated in pregnancy.
แองจิโอเทนซินแปลงสารยับยั้งเอนไซม์ระดับของยา ( เช่น ไล โนพริล 10 – 40 มิลลิกรัมต่อวัน หรือเทียบเท่า ) แสดงผลในการลดความดันโลหิตในผู้สูงอายุ คือ โดยทั่วไปแล้วการยอมรับและแสดงถึงการยอมรับการรักษาทางเลือกที่ 2 หรือรวมกันกับไทอาไซด์ประเภท ขับปัสสาวะตัวแทนเหล่านี้มีความปลอดภัยและที่สำคัญไม่มีโปรไฟล์อันเกี่ยวกับการเผาผลาญอาหารหรือผลข้างเคียง โดยเฉพาะอย่างยิ่ง aceis ได้แสดงประโยชน์ที่สำคัญในผู้ป่วยโรคเบาหวาน ( โดยเฉพาะอย่างยิ่งกับ coexistent โรคไต ) และผู้ที่มีหัวใจห้องล่างซ้ายบีบตัวผิดปกติ ในเงื่อนไขทางคลินิกหลาย ระดับนี้จะเกี่ยวข้องกับการดูแลรักษาการทำงานของไตผลข้างเคียงทั่วไป ได้แก่ ไอ ก่อนอาหารเย็น ( โดยเฉพาะในภาวะโพแทสเซียมในเลือดสูง , การตั้งค่าของไตไม่เพียงพอหรือใช้ร่วมกับยาต้านการอักเสบหรือ potassiumsparing diuretics ) และไตวายเฉียบพลันในผู้ป่วยที่มีระดับทวิภาคีลัตเวีย . ตัวแทนเหล่านี้เป็น contraindicated ในการตั้งครรภ์
Angiotensin receptor blockers To date, there are no randomized controlled trials comparing ARBs with diuretics and their effects on treatment outcomes in the elderly. A single meta-analysis has suggested that therapy with diuretics is superior to that with ARBs for most outcomes. As a result, this class is not generally recommended as first-line therapy in uncomplicated HTN. Rather, they should be considered in those patients with diabetes, CHF, or chronic kidney disease who are intolerant of ACEIs. Angioedema is considered rare with ARBs and they are not a cause of cough.
Calcium channel antagonists Although all three chemical classes of CCAs have shown effectiveness in lowering BP in the older hypertensive patient, it is the long-acting dihydropyridine class that has been the most widely studied. Significant reductions in stroke risk in older hypertensive patients were demonstrated in the Systolic Hypertension in Europe23 and China Trials.24 Results from patients with very high cardiac risk enrolled in the Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial demonstrated the superiority of an ACEI-CCA (amlodipine) combination over an ACE-thiazide combination with regard to a decrease in cardiovascular events despite comparable BP-lowering effects.25 As a result of age-related pharmacokinetic changes (decreased clearance and increased plasma levels), lower CCA dosages should be used in the elderly. It should be emphasized that the longacting formulations are preferred, and that there is no role for short-acting CCAs in the treatment of HTN due to their propensity to lower SBP rapidly. Side effects include headache, lower extremity edema, gingival hyperplasia, worsening of gastroesophageal reflux symptoms due to relaxation of the lower esophageal sphincter, and constipation.
Beta receptor antagonists Review of data from randomized controlled trials has questioned the efficacy of beta-receptor antagonists in the treatment of older individuals with HTN. These agents appear to be less effective than low-dose thiazide diuretics with regard to improving BP and cardiovascular outcomes as initial therapy, and are more likely to be discontinued due to adverse side effects. As a result, this class is designated as a second-line therapy by JNC 7 and should not be considered as first-line in uncomplicated HTN in the elderly. Clearly, these agents are indicated in the older HTN population with certain comorbidities, such as symptomatic CAD, in secondary prevention after myocardial infarction, and in some patients with systolic dysfunction.
