Blog | Wednesday, November 2, 2011

QD: News Every Day--Hypertension often not assessed in very elderly patients


Five easy steps to assess hypertension in the very elderly often go undone, with even the most commonly performed test being done by less than three in 10 doctors, a reader poll found.

Hypertension continues to be undertreated in the elderly, even though it can lead to significant clinical events, such as stroke, myocardial infarction, heart failure, PAD and atrial fibrillation. As was addressed in ACP Internist's October cover story, the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) 2011 Expert Consensus Document on Hypertension in the Elderly gives five tips for evaluating hypertension in older patients:
--Take at least three different blood pressure measurements on two different office visits.
--Two of those measurements should be obtained after the patient has been seated comfortably for at least five minutes with the back supported, feet on the floor, and arm supported in horizontal position, with the blood pressure cuff at heart level.
--Take a blood pressure measurement with the patient standing for one to three minutes, particularly after a meal, to evaluate for postural hypotension or hypertension.
--The older the patient, the more likely that PAD is present, so it is important to take an ankle brachial index (ABI). Diagnose PAD if the ABI is less than 0.90 or 1.4 and higher.
--Target systolic blood pressure is =140/90 mm Hg in patients aged 55 to 79; a systolic blood pressure of 140 to 145 mm Hg, if tolerated, can be acceptable for those older than 80.

Consensus statements, like all medical knowledge, take a long time to filter into clinical practice. ACP Internist polled its readership online, asking them throughout October how many, if any, of these tests were performed. Among 179 voters (who could pick more than one response):
--I obtain two blood pressure measurements after the patient has been seated comfortably for at least five minutes with the back supported, feet on the floor, and arm supported in horizontal position, (53 votes, 29.61%);
--I target systolic blood pressure of 140/90 mm Hg in patients aged 55 to 79; a systolic blood pressure of 140 to 145 mm Hg, if tolerated, can be acceptable for those older than 80, (46, 25.7%);
--I take at least three different blood pressure measurements on two different office visits, (41, 22.91%);
--I take a blood pressure measurement with the patient standing for one to three minutes, particularly after a meal, to evaluate for postural hypotension or hypertension, (21, 11.73%); and
--I take an ankle brachial index (ABI) in order to diagnose PAD if the ABI is less than 0.90 or 1.4 and higher, (13, 7.26%).
--I don't perform any of these tips (5, 2.79%)

It's no surprise that fewer than one in 10 doctors perform the ankle-brachial index. ACP Internist reported in April 2011, the exam is simple, effective and entirely overlooked in the primary care setting. A lack of vascular training outside the heart, and inconsistent reimbursement are leading reasons for the oversight.

Still, the benefits of treating hypertension in the very elderly are known. Hypertension in the Very Elderly Trial (HYVET) published in the New England Journal of Medicine in 2008, found that hypertensive therapy in people aged 80 and older leads to a 30% reduction in stroke, a 23% reduction in cardiovascular death, a 64% reduction in heart failure, and a 21% reduction in all-cause mortality.

Angiotensin converting enzyme (ACE) inhibitors, beta-blockers, angiotensin receptor blockers (ARBs), diuretics, and calcium-channel blockers are effective, although over-the-counter NSAIDs can increase blood pressure, interfere with the action of many drugs for hypertension, precipitate and aggravate heart failure, induce acute renal failure in patients with heart failure and chronic renal impairment, and cause cardiovascular events.

It's not just clinical knowledge that takes a long time to implement. Doctors have to also manage their practices, and sometimes that involves re-engineering the structure of the clinical encounter. ACP Internist continues its reader polls this month by asking readers how far they've gone (if at all) in implementing the concepts of a patient-centered medical home.

While the idea is probably foreign to many established physicians, medical schools are incorporating this practice model into their residency programs in an effort to make the practice experience more relevant to the way their graduates will practice. Take the poll and tell us how far you've gotten in re-engineering your practice.