Ask the Doctors February 2012 Issue

Ask The Doctors: February 2012

Iíve read reports that target blood pressures in older adults donít always have to get below 140/90. Iím 78 and am close to that level now. Iím in relatively good health, but I take two medications for blood pressure and am wondering if I can relax a little about that 140/90 goal?

A document known as the JNC-7 is our main set of guidelines for blood pressure therapy. It defines normal blood pressure as a systolic blood pressure (SBP) 140 mm Hg or the DBP is >90 mm Hg. In between the normal and hypertensive ranges, when the SBP is 120-139 mm Hg or the DBP is 80-85 mm Hg, is referred to as pre-hypertension. Generally, pre-hypertension is only treated with lifestyle modifications, including pursuance of a low-sodium diet, weight loss, exercise, moderate alcohol consumption, and smoking cessation. Frank hypertension generally requires drug therapy. Patients with other cardiovascular risk factors, such as coronary artery disease, diabetes and chronic kidney disease have stricter goals for blood pressure control.

As you mention, the treatment guidelines differ somewhat for adults >80 years of age. A well-designed study called the Hypertension in the Very Elderly Trial (HYVET), which was published in the New England Journal of Medicine in 2008, helped to provide the impetus for this change. In the study, a BP of 160mm Hg or higher was used as the threshold for treatment of high blood pressure, and a more conservative BP goal of 150/80 mm Hg was targeted.† Subjects in the study were randomized either to placebo, or to antihypertensive therapy with the diuretic indapamide, with or without the ACE-inhibitor perindopril.† Patients in the treatment arm tended to live longer, and had decreased rates of fatal stroke, cardiovascular events, and heart failure. The study also suggested that antihypertensive therapy would probably decrease the total risk of stroke, as well. All of this was achieved with a less-aggressive BP goal than recommended by JNC-7.†

Largely based upon the HYVET results, our most recent set of guidelines from April 2011 indicate that for patients older than 80 years, a reasonable target is a SBP of 140-145 mm Hg (no goal for DBP is provided).† Since the very elderly are at higher risk for their BP dropping when standing up, they should always have their BP measured in the doctorís office while standing, as well as while sitting or lying down. Due to lack of evidence in this population, more aggressive BP goals are not recommended for those with CAD, diabetes, or CKD. Finally, unlike in younger patients, a SBP 80 years of age.

My husband is going to get a pacemaker. Iím hoping you can clear up a few things, such as what kinds of precautions will he have to take at airports, around microwave ovens, with cell phones, etc.?

I think you will most likely find that your husbandís life with a pacemaker is going to be easier than expected. It is true that years ago, older models of pacemakers could be adversely affected by cell phone signals, microwave ovens, and other sorts of radiation. Currently, these devices are immune to such problems. The only situation which must be avoided is an MRI, which would be extremely dangerous, due to the effects of the magnetic field on the metal pacemaker. The most important step after getting a pacemaker is to maintain frequent follow-up, to ensure the pacemaker is functioning normally. At Cleveland Clinic, patients generally transmit information by telephone on their pacemakers every threee months, and undergo annual office visits. Any redness, warmth, tenderness, or swelling of the pacemaker ďpocketĒ on the chest wall should be immediately investigated by your husbandís cardiologist.