Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC xvGXvq3Q4HcnKXTNkX3PmzL S0066-782X2016004800064 10.5935/abc.20160161 Diretrizes 7th Brazilian Guideline of Arterial Hypertension: Chapter 11 - Arterial Hypertension in the elderly Malachias MVB Ferreira S Filho Souza WKSB Ribeiro JM Miranda RD Jardim TSV 09 2016 107 3 Suppl 3 64 66 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Arterial hypertension is the most common chronic noncommunicable disease among the elderly.1 Its prevalence increases progressively with aging, AH being considered the major modifiable CVRF in the geriatric population.2 From the chronological viewpoint, elderly are individuals aged 65 years and older, living in developed countries, or individuals aged 60 years and older, living in developing countries.3 Within that age group, the very elderly are those in their eighth decade of life.4

There is a direct and linear relationship between BP and age, the prevalence of AH being greater than 60% in the age group older than 65 years.5 The Framingham Study has reported that 90% of the individuals with normal BP levels up to the age of 55 years will develop AH throughout life.6 In addition, that study has shown that both SBP and DBP, in both sexes, increase up to the age of 60 years, when DBP begins to decrease. Systolic BP, however, continues to increase linearly.7 The high prevalence of other concomitant RFs in the elderly and the consequent increase in the rate of CV events, in addition to the presence of comorbidities, compound the relevance of AH with aging.8

Vascular aging is the major aspect related to BP elevation in the elderly, characterized by changes in the microarchitecture of vascular walls, with consequent arterial stiffening. Large vessels, such as the aorta, lose their distensibility, and, although the precise mechanisms are not clear, they primarily involve structural changes in the media layer of the vessels, such as fracture due to elastin fatigue, collagen deposition and calcification, resulting in increased vascular diameter and IMT. Clinically, arterial wall stiffness is expressed as ISH, highly prevalent in the geriatric population, and considered an independent RF for the increase in CV morbidity and mortality.6,9-11 Other consequences are increased PWV and elevated PP.12

Changes inherent in aging determine different aspects in that population's BP, such as the higher frequency of auscultatory gap, which consists in the disappearance of the Korotkoff sounds during cuff deflation, usually between the end of phase I and beginning of phase II, resulting in falsely low SBP levels or falsely high DBP levels.

The wide BP variability in the elderly throughout 24 hours makes ABPM useful. Pseudohypertension, which is associated with the atherosclerotic process, can be detected by use of Osler's maneuver, that is, the radial artery remains palpable after cuff inflation at least 30 mm Hg above the reading of radial pulse disappearance. The higher occurrence of WCE and orthostatic and postprandial hypotension, and the presence of arrhythmias, such as atrial fibrillation, can hinder BP measurement.5

In the elderly, BP should be carefully measured from the technical viewpoint. The recommendations in Chapter 2 should be observed. In addition, it is necessary to assess the presence of postural hypotension, defined as a SBP reduction equal to or greater than 20 mm Hg, or any SBP decrease accompanied by clinical symptoms, and/or a 10-mmHg reduction in DBP when comparing, after 3 minutes, the BP levels obtained in the standing position with those obtained in the decubitus or sitting position.13

Previous diagnosis of AH is estimated to occur in 69% of the elderly with previous AMI, in 77% of those with history of stroke, and in 74% of those with history of HF. Although individuals in that age group are more aware of their condition and more frequently undergo treatment than middle-aged hypertensive individuals, the BP control rates among the elderly are lower, especially after the age of 80 years.6

In that age group, the treatment of AH has unequivocal benefits in reducing major CV events (AMI, stroke and HF). In addition, there is evidence that it might prevent dementia syndrome, an additional benefit that should be considered in the therapeutic decision.14-16

The NPT should be encouraged for all AH stages, based on the adoption of a healthy lifestyle. Although it might be simple and apparently easy to adopt, there is resistance, because it implies changes in old habits.

The main guidance on lifestyle changes that reduces BP and minimizes the CV risk are: physical activity; smoking cessation; loss of excessive body weight; and balanced diet (low-sodium, rich in fruits and vegetables).15,16 (GR: I; LE: A). This type of therapy is recommended for the elderly, whose diet is benefited from moderate salt reduction. This lifestyle change is one of the best studied interventions for BP control; the BP reduction is usually more significant when the oldest individuals are considered. The TONE study17 provides strong evidence about the effects of dietary sodium reduction for the elderly, with a 4.3-mmHg decrease in SBP and 2-mmHg decrease in DBP of individuals aged 60-80 years with BP < 145/85 mm Hg and daily sodium intake of 5 grams. The benefits of the regular physical activity for the elderly largely extrapolate BP reduction, because it provides better control of other comorbidities, reducing global CV risk. In addition, regular physical activity can reduce the risk of falls and depression, promoting the sensation of general well-being, improving self-esteem and quality of life.18

The patients should preferably be accompanied by a multidisciplinary team, and their families should be involved in the entire process, which increases adherence to treatment and its chances of success.5

The HYVET study19 has shown that active treatment significantly reduces the rates of HF and global mortality in that group. That study has compared active treatment (DIU: indapamide plus, if necessary, ACEI: perindopril) with placebo for octogenarians with initial SBP greater than 160 mm Hg. Target SBP was lower than 150 mm Hg, with a mean BP of 144 mm Hg. A limitation of that important study was that it included elderly usually healthier than the general population.

A large number of randomized studies on the antihypertensive treatment of elderly, including patients aged 80 years and older,19 has shown a reduction in CV events due to BP reduction; however, the mean SBP levels attained were never below 140 mm Hg.20 Two Japanese studies, comparing strict treatment with mild treatment, have not been able to show any benefit by reducing mean SBP levels to 136 and 137 as compared to 145 and 142, respectively.21,22 An analysis of the elderly subgroup in the FEVER study23 has shown a reduction in CV events with SBP lowering to below 140 mm Hg, as compared to 145 mm Hg.

There is strong evidence of the benefit of BP reduction with antihypertensive treatment in elderly aged 80 years and older. That advantage is limited to individuals with SBP ≥ 160 mm Hg, whose SBP was reduced to < 150 mm Hg (GR: I; LE: A).

For elderly under the age of 80 years, the antihypertensive treatment should be considered for those with SBP > 140 mm Hg, with target SBP < 140 mm Hg, if they have a good clinical condition and tolerate the treatment well.19-23 (GR: IIb; LE: C).

The randomized controlled studies showing the successful effects of antihypertensive treatment on the elderly have used different drug classes. There is evidence favoring DIUs,12,19,24-27 CCBs,28-30 ACEIs30 and ARBs.31 The three studies on ISH have used DIUs12 or CCBs.28,29

A prospective meta-analysis has compared the benefits of different therapeutic regimens for patients divided into two groups by age: under 65 years and 65 years and older. It has confirmed the lack of evidence that different drug classes have different effectiveness in younger or older patients.32

It is worth noting the likelihood of secondary AH in the elderly, whose most frequent causes are stenosis of the renal artery, obstructive sleep apnea-hypopnea syndrome (OSAHS), thyroid function changes, and use of drugs that can raise BP.24,33-35

Investigating secondary AH in the elderly might be necessary as part of the diagnosis.

Some features of the elderly are worth noting and require a differentiated approach. Elderly with multiple non-CV morbidities, frailty syndrome and/or dementia have an increased risk for functional dependence and death.36,37 Despite the trend towards slow BP reduction with the progression of those conditions and organic reserve decrease, some still have significantly high BP levels. Those elderly have not been included in randomized clinical trials, and, thus, should be assessed in an even more global way, carefully weighing the individual priorities and the risk/benefit of antihypertensive treatment, either pharmacological or not. The treatment target should be less strict, with special attention paid to the higher risk of postural and postprandial hypotension. In addition, frail elderly are at higher CV risk, and their treatment should be individualized.

In the presence of established CVD or TOD, they become a priority and should guide both the intensity of treatment, and the choice of drugs.38-40 (GR: IIa; LE: C).

