Abstract              Background: Elderly persons with untreated hypertension are at higher risk of suffering from stroke and other major cardiovascular events. Knowledge of the extent of the problem in a region helps in taking the preventing measures. Aim: To study the clinical profile of elderly patients with hypertension at a tertiary care hospital. Material and Methods: All patients above the age of 65 years, irrespective of their hypertensive status were included in this study. All patients were classified according to blood pressure readings. In all patients, ECG and fundus examination was done. 2D Echo was done whenever necessary. Results: Of the 127 hypertensive patients, 74 (58%) were males and 53 (42%) were females. The most common presentation was fatigue 35%, followed by angina 15% and giddiness 13% and 4% were asymptomatic. Isolated systolic hypertension was diagnosed in 25 (19.9%) patients. Hypertensive retinopathy was found in 74 (37%) patients and dyslipidemia was found in 47 (23.5%) patients. Conclusion: The degree of risk from hypertension can be categorized with reasonable accuracy by taking into account the level of blood pressure and the biological aggressiveness of the hypertension. The present study reiterates the need for early detection, assessment of overall cardiovascular risk and treatment of hypertension in the elderly.

Key Words: Hypertension, Elderly, Isolated systolic hypertension, retinopathy.

 

INTRODUCTION

As per the global demographic trends, the proportion of elderly people is projected to increase to 12% of the world wide population that is 973 million in the year 2030.¹ The Indian scenario is similar, elderly people constitute 7.2% of the population and it is projected to increase to 12% of the population in the year 2025.² As the population grows older, the incidence of hypertension, continues to increase in the developed and developing societies. Hypertension is a major health problem worldwide and its complications have significant socioeconomic impact. Elderly persons with untreated hypertension are at higher risk of suffering from stroke and other major cardiovascular events.¹ The cardiovascular and cerebrovascular risks associated with hypertension are greater in the elderly people. Knowledge of the extent of the problem in a region helps in taking the preventing measures. Thus, the present study was undertaken to study the clinical profile of elderly patients with hypertension at a tertiary care hospital.

 

MATERIAL AND METHODS

The study included 200 patients above 65 years of age, who were admitted under various departments like Medicine, Surgery, Gynaecology and allied branches in AL-Ameen Medical College and District Hospital, Bijapur. All patients were subjected to detailed clinical examination and investigations.

Inclusion Criteria

All patients above the age of 65 years, irrespective of their hypertensive status, i.e., whether known hypertensive undergoing treatment, recently detected hypertensive or non-hypertensive.

Exclusion Criteria

Patients below 65 years age group and with retroviral disease.

Classification of blood pressure: All patients were classified according to the VIIth US Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure.³

 

Table 1:

 

Blood pressure was taken in all patients in both arms, supine as well as standing and in both lower limbs. In patients who were bedridden, comatose, only supine blood pressure in arm and leg were taken. In patients with atrial fibrillation, a set of three readings and their mean was taken into consideration. In all patients, ECG and fundus examination was done.2D Echo was done whenever necessary. Routine urine examination, blood urea, serum creatinine and USG abdomen was done to look for evidence of hypertensive nephropathy. CT Brain was done if there were clinical features of cerebrovascular accident to rule out haemorrhage and infarction.

 

RESULTS

The present study included 200 patients, of which 125 were male patients and 75 were female patients. Out of these 200 patients, 127 (64%) were found to be hypertensive. Of the 127 hypertensive patients, 74 (58%) were males and 53 (42%) were females. Out of the 127 patients, 83 (62.5%) were known hypertensive and 44 (35.5%) were newly detected. Only 15 patients had the blood pressure well controlled below 120/80 mm Hg.

 

Table 2: Classification of hypertension in study population

The most common presentation was fatigue 35%, followed by angina 15% and giddiness 13% and 4% were asymptomatic (Table 2).

 

 

 

 

 

Table 3: Clinical presentation of hypertensive population

Isolated systolic hypertension is said to be present if the systolic blood pressure is more than 140 mm Hg and diastolic blood pressure is less than 90 mm Hg. Among 127 hypertensive patients, isolated systolic hypertension was diagnosed in 25 (19.9%) patients in whom 13 (52%) were males and 12 (48%) were females. Hypertensive retinopathy was found in 74 (37%) patients of whom 49 (66.2%) were males and 25 (33.8%) were females. Of the 200 patients in our study, dyslipidemia was found in 47 (23.5%) patients, of whom 28 (59.5%) were males and 19 (40.5%) were females.  On ECG, ST-T changes were seen in 57 patients followed by LVH in 43 patients (males- 29 and females - 14), left atrial enlargement in 8 patients, P-Pulmonale in 5 patients and RVH in 4 patients. Of the 71 patients who underwent 2D Echo, the most common finding was sclerotic aortic valve which was found in 27 (38%) patients of which 13 (48%) were males and 14 (52%) were females and 24 (33.8%) patients had LVH.

