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1、Hypertension in the Very Elderly Lisheng LIU,Epidemiology HYVET Study,The prevalence of hypertension in elderly population for China & Japan from the national surveys conducted in 1992 & 1993,Japan definition: 160/95 mmHg; China definition: 160/95 mmHg or under antihypertensive treatment,XH Zhang, B
2、HLI 2009,The effect of SBP on stroke mortality by age groups in Chinese elderly populations,0.5,1.0,2.0,4.0,8.0,16.0,140,140-159,160-179,=180,SBP (mmHg),RR of stroke mortality,Age=78y Age=74-77y Age=70-73y,XH Zhang, BHLI 2009,Stroke mortality in Asian men from 1987 to 2007,Hong Kong,Japan,Korea,Sing
3、apore,China_rural,China_urban,Mortality, per 100,000,Year,Stroke mortality in Asian women from 1987 to 2007,Year,Blood pressure and stroke mortality in the Chinese elderly cohort (n=4814),XH Zhang, BHLI 2009,Blood pressure and stroke mortality in the Chinese elderly cohort (n=4814),XH Zhang, BHLI 20
4、09,The effects of BP on the risk of stroke mortality by age gr. in the elderly (Cox proportional hazard regression model, controlled for age and smoking, stratified by sex),XH Zhang, BHLI 2009,Stroke mortality (per 100,000 population per year) of elderly ( 80yrs) in Asia in the latest available year
5、,XH Zhang, BHLI 2009,The development trend of the elderly population( number in 100 million ),Data source：Du P. Policy research on aging in 21 century in China ,1999,BMI & Hypertension Prevalence （3257 sub., Beijing),Prevalence（）,BMI,age,XH Fang, Chinese J. of Epidemiology, 2002；23：28-31,Metabolic S
6、yndrome in Beijing （1827 sub., 2000）,SC Guan. Chinese J. of Geriatrics, 2006;25(3):219-221,Overweight & Obesity in Beijing （1827 sub., 2000）,SC Guan. Chinese J. of Geriatrics, 2006;25(3):219-221,BMI & 5 Yr. All Cause Mortality,75岁,=75岁,BMI,XH Fang, et al. Chinese J. of Epidemiology, 2002;23:28-31,Co
7、gnitive Function & 5 Yr. Survival Rate,FU (mon.),S. Meng, Chinese J. of Geriatrics, 2004;23:507-509,Renal Function (CISC cohort),GFR in each age group (weighted and not),The over-80s are the fastest-growing group on the planet Age and SBP are two major components of CV risk Antihypertensive therapy
8、reduces CV risk and mortality in patients under 80,Conclusions,Epidemiology HYVET Study,Baseline data, Fall in SBP 20mmHg and/or fall in DBP 10mmHg,Baseline Data (Previous Cardiovascular History),Baseline data (Cardiovascular Risk factors),Reported characteristics of subjects at entry to the HYVET 1
9、) in China and 2) in the other Countries. Statistical comparisons include a gender x region interaction term,CHF=Congestive Heart Failure; Gender difference (P0.01);Regional difference (P0.01);￥Statistically significant interaction term (P0.05),Gender difference(P0.05); Gender difference（P0.0 I）;Reg
10、ional difference (P0.01)Regional difference (P0.05);￥Gender regional interaction term (P0.05) ￥ Gender regional interaction term (P0.01),Measurements on subjects entered in the HYVET at baseline,Chinese subjects in HYVET,Were slightly younger, had less previous hypertension but more previous strokes
11、. Smoked more than the other trial participants but drank less alcohol. Less previous episodes of MI, lighter & shorter. Had lower mean concentrations of blood urea, uric acid and Cr & higher concentrations of HDLC. Blood glucose & TC lower. Serum Na & K, blood haematocrit & Hb were all lower.,Blood
12、 pressure separation,Median follow-up 1.8 years,15 mmHg,6 mmHg,All stroke (30% reduction),Placebo IndapamideSR perindopril,Indapamide SR perindopril,Placebo,P=0.055,Total Mortality (21% reduction),Placebo,Indapamide SR perindopril,P=0.019,Placebo IndapamideSR perindopril,Fatal Stroke (39% reduction)
13、,Indapamide SR perindopril,Placebo,P=0.046,Placebo IndapamideSR perindopril,Heart Failure (64% reduction),P0.0001,Placebo,IndapamideSR perindopril,Placebo IndapamideSR perindopril,ITT Summary,Per-Protocol,Biochemical Changes from Baseline (2 year cohort),In 2 year cohort there were no significant di
14、fferences between the groups with regard to change in serum. Potassium Uric acid Glucose Creatinine At 2 years 73.4% on combination treatment in act. (85.2% pl.),Safety,Reported serious adverse events (after randomisation) 448 in the placebo group vs 358 in active (p=0.001) Only 5 categorised by the
15、 local investigator possible SADRs (3 in placebo group, 2 being in active),Conclusions,Antihypertensive treatment based on indapamide (SR) 1.5mg ( perindopril) reduced stroke mortality and total mortality in a very elderly cohort. NNT (2 years) = 94 for stroke 40 for mortality Large and significant
