Indian Journal for the Practising Doctor

Chowta K N, Sundeep S, Chowta M N

Dr Nithyananda K Chowta, MD, (Associate Professor) and Dr S Sundeep, MD, (Consulting Physician), Department of Medicine;
Dr Mukta N Chowta, MD, (Associate Professor), Department of Pharmacology, Kasturba Medical College Hospital, Mangalore.

Correspondence: Dr. K Nithyananda Chowta, Department of Medicine, KMC Hospital, Attavar, Mangalore-575001 [Phone numbers: 0825-2445858, Facsimile numbers:0824-2445858; E-mail address: knchowta(at)yahoo.com]

ISSN: 0973-516X

Abstract

Context: Hypertension, though a common medical problem in the elderly, is not limited to the elderly population, but also involves younger people. In India, the awareness of hypertension, its risk factors and complications is very poor. Scanty information is available from India regarding the prevalence of hypertension and its complications in the younger age group.
Aims: Present study aims at comparative analysis of common symptoms of presentation and prevalence of target organ damage among the elderly and the young hypertensives.
Settings and Design: Prospective, comparative study between the two groups (>60 & <40 yr).
Methods and Material: Two hundred adult patients with hypertension who were diagnosed at the age of 60years or above and two hundred adult patients with hypertension aged below 40years were included in the study. Age, sex, body mass index, presenting complaints and their progress, duration of hypertension, history of other concomitant diseases, smoking, alcohol intake, family history of hypertension were recorded. Blood pressure was recorded in the right arm, with the subjects seated with their arm supported at heart level. Two readings were taken separated by 2 minute interval. Target organ damage was assessed in each patient by evaluating ECG, laboratory investigations, history, and clinical examination.
Statistical analysis used: Chi square and Guassian(Z) test
Results: Present study included 200 young (<40 yr old) hypertensives and 200 elderly (>60 yrs old) hypertensives. 68 of the the young hypertensives and 72 of the elderly hypertensives presented with headache. Hypertension was detected during routine clinical evaluation in 62 young and 56 elderly hypertensives. 123 of the elderly hypertensives, had evidence of cardiovascular complications as compared to 74 of the young hypertensives. Cerebrovascular complications were seen in 29 elderly and 8 young hypertensives. 158 elderly patients had evidence of one or more target organ damage compared to 92 young hypertensives which was statistically significant (p<0.001).
Conclusions: In both, the young and elderly hypertensives, headache was the chief complaint. The prevalence of target organ damage was significantly higher in the elderly hypertensives compared to the young hypertensives.

Key-words: Hypertension, target organ damage, headache

Introduction

Hypertension is a major health problem worldwide and its complications have significant socioeconomic impact. Hypertension is well known to be one of the major risk factor for stroke, coronary heart disease and renal failure. Therefore prevention and treatment of hypertension and the associated target organ damage remains important public health challenges. Although many hypertensives have symptoms that they ascribe to their elevated blood pressure¹, most of these symptoms are due to the functional somatic syndromes seen in people who believe they have a serious disease². Many of the symptoms described by hypertensives, such as band like headaches, dizziness and light headedness, fatigue, palpitations and chest discomfort – a common problem among patients but likely even more common among the hypertensives who are anxious over their diagnosis and its implications³.

Among the symptoms reported, headache is the most common especially in those aware of the diagnosis⁴. Apartment from headache, other symptoms attributable to target organ damage such as transient weakness, loss of visual acuity, chest pain, dyspnoea, edema and claudication are seen in the hypertensives.

Hypertension, though a common medical problem in the elderly, is not limited to the elderly population, but also involves younger people. As the prevalence of hypertension is seen to be rising in younger individuals also, more and more information regarding the profiles of young hypertensives is needed. This recently observed increase may be due to a change in life style leading to obesity and other risk factors as progressively increasing stress. In India, the awareness of hypertension, its risk factors and complications is very poor. Scanty information is available regarding the prevalence of hypertension and its complications in younger Indians. Present study is aimed at the comparative analysis of common symptoms of presentation and the prevalence of target organ damage among elderly and young hypertensive patients.