 

DISCUSSION

Hypertension is one of the leading cause of morbidity and mortality in the world and will increase in worldwide importance as a public health problem by 2020. Detection, evaluation and treatment strategies for the older hypertensive have been implemented in similar manner as the general population. However, the older population with elevated blood pressure is associated with several unique attributes that should be considered for effective high blood pressure control. Several cohort studies have documented the association of isolated systolic hypertension and increased risk of stroke in the older population. Our study consisted of 200 patients, of which 125 were males and 75 were females. The incidence of hypertension was found to be 64% (127/200). Of the detected hypertensive, 74 (58%) were males and 53 (42%) were females. In a study done by Farook et al,⁴ the incidence of established hypertension among elderly was 61.4% of which 64.4% were females and 58% were males. A study by Gupta et al showed a female preponderance of 69.9% vs 59.9%.⁵ Isolated systolic hypertension is the most common form of hypertension in the elderly. It was considered part of ageing and like essential hypertension benign, however there is now compelling evidence from cross-sectional, longitudinal and randomized controlled trials that isolated systolic hypertension confers substantial cardiovascular risk,⁶ despite this it remains under diagnosed and largely untreated the roots of this essentially lie in over importance of diastolic blood pressure and unjustified consensus about the adverse consequences regarding treating systolic hypertension.⁷ In our study of 200 patients of which 127 were hypertensive, isolated systolic hypertension was diagnosed among 25 (19.9%) patients, of which 13 (52%) were males and 12 (48%) were females. In a study conducted by Gupta et al,⁵ systolic hypertension was found in 12 (6%) patients while Dwivedi et al⁸ in their study recorded the incidence of 24.56% and Kulkarni et al⁹ found the incidence of 56.6%. The latest observation from Framingham study of 2000 elderly patients indicated that arterial stiffness is the key determinant in cardiovascular risk mortality.¹⁰The benefits of treating isolated systolic hypertension is well established.⁶The relative risk reduction of cardiovascular events in the elderly people with isolated systolic hypertension is similar to that in young people. Retinopathy is one of the several markers of target organ damage in hypertension. On the basis of JNC-VII criteria,³ the presence of retinopathy may be an indication for initiating anti-hypertensive therapy. There is no clear consensus regarding the classification of hypertensive retinopathy or whether a retinal examination is useful for risk stratification. In our study, hypertensive retinopathy was found in 74 (37%) of 200 patients, of whom 49 (66.2%) were males and 25 (33.8%) were females. Kulkarni et al found hypertensive retinopathy among 69/179 (38.5%) among which 40 had stage II hypertension.⁹ In a study carried out by Chaturvedi et al¹¹ of 651 patients the incidence was found to be 11% and a study carried out by Michele et al the incidence was 55.8%.¹² Dyslipidemia is an important factor for atherogenesis. Accelerated atherosclerosis is an invariable companion of hypertension, smoking, alcohol consumption and diabetes also affect the serum lipid profile. However, the Framingham study found out an independent association between hyperlipidemia and hypertension. Our study also confirmed this association and increased incidence of cardiovascular complications in them. In our study, dyslipidemia was found in 47 (23.5%) patients. 28 (59.5%) were males and 19 (40.5%) were females. Of the 47 patients, 40 (20%) patients had hypercholesterolemia whereas 34 (17%) patients had hypertriglyceridemia. A study carried out by Kulkarni et al⁹ found the incidence of hyperlipidemia to be 55.9% which 30.9% were males and 25% were females. While a study carried out by Aranda P et al¹³ found the incidence to be 26.2%. Another study done by Farook et al of 200 patients, hypercholesterolemia was present in 62%, their study included only elderly diagnosed hypertensive which may account for high incidence.⁴The most common ECG finding in our study was ischemicchanges 57 (43.5%) patients of which 33 (57.8%) were males and 24 (42.2%) were females. Males were having higher incidence of ischemic heart disease. The next most common thing in ECG was left ventricular hypertrophy, 43 (32.3%) patients had left ventricular hypertrophy of which 29 (67.5%) were males and 14 (32.5%) were females. Left atrial enlargement was found in 8 patients, P-pulmonale in 5 patients had significant right ventricular hypertrophy but was associated with chronic obstructive pulmonary disease. 18 patients had evidence of myocardial infarction. Other findings were atrial fibrillation, left and right bundle branch block. In a study Dwivedi et al⁸found the incidence of left ventricular hypertrophy was 12.8% while Kulkarni et al found the incidence of 36.3%.⁹ Left ventricular mass directly relates to cardiovascular mortality as was determined in the Framingham heart study. It has been determined that in men the risk factor adjusted relative risk of cardiovascular disease was 1.49 for each increment of 50 gms/m of left ventricular mass correlated to subject’s height.¹⁴ In women it was 1.57. In our study 2D Echo was done in 71 out of 200 patients, which included 45 males and 26 females. The next most common finding was concentric left ventricular hypertrophy, which was found in 24 (33.8%) patients. A study done by Kulkarni et al⁹ found the incidence of left ventricular hypertrophy to be 46.4%. While in a study carried out by Paolo et al¹⁵in 97 elderly patients it was found in 43% and was clearly elevated as compared to values in age and sex matched 98 normotensive subjects. Whether there are sex differences in cardiac adaptation in hypertension and whether geometric classification be used to adjust treatment remains to be investigated.

 

CONCLUSION

As more people live longer, more hypertensives particularly isolated systolic hypertensive patients will be seen. The degree of risk from hypertension can be categorized with reasonable accuracy by taking into account the level of blood pressure and the biological aggressiveness of the hypertension based on the degree of target organ damage and the co-existence of other risk factors. The present study reiterates the need for early detection, assessment of overall cardiovascular risk and treatment of hypertension in the elderly.

 

 

 

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