16、benefit in reduction of heart failure events and for combined endpoint of cardiovascular events Benefits seen early Treatment regime employed was safe,Cautions,Subjects recruited generally healthier than those within a general population Benefit from treating systolic pressures less than 160mmHg req
17、uires further research Target BP was 150/80 mmHg Benefit from lower targets still needs to be established,Characteristics of Very Elderly Hypertensive Patients with Atrial Fibrillation (AF) in HYVET,J. of Hypertension, 2006, Abstract Book,Atrial fibrillation in Chinese No.29,079 ,Age 30-85, ( 2001),
18、Overweight in 1575 subjects (May, 2004),Standing BP fall in untreated by age (95% CI),N. Beckett, et al., J. of Hypertens 2004;22(Suppl. 2):S291,Co-Morbidity for 2216 patients in HYVET (Age 83.8 yrs. & mean sitting BP was 173.7 mmHg),BP Profile in 48 Very Elderly Hypertensives: Decrease in nocturnal
19、 BP Fall,Hypertensive pts. over 80 yrs. showed a decrease in nocturnal BP fall as compared to younger populations.,The determination of ABP in 50 very elderly hypertensives: effects of lying or sleeping in day time,Daytime SBP: 128.1. When values for only sitting/standing pt. were used SBP was 133.6
20、. For measurement during the day when the pts. Were lying down SBP decreased to 118.7 (p0.001). Daytime DBP: 76.6, sitting/standing-day time 81.1 and lying down 69.0 (p0.001). The Lower pressures when lying are thought to be due to sleeping or resting. In very elderly pts. It is important to account
21、 for body position in the interpretation in day time ABP recordings.,The effect of treatment based on indapamide and perindopril on incident fractures in a very elderly hypertensive population, data from HYVET,Results 3845 participants 102 fractures (42 in Act. & 60 in PL.). validated fractures 90 (
22、38 in Act. & 52 in PL.). HR 0.69 (95% CI 0.45-1.04), p=0.08. Conclusion indapamide SR & perindopril may reduce fracture risk despite the lowering of BP.,HYVET-COG, Dementia rises with increasing age, 20% in age 80 years, 40% at age 90 HT also rises with age. SBP & DBP in Framingham cohort related to
23、 lower cognitive function 12-14 yrs later. Other studies demonstrate similar findings for SBP/DBP and cognitive function between 2 and 25 yrs. High BP in elderly adults may be a RF for dementia and a small reduction in BP (5/3mmHg) may result in improvements in MMSE scores,Objective,To determine whe
24、ther treatment of hypertension in patients 80s would reduce the incidence of dementia, both Vascular dementia and Alzheimers Disease.,Cognitive function and incident dementia,MMSE at baseline and annually A fall to 3 points in one year resulted in assessment for possible dementia Possible incident d
25、ementia cases were assessed using Diagnostic Statistical Manual edition IV DSMIV CT scan (or a full Hachinski Ischemic Score HIS was performed) Modified Ischemic Score MIS,Analysis,The results were analysed in two ways: to assess the impact of BP lowering on cognitive decline (mean follow up 2 yrs w
26、ith 6680 pts. yrs of follow up) to assess the impact of BP lowering on diagnosed dementia (mean follow up 2.2 yrs with 7400 patient yrs).,Results,Peters R., Beckett N., Forette F. t al. Incident dementia and blood pressure lowering in the Hypertension in the very Elderly Trial cognitive function ass
27、essment (HYVETCOG): a double-blind, placebo controlled trial. Lancet 2008 August; 7: 683-689.,Meta-analysis of double blind placebo controlled trials,* Relative risks calculated as part of meta-analysis using the numbers above and therefore differ from Hazard Ratios calculated via survival analysis
28、with Cox proportional hazard regression - Relative Risk (95% confidence interval) * Peters R., Beckett N., Forette F. t al. Incident dementia and blood pressure lowering in the Hypertension in the very Elderly Trial cognitive function assessment (HYVETCOG): a double-blind, placebo controlled trial.
29、Lancet 2008 August; 7: 683-689.,HYVET-COG,HYVET-COG shows a tendency for a reduction in incident cases with active treatment which could be considered to have clinical although not statistical significance. When the HYVET-COG data is added to that from previous trials using a meta-analytic technique, the result is significantly in favor of treatment.,Thank you!,