Subjects and Methods: Two hundred elderly patients diagnosed to have hypertension at the age of 60 years or above and two hundred young hypertensives aged below 40 years were included in the study. The study was approved by the institutional ethics committee and informed consent was taken from each patient. The study included both newly-diagnosed patients as well as known hypertensives. Diagnosis of hypertension was based on the 7th Joint National Committee criteria5. Age, sex, body mass index, presenting complaints and their progress, duration of hypertension, history of other concomitant diseases, smoking, alcohol use, and family history of hypertension were recorded. Blood pressure was recorded in the right arm in the seated subjects with their arm supported at heart level. Two readings were taken separated by 2 minutes. Complete clinical examination including funduscopy was done in all patients. Routine investigations including fasting lipid profile, electrocardiogram, ultrasound abdomen and echocardiography were done in each patient. CT scan was done where indicated. Target organ damage was assessed in each patient by evaluating ECG (IHD, LVH), laboratory investigations (Serum creatinine, proteinuria), history (stroke, TIA), and clinical examination (retinopathy, CCF). Statistical analysis was done by using chi square tests and Gaussian test. Results: Among the 2000 young hypertensives 142 were males and 58 were females, while in the elderly group, 140 were males and 60 were females. Hence the sex-wise distribution of patients was identical in both groups (p=0.826, not significant). 58 of the elderly patients were newly detected hypertensives in comparison to 97 of the younger patients. The difference in the incidence of newly detected hypertension is statistically significant (p<0.001). Family history of hypertension was present in 105 elderly patients and in 102 young hypertensives (p=0.764, not significant). The body mass index was less than 30kg/m² in 171 elderly patients and in 163 younger patients. BMI was more than 30kg/m² in 29 elderly hypertensives and in 37 young hypertensives (p=0.281, not significant). Table 1 shows the distribution of signs and symptoms of hypertension. Headache was the chief presenting complaint in both the group: 68 young hypertensives and 72 elderly ones presented with headache. Hypertension was detected during routine clinical evaluation in 62 young and 56 elderly hypertensives. Dyspnoea was present in 16 young and 22 elderly hypertensives. Palpitation was the prominent symptom in 12 young and 16 elderly hypertensives. Among the young hypertensives 26 had chest pain as compared to 32 elderly patients. Blurring of vision was the presenting complaint in 10 elderly hypertensives; none of the young hypertensives had this complaint (p<0.005, significant). Hemiplegia was detected during presentation in 3 young hypertensives and 18 elderly hypertensives (p<0.001, very significant). 3 young and 11 elderly patients had loss of consciousness, showing significant difference between the two groups (p<0.05). Convulsions were present in 2 young hypertensives and 4 elderly hypertensives. Decreased urine output was the complaint in 5 young hypertensives and 7 elderly hypertensives. Pedal edema was seen in 6 young and 10 elderly hypertensives.

Table 2 shows the distribution of target organ damage in the elderly and the young hypertensives. 123 elderly patients had evidence of cardiovascular complications; of them, 85 showed left ventricular hypertrophy in the echocardiogram. ECG showed left ventricular hypertrophy in 22 of these 85 patients. 26 patients had evidence of ischaemic heart disease and 12 patients were admitted with left ventricular failure. In the young hypertensives, 74 patients had cardiovascular complications; 58 of them had left ventricular hypertrophy in echocardiography. 10 out of these 58 patients had ECG-wise left ventricular hypertrophy, 12 patients had ischaemic heart disease and 4 patients came with left ventricular failure. The increased prevalence of cardiovascular complications in the elderly hypertensives in comparison to the young was statistically significant (p=0.001).

Table 1. Clinical presentation in hypertensives

Symptom/sign	< 40 yr No. (%)	> 60 yr No. (%)	χ2
Headache	68(34)	72(36)	0.176
Dyspnoea	16(8)	22(11)	1.047
Palpitations	12(6)	16(8)	0.514
Chest pain	26(13)	32(16)	0.726
Hemiplegia	3(1.5)	18(9.9)	11.314٭٭٭
Convulsions	2(1)	4(2)	0.671
Loss of consciousness	3(1.5)	11(5.5)	4.738٭
Blurring of vision	0	10(5)	10.256٭٭
Decreased urine output	5(2.5)	7(3.5)	0.344
Pedal edema	6(3)	10(5)	1.042
Routine evaluation	62(31)	56(28)	0.444

٭p<0.05(significant)٭٭p<0.005(highly significant), ٭٭p<0.001(very highly significant)

Table 2. Comparison of distribution of target organ damage in young and elderly hypertensives

Target organ	< 40years No. (%)	> 60yr No. (%)	Total (n)	Z
Cardiac	123(61.5)	74(37)	197	4.901٭٭
CNS	29(14.5)	8(4)	37	3.624٭٭
Renal	49(24.5)	27(13.5)	76	2.804٭
Retinal	83(41.5)	49(24.5)	129	3.615٭٭

Z=Guassian test for proportion ٭p<0.005(highly significant), ٭٭p<0.001(very highly significant)

Cerebrovascular complications were seen in 29 elderly patients, of whom 25 had ischaemic stroke, 3 had haemorrhagic stroke and one patient had hypertensive encephalopathy. Among the young hypertensives, 8 patients had cerebrovascular complications, of whom 6 had ischaemic stroke and 2 had haemorrhagic stroke. Cerebrovascular complications were more frequent in the elderly. The differences between the two groups were statistically significant (p=0.001).

Renal complications in the form of elevated serum creatinine (>1.5mg/dl) and/or proteinuria (>1+) were seen in 49 elderly hypertensives as compared to 27 young hypertensives. Higher prevalence of renal complications in the elderly hypertensives was statistically significant (0.005).

Among the elderly hypertensives, retinopathy was present in 83 patients. Of them 38 had grade 1, 40 grade 2, 3 grade 3 and 2 grade 4 hypertensive retinopathy. Among the young hypertensives, retinopathy was present in 49 patients, of whom 31 had grade 1 retinopathy, 16 grade 2 and 2 grade 3 hypertensive retinopathy. The increased prevalence of hypertensive retinopathy in the elderly hypertensives compared to the young was statistically significant (0.001).

Of the elderly hypertensives, 158 patients had evidence of one or more target organ damage compared to 92 young hypertensives which is statistically significant (p<0.001).

Discussion

The objective of the present study was to compare the clinical profile and target organ damage in young and elderly hypertensives. We have found head ache as the predominant complaint, accounting for 34% young and 36% elderly hypertensives. Apart from headache, other symptoms attributable to target organ damage such as chest pain, palpitation, breathlessness, hemiplegia, convulsions, decreased urine output and pedal edema were present in both elderly and young hypertensives. Page6 also reported headache as the commonest complaint in hypertensive patients. The same study reported cardiovascular symptoms in 29.8% and symptoms suggestive of central nervous system involvement in 22.5% of patients. Study by Kullrami et al⁷ showed headache as the chief complaint presenting in 77.9% patients. Kjellgren et al1 assert that, although many hypertensives have symptoms that they ascribe to their elevated blood pressure, most of these symptoms are due to the functional somatic syndromes seen in people who believe that they have a serious disease. Kaplan et al³ have documented that symptoms like headache and palpitations are more common among hypertensives who are anxious over their diagnosis and its implications.

The primary target organ in hypertension is the arterial system. The pathophysiology of essential hypertension is characterized by increased peripheral vascular resistance due to hypertrophy of arterial vessel walls, which in the elderly is usually associated with a reduction in the cardiac output. In elderly hypertensives, arterial stiffening associated with age and hypertension is caused by the disturbance of the normal elasticity of the arterial wall which is a determinant of systolic blood pressure⁸. In addition, elderly subjects tend to experience modifications in other cardiovascular and renal parameters that regulate arterial blood pressure, such as increased catecholamine levels, reduced renal blood flow, reduced renal natriuretic capacity, reduced glomerular filtration rate and reduced baroreceptor sensitivity. Stress may activate the sympathetic nervous system directly.

Considerable evidence supports the presence of increased sympathetic nervous system activity in early hypertension. Various indices of sympathetic nerve hyperactivity are seen exclusively or mainly in young hypertensives.⁹ Amery et al¹⁰ in their study of 424 elderly hypertensives found cardiovascular complications in 42.5% patients and cerebrovascular complications in 13.7% patients. Our study has shown still higher incidence of cardiovascular complications in elderly hypertensives (61.5%). Study by Coope et al¹¹ in 465 elderly patients showed cardiovascular target organ damage only in 25.9% patients. But in this study also, prevalence of cardiovascular target organ damage was more compared to other target organ damage. Similar observations were made by Kulkarni et al⁷ . Our study has showed cardiovascular target organ damage in 37% of young hypertensive patients. Smith et al¹² showed cardiovascular disease in 29% young patients and Helgeland et al¹³ found 10.6% young hypertensive patients with cardiovascular complications. Hypertension is associated with multiple factors that accelerate coronary artery disease including acceleration of atherosclerotic narrowing of larger coronary arteries, impaired endothelium dependent vasodilatation, limited coronary reserve, with or without LVH^14-16.

In consistent with the earlier studies^17-20, present study has shown higher prevalence of target organ damage in elderly hypertensives as compared to the young (79% vs. 46%, p=0.001). Hypertension causes target organ damage by the direct physical effect of increased blood pressure, as well as the active promotion of atherosclerosis and thrombogenesis. The presence of target organ damage makes a dramatic difference to clinical outcome in hypertension. The “target organ” effects of hