Ask the Doctors December 2013 Issue

Ask The Doctors: December 2013

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. Hypertension generally requires drug therapy, though other medical conditions can warrant stricter goals.

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 Hg should be reasonably avoided in patients >80 years of age.

Iím 81 and had a bovine aortic heart valve put in 12 years ago, along with bypass surgery. Iím in generally good health, but the valve is starting to leak. The hospital where I have gotten my care doesnít seem anxious to operate on an 81-year-old. What are my options regarding my aortic valve?

Whether or not you should get surgery for your leaking bioprosthetic aortic valve depends on more factors than just your age. The fact that this would be your second open heart surgery would make the procedure more risky, mainly due to the presence of postsurgical scar tissue known as ďadhesionsĒ which tend to form in the chest. My recommendation would be for you to get a second opinion from a large academic medical center, such as Cleveland Clinic. The possibility of a second heart surgery should still be considered, because it is the tried-and-true method for fixing the problem. However, if the risks are felt to outweigh the benefits by the doctors evaluating you, another option could be transcatheter aortic valve insertion (TAVI), a minimally-invasive procedure in which cardiologists implant a new valve inside of the old one.
Be advised, however, that at the present time TAVI is only FDA-approved for use in severe narrowing of the native aortic valve. Only a few patients have received TAVI for your problem, and as such this treatment for a leaking bioprosthetic valve would still have to be considered ďexperimental.Ē

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