References 1 Wolz M, Cutler J, Roccella EJ, Rohde F, Thom T, Burt V. Statement from the National High Blood Pressure Education Program: prevalence of hypertension. Am J Hypertens. 2000;13(1 Pt 1):103-4. Wolz M Cutler J Roccella EJ Rohde F Thom T Burt V Statement from the National High Blood Pressure Education Program: prevalence of hypertension Am J Hypertens 2000 13 1 Pt 1 103 104 2 Messerli FH, Mancia G, Conti CR, Hewkin AC, Kupfer S, Champion A, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med. 2006;144(12):884-93. Messerli FH Mancia G Conti CR Hewkin AC Kupfer S Champion A Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006 144 12 884 893 3 World Health Organization. (WHO). The uses of epidemiology in the study of the elderly. Geneva;1984. World Health Organization The uses of epidemiology in the study of the elderly Geneva 1984 4 Panagiotakos DB, Chrysohoou C, Siasos G, Zisimos K, Skoumas J, Pitsavos C, et al. Sociodemographic and lifestyle statistics of oldest old people (>80 years) living in Ikaria Island: the Ikaria study. Cardiol Res Pract. 2011;2011:679187. Panagiotakos DB Chrysohoou C Siasos G Zisimos K Skoumas J Pitsavos C Sociodemographic and lifestyle statistics of oldest old people (>80 years) living in Ikaria Island: the Ikaria study Cardiol Res Pract 2011 2011 679187 679187 5 Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. [VI Brazilian Guidelines on Hypertension]. Arq Bras Cardiol. 2010;95(1 Suppl):1-51. Erratum in: Arq Bras Cardiol. 2010;95(4):553.. Sociedade Brasileira de Cardiologia Sociedade Brasileira de Hipertensão Sociedade Brasileira de Nefrologia VI Brazilian Guidelines on Hypertension nullErratum in Arq Bras Cardiol. 2010;95(4):553 Arq Bras Cardiol 2010 95 1 Suppl 1 51 6 Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, et al; ACCF Task Force. 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. Circulation. 2011;123(21):2434-506. Erratum in: Circulation. 2011;123(21):e616. Circulation. 2011;124(5):e175. Aronow WS Fleg JL Pepine CJ Artinian NT Bakris G Brown AS ACCF Task Force 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 nullErratum in Circulation. 2011;123(21):e616 Circulation 2011 123 21 2434 2506 7 Kannel WB, Gordan T. 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Lewington S Clarke R Qizilbash N Peto R Collins R Prospective Studies Collaboration Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies Lancet nullErratum in Lancet. 2003;361(9362):1060 2002 360 9349 1903 1913 10 Chae CU, Pfeffer MA, Glynn RJ, Mitchell GF, Taylor JO, Hennekens CH. Increased pulse pressure and risk of heart failure in the elderly. JAMA. 1999;281(7):634-9. Chae CU Pfeffer MA Glynn RJ Mitchell GF Taylor JO Hennekens CH Increased pulse pressure and risk of heart failure in the elderly JAMA 1999 281 7 634 639 11 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). SHEP Cooperative Research Group. JAMA. 1991;265(24):3255-64. 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) SHEP Cooperative Research Group JAMA 1991 265 24 3255 3264 12 Dart AM, Kingwell BA. Pulse pressure - a review of mechanisms and clinical relevance. J Am Coll Cardiol. 2001;37(4):975-84. Dart AM Kingwell BA Pulse pressure - a review of mechanisms and clinical relevance J Am Coll Cardiol 2001 37 4 975 984 13 Lanier JB, Mote MB, Clay EC. Evaluation and management of orthostatic hypotension. Am Fam Physician. 2011;84(5):527-36. Lanier JB Mote MB Clay EC Evaluation and management of orthostatic hypotension Am Fam Physician 2011 84 5 527 536 14 Forette F, Seux ML, Staessen JA, Thijs L, Babarskiene MR, Babeanu S, et al; Systolic Hypertension in Europe Investigators. The prevention of dementia with antihypertensive treatment: new evidence from the Systolic Hypertension in Europe (Syst-Eur) Study. Arch Intern Med. 2002;162(18):2046-52. Erratum in: Arch Intern Med. 2003;163(2):241. Forette F Seux ML Staessen JA Thijs L Babarskiene MR Babeanu S Systolic Hypertension in Europe Investigators The prevention of dementia with antihypertensive treatment: new evidence from the Systolic Hypertension in Europe (Syst-Eur) Study nullErratum in Arch Intern Med. 2003;163(2):241 Arch Intern Med 2002 162 18 2046 2052 15 Tzourio C, Anderson C, Chapman N, Woodward M, Neal B, MacMahon S, et al; PROGRESS Collaborative Group. Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Arch Intern Med. 2003;163(9):1069-75. Tzourio C Anderson C Chapman N Woodward M Neal B MacMahon S PROGRESS Collaborative Group Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease Arch Intern Med 2003 163 9 1069 1075 16 Skoog I, Lithell H, Hansson L, Elmfeldt D, Hofman A, Olofsson B, et al; SCOPE Study Group. Effect of baseline cognitive function and antihypertensive treatment on cognitive and cardiovascular outcomes: Study on Cognition and Prognosis in the Elderly (SCOPE). Am J Hypertens. 2005;18(8):1052-9. Skoog I Lithell H Hansson L Elmfeldt D Hofman A Olofsson B SCOPE Study Group Effect of baseline cognitive function and antihypertensive treatment on cognitive and cardiovascular outcomes: Study on Cognition and Prognosis in the Elderly (SCOPE) Am J Hypertens 2005 18 8 1052 1059 17 Whelton PK, Apple LJ, Espeland MA, Applegate WB, Ettinger WH Jr, Kostis JB, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of non-pharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA.1998;279(11):839-46. Whelton PK Apple LJ Espeland MA Applegate WB Ettinger WH Jr Kostis JB Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of non-pharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group JAMA 1998 279 11 839 846 18 Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, et al; American College of Sports Medicine; American Heart Association. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1094-105. Nelson ME Rejeski WJ Blair SN Duncan PW Judge JO King AC American College of Sports MedicineAmerican Heart Association Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association Circulation 2007 116 9 1094 1105 19 Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, et al; HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358(18):1887-98. Beckett NS Peters R Fletcher AE Staessen JA Liu L Dumitrascu D HYVET Study Group Treatment of hypertension in patients 80 years of age or older N Engl J Med 2008 358 18 1887 1898 20 Zanchetti A, Grassi G, Mancia G. When should antihypertensive drug treatment be initiated and to what levels should systolic blood pressure be lowered? A critical reappraisal. J Hypertens. 2009;27(5):923-34. Zanchetti A Grassi G Mancia G When should antihypertensive drug treatment be initiated and to what levels should systolic blood pressure be lowered? A critical reappraisal J Hypertens 2009 27 5 923 934 21 JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res. 2008;31(12):2115-27. JATOS Study Group Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS) Hypertens Res 2008 31 12 2115 2127 22 Ogihara T, Saruta T, Rakugi H, Matsuoka H, Shimamoto K, Shimada K, et al; Valsartan in Elderly Isolated Systolic Hypertension Study Group. Target blood pressure for treatment of isolated systolic hypertension in the elderly: Valsartan in Elderly Isolated Systolic Hypertension Study. Hypertension. 2010;56(2):196-202. Ogihara T Saruta T Rakugi H Matsuoka H Shimamoto K Shimada K Valsartan in Elderly Isolated Systolic Hypertension Study Group Target blood pressure for treatment of isolated systolic hypertension in the elderly. Valsartan in Elderly Isolated Systolic Hypertension Study Hypertension 2010 56 2 196 202 23 Zhang Y, Zhang X, Liu L, Zanchetti A; FEVER Study Group. Is a systolic blood pressure target &lt; 140 mmHg indicated in all hypertensives? Subgroup analyses of findings from the randomized FEVER trial. Eur Heart J. 2011;32(12):1500-8. Zhang Y Zhang X Liu L Zanchetti A FEVER Study Group Is a systolic blood pressure target &lt; 140 mmHg indicated in all hypertensives? Subgroup analyses of findings from the randomized FEVER trial Eur Heart J 2011 32 12 1500 1508 24 Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M, et al; Task Force Members. 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). J Hypertens. 2013;31(7):1281-357. Mancia G Fagard R Narkiewicz K Redón J Zanchetti A Böhm M Task Force Members 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) J Hypertens 2013 31 7 1281 1357 25 Dahlof B, Lindholm LH, Hansson L, Schersten B, Ekbom T, Wester PO. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet. 1991;338(8778):1281-5. Dahlof B Lindholm LH Hansson L Schersten B Ekbom T Wester PO Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension) Lancet 1991 338 8778 1281 1285 26 Amery A, Birkenhager W, Brixko P, Bulpitt C, Clement D, Deruyttere M, et al. Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial. Lancet. 1985;1(8442):1349-54. Amery A Birkenhager W Brixko P Bulpitt C Clement D Deruyttere M Mortality and morbidity results from the European Working Party on High Blood Pressure in the Elderly trial Lancet 1985 1 8442 1349 1354 27 Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party. BMJ.1992;304(6824):405-12. Medical Research Council trial of treatment of hypertension in older adults: principal results. MRC Working Party MRC Working Party BMJ 1992 304 6824 405 412 28 Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhager WH, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997;350(9080):757-64. Staessen JA Fagard R Thijs L Celis H Arabidze GG Birkenhager WH Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators Lancet 1997 350 9080 757 764 29 Liu L, Wang JG, Gong L, Liu G, Staessen JA. Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Systolic Hypertension in China (Syst-China) Collaborative Group. J Hypertens. 1998;16(12 Pt 1):1823-9. Liu L Wang JG Gong L Liu G Staessen JA Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Systolic Hypertension in China (Syst-China) Collaborative Group J Hypertens 1998 16 12 Pt 1 1823 1829 30 Hansson L, Lindholm LH, Ekbom T, Dahlof B, Lanke J, Schersten B, et al. Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study. Lancet. 1999;354(9192):1751-6. Hansson L Lindholm LH Ekbom T Dahlof B Lanke J Schersten B Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study Lancet 1999 354 9192 1751 1756 31 Lithell H, Hansson L, Skoog I, Elmfeldt D, Hofman A, Olofsson B, et al; SCOPE Study Group. The Study on Cognition and Prognosis in the Elderly (SCOPE): principal results of a randomized double-blind intervention trial. J Hypertens. 2003;21(5):875-86. Lithell H Hansson L Skoog I Elmfeldt D Hofman A Olofsson B SCOPE Study Group The Study on Cognition and Prognosis in the Elderly (SCOPE): principal results of a randomized double-blind intervention trial J Hypertens 2003 21 5 875 886 32 Turnbull F, Neal B, Ninomiya T, Algert C, Arima H, Barzi F, et al; Blood Pressure Lowering Treatment Trialists' Collaboration. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomized trials. BMJ. 2008;336(7653):1121-3. Turnbull F Neal B Ninomiya T Algert C Arima H Barzi F Blood Pressure Lowering Treatment Trialists' Collaboration Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomized trials BMJ 2008 336 7653 1121 1123 33 Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008;52(8):686-717. Somers VK White DP Amin R Abraham WT Costa F Culebras A Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing J Am Coll Cardiol 2008 52 8 686 717 34 Munoz R, Duran-Cantolla J, Martínez-Vila E, Gallego J, Rubio R, Aizpuru F, et al. Severe sleep apnea and risk of ischemic stroke in the elderly. Stroke. 2006;37(9):2317-21. Munoz R Duran-Cantolla J Martínez-Vila E Gallego J Rubio R Aizpuru F Severe sleep apnea and risk of ischemic stroke in the elderly Stroke 2006 37 9 2317 2321 35 Streeten DH, Anderson GH Jr, Howland T, Chiang R, Smulyan H. Effects of thyroid function on blood pressure: recognition of hypothyroid hypertension. Hypertension. 1988;11(1):78-83. Streeten DH Anderson GH Jr Howland T Chiang R Smulyan H Effects of thyroid function on blood pressure: recognition of hypothyroid hypertension Hypertension 1988 11 1 78 83 36 Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392-7. Morley JE Vellas B van Kan GA Anker SD Bauer JM Bernabei R Frailty consensus: a call to action J Am Med Dir Assoc 2013 14 6 392 397 37 Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. Fried LP Tangen CM Walston J Newman AB Hirsch C Gottdiener J Cardiovascular Health Study Collaborative Research Group Frailty in older adults: evidence for a phenotype J Gerontol A Biol Sci Med Sci 2001 56 3 M146 M156 38 Poortvliet RK, Blom JW, de Craen AJ, Mooijaart SP, Westendorp RG, Assendelft WJ, et al. Low blood pressure predicts increased mortality in very old age even without heart failure: the Leiden 85-plus Study. Eur J Heart Fail. 2013;15(5):528-33. Poortvliet RK Blom JW de Craen AJ Mooijaart SP Westendorp RG Assendelft WJ Low blood pressure predicts increased mortality in very old age even without heart failure: the Leiden 85-plus Study Eur J Heart Fail 2013 15 5 528 533 39 Odden MC, Peralta CA, Haan MN, Covinsky KE. Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty. Arch Intern Med. 2012;172(15):1162-8. Odden MC Peralta CA Haan MN Covinsky KE Rethinking the association of high blood pressure with mortality in elderly adults: the impact of frailty Arch Intern Med 2012 172 15 1162 1168 40 Mallery LH, Allen M, Fleming I, Kelly K, Bowles S, Duncan J, et al. Promoting higher blood pressure targets for frail older adults: a consensus guideline from Canada. Clevev Clin J Med. 2014;81(7):427-37. Mallery LH Allen M Fleming I Kelly K Bowles S Duncan J Promoting higher blood pressure targets for frail older adults: a consensus guideline from Canada Clevev Clin J Med 2014 81 7 427 437 7ª Diretriz Brasileira de Hipertensão Arterial: Capítulo 11 - Hipertensão Arterial no Idoso Malachias MVB Ferreira S Filho Souza WKSB Ribeiro JM Miranda RD Jardim TSV

A HA é a doença crônica não transmissível mais predominante entre os idosos.1 Sua prevalência aumenta progressivamente com o envelhecimento, sendo considerada o principal FRCV modificável na população geriátrica.2 São considerados idosos, sob o ponto de vista cronológico, indivíduos com 65 anos ou mais de idade, vivendo em países desenvolvidos, ou com 60 anos ou mais, em países em desenvolvimento.3 Dentro desse grupo etário, são chamados de muito idosos aqueles que já alcançaram a oitava década de vida.4

Existe uma relação direta e linear da PA com a idade, sendo a prevalência de HA superior a 60% na faixa etária acima de 65 anos.5 O Estudo de Framingham aponta que 90% dos indivíduos com PA normal até os 55 anos desenvolverão HA ao longo da vida.6 Além disso, mostra que tanto a PAS quanto a PAD, em ambos os sexos, aumentam até os 60 anos, quando, então, a PAD começa a diminuir. Por outro lado, a PAS segue aumentando de forma linear.7 A alta prevalência de outros FR concomitantes nos idosos e o consequente incremento nas taxas de eventos CV, bem como a presença de comorbidades, ampliam a relevância da HA com o envelhecimento.8

O envelhecimento vascular é o aspecto principal relacionado à elevação da PA nos idosos, caracterizado por alterações na microarquitetura da parede dos vasos, com consequente enrijecimento arterial. Grandes vasos, como a aorta, perdem sua distensibilidade e, apesar de os mecanismos precisos não estarem claros, envolvem primariamente mudanças estruturais na camada média dos vasos, como fratura por fadiga da elastina, depósito de colágeno e calcificação, resultando no aumento do diâmetro dos vasos e da EMI. Clinicamente, a rigidez da parede das artérias se expressa como HSI, condição com alta prevalência na população geriátrica e considerada um FR independente para aumento da morbimortalidade CV.6,9-11 Outras consequências são o aumento da VOP e a elevação da PP.12

Alterações próprias do envelhecimento determinam aspectos diferenciais na PA dessa população, como maior frequência de hiato auscultatório, que consiste no desaparecimento dos sons durante a deflação do manguito, geralmente entre o final da fase I e o início da fase II dos sons de Korotkoff, resultando em valores falsamente baixos para a PAS ou falsamente altos para a PAD.

A maior variabilidade da PA nos idosos ao longo das 24 horas torna a MAPA útil. A pseudo-hipertensão, associada ao processo aterosclerótico, pode ser detectada pela manobra de Osler, ou seja, permanência de artéria radial palpável após a insuflação do manguito pelo menos 30 mmHg acima do desaparecimento do pulso radial. A maior ocorrência do EAB, hipotensão ortostática e pós-prandial e, finalmente, a presença de arritmias, como fibrilação atrial, podem dificultar a medição da PA nesses indivíduos.5

A medição da PA em idosos deve ser revestida de cuidados especiais do ponto de vista técnico. Devem-se seguir as recomendações descritas no capítulo de Diagnóstico. Além disso, há sempre a necessidade da avaliação de hipotensão postural, definida como redução igual ou superior a 20 mmHg na PAS, ou diminuição de qualquer valor seguida de sintomas clínicos e/ou redução de 10 mmHg ou mais na PAD quando comparados, após 3 minutos, os valores obtidos na posição ortostática com aqueles medidos nas posições de decúbito ou sentada.13

Estima-se que 69% dos idosos com antecedente de IAM, 77% com antecedente de AVE e 74% com histórico de IC tenham diagnóstico prévio de HA. Apesar de os indivíduos nessa faixa etária serem mais conscientes de sua condição e estarem mais frequentemente sob tratamento do que os hipertensos de meia-idade, as taxas de controle da PA nos idosos são inferiores, em especial após os 80 anos.6

O tratamento da HA nesse grupo de pacientes traz benefícios inequívocos na redução de eventos CV maiores (IAM, AVE e IC). Além disso, existem evidências sobre a possibilidade de prevenção de síndrome demencial, sendo esse um benefício adicional que deve ser considerado na decisão terapêutica.14-16

O TNM deve ser encorajado em todos os estágios da HA e baseia-se na prática de um estilo de vida saudável. Apesar de ser simples e de aparente fácil adoção, encontra grande resistência, pois implica mudanças de hábitos antigos.

As principais orientações de MEV que comprovadamente reduzem a PA e minimizam o risco CV são: atividade física, abandono do tabagismo, diminuição do peso quando elevado e dieta balanceada (hipossódica, rica em frutas e verduras).15,16 (GR: I; NE: A). Esse tipo de terapêutica é recomendado para os idosos, sendo benéfica a redução moderada de sal na dieta. Essa MEV é uma das mais bem estudadas como intervenção para o controle da PA; verifica-se que a redução da PA geralmente é mais significativa quando levamos em conta adultos mais velhos. O estudo TONE17 fornece fortes evidências sobre os efeitos da redução do sódio da dieta dos idosos, com diminuição de 4,3 mmHg na PAS e 2 mmHg na PAD em indivíduos entre 60 e 80 anos com PA < 145/85 mmHg com consumo de 5 gramas de sódio por dia. Os benefícios da atividade física regular nos idosos extrapolam em muito a redução da PA, pois propiciam melhor controle de outras comorbidades, reduzindo o risco CV global. Além disso, é capaz de diminuir o risco de quedas e depressão, promovendo a sensação de bem-estar geral, melhorando a autoconfiança e a qualidade de vida.18

Recomenda-se, preferencialmente, que os pacientes sejam acompanhados por equipe multidisciplinar e que seus familiares sejam envolvidos em todo o processo, o que aumenta as taxas de adesão e as chances de sucesso com o tratamento.5

O estudo HYVET19 demonstrou que o tratamento ativo reduziu significativamente as taxas de IC e mortalidade global nesse grupo. Esse estudo comparou o tratamento ativo (DIU indapamida acrescido, se necessário, do IECA perindopril) com placebo em octogenários com PAS inicial maior do que 160 mmHg. A meta de PAS foi inferior a 150 mmHg, com uma média de PA de 144 mmHg. Uma limitação desse importante estudo é que os idosos incluídos eram, de forma geral, mais saudáveis que os da população geral.

Em um grande número de estudos randomizados de tratamento anti-hipertensivo em idosos, incluindo pacientes com 80 anos ou mais,19 demonstrou-se a redução de eventos CV pela redução da PA; entretanto, os valores médios de PAS atingidos nunca foram inferiores a 140 mmHg.20 Dois estudos japoneses, comparando tratamentos mais intensivos a tratamentos menos intensivos, não foram capazes de demonstrar benefícios em reduzir valores médios de PAS entre 136 e 137 comparados a 145 e 142 respectivamente.21,22 Por outro lado, uma análise do subgrupo de idosos do estudo FEVER23 demonstrou redução de eventos CV com a redução da PAS abaixo de 140 mmHg (comparado com 145 mmHg).

Existem evidências robustas do benefício de reduzir a PA com o tratamento anti-hipertensivo em idosos com 80 anos ou mais. Essa vantagem está limitada a indivíduos com PAS ≥ 160 mmHg, nos quais a PAS foi reduzida a valores < 150 mmHg (GR: I; NE: A).

Em indivíduos idosos com menos de 80 anos, o tratamento anti-hipertensivo pode ser considerado para aqueles com PAS > 140 mmHg, para uma meta de PAS < 140 mmHg, desde que os indivíduos apresentem uma boa condição clínica e o tratamento seja bem tolerado.19-23 (GR: IIb; NE: C).

Estudos randomizados controlados que demostraram, com sucesso, os efeitos do tratamento anti-hipertensivo nos idosos usaram diferentes classes de medicamentos. Existe evidência em favor de DIU,12,19,24-27 BCC,28-30 IECA30 e BRA.31 Os três estudos em HSI usaram DIU12 ou BCC.28,29

Uma meta-análise prospectiva comparou os benefícios de diferentes regimes terapêuticos em pacientes com idade superior ou inferior a 65 anos, confirmando que não existem evidências de que diferentes classes possuam efetividades diferentes em pacientes mais jovens ou mais velhos.32

Um aspecto que merece destaque é a possibilidade de HA secundária no idoso, cujas causas mais frequentes são estenose de artéria renal, síndrome da apneia e hipopneia obstrutiva do sono (SAHOS), alterações de função tireoidiana e uso de medicamentos que podem elevar a PA.24,33-35

Investigação de HA secundária em idosos pode ser necessária como parte do diagnóstico.

Algumas situações entre os idosos merecem destaque especial e uma abordagem diferenciada. Idosos portadores de multimorbidades não CV, síndrome da fragilidade e/ou demência possuem risco aumentado de dependência funcional e morte.36,37 Apesar da tendência de redução lenta da PA com a progressão desses quadros e diminuição da reserva orgânica, muitos ainda possuem níveis significativamente elevados de PA. Esses pacientes não foram incluídos nos ensaios clínicos randomizados, devendo, por isso, ser avaliados de forma ainda mais global, pesando cuidadosamente as prioridades individuais e o risco/benefício do tratamento anti-hipertensivo, medicamentoso ou não. A meta de tratamento deve ser menos rígida, com especial atenção ao maior risco de hipotensão postural e pós-prandial. Por outro lado, idosos frágeis possuem também maior risco CV, devendo o tratamento ser individualizado.

Nos casos de DCV estabelecida ou LOA, essas se tornam uma prioridade e devem nortear tanto a intensidade do tratamento, quanto os medicamentos a serem escolhidos.38-40 (GR: IIa; NE: C).