Alpha receptor antagonists Although this class has been demonstrated to reduce peripheral vascular resistance and lower BP, the development of symptomatic postural hypotension has severely limited their utility, particularly in the elderly. In addition, data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) showed that subjects randomized to doxazosin had a 2-fold higher risk of hospitalization for CHF compared with those randomized to the diuretic arm.21 These medications may be considered as additional therapy, particularly in older hypertensive men with benign prostatic hypertrophy.
Aldosterone antagonists Initially developed as therapy for cirrhosis and primary hyperaldosteronism, and later as additional agents in the treatment of CHF, aldosterone antagonists may prove useful as first-line agents in the elderly with uncomplicated HTN. As with thiazide-type diuretics, the aldosterone antagonists preferentially lower SBP. In addition, this class antagonizes aldosterone’s metabolic effects of increasing sodium resorption, altering renal hemodynamics, and increasing afterload and vascular stiffness, all of which are important pathophysiologic characteristics of geriatric HTN.
Follow-up visits Follow-up visit frequency is based on the level of HTN at presentation and for most patients (except those with SBP . 180 mmHg), a visit frequency of once every 1–2 months for dosage adjustment is appropriate. Achieving target BP levels rapidly (except in cases of hypertensive emergencies) is unnecessary and should be avoided because overtreatment may result in decreased cerebral and coronary perfusion, and subsequent postural or postprandial hypotension. At each visit, both supine and standing BPs should be determined. Adjustments to therapy may need to be based on standing values if postural hypotension is present. Before instituting an increase in dosage or an additional agent, the patient’s adherence to therapy should be thoroughly assessed. The use of medications that can worsen BP control (eg, nonsteroidal anti-inflammatory drugs, including Cox-2 agents, and corticosteroids) should also be reviewed. If, after performing the above review, a patient’s BP is still not at target, then a careful increase in dosage, addition of another agent (thiazide if not already being used and renal function is appropriate with a calculated creatinine clearance of .30–40 mL/min), or switching to another class of medication can be considered. Continuing efforts at lifestyle modifications should be re-emphasized, along with counseling that several months may be needed to achieve the target value. In general, target BPs are the same as those in a younger population, and are outlined in JNC 7. Provided there is no evidence for a significant orthostatic drop in SBP, a goal of ,140/90 mmHg is reasonable. In patients with diabetes mellitus and/or CKD the goal becomes ,130/80 mmHg. As with the younger hypertensive population, if target BP is not achieved on a 3-drug regimen with documented compliance, then an evaluation for resistant or secondary HTN (renovascular, primary hyperaldosteronism, obstructive sleep apnea, renal artery stenosis, pheochromocytoma, Cushing’s) should be undertaken. Finally, after more than a year of stable BP control at target levels, consideration can be given to a step-down in therapy, especially in patients who have been successful in lifestyle modifications. Nevertheless, dosages should be decreased slowly and cautiously while maintaining close BP monitoring.
Hypertensive emergencies and urgencies By definition, a hypertensive emergency involves an elevated BP (usually .180 mmHg systolic) in association with signs and/or symptoms of target organ damage. The resultant vascular compromise of the affected organ may include hypertensive encephalopathy, acute heart failure with pulmonary edema (flash pulmonary edema), dissecting aortic aneurysm, acute renal failure, and unstable angina. Management requires acute hospitalization for administration of parenteral antihypertensives, with continuous BP monitoring to lower BP rapidly yet not initially to a normal level. Normalization of BP immediately can lead to coronary and cerebral hypoperfusion syndromes. Therefore, BP should be lowered no more than 25% in the first 2 hours, with gradual lowering over the first 6 hours to a target of less than 160/100 mmHg. In comparison with emergencies, hypertensive urgencies are situations requiring BP lowering within 24 hours in order to avoid target organ damage. Again, gradual lowering of BP is indicated, and can be obtained by administering oral agents in the setting of close follow-up.
Conclusion In order to avoid the aforementioned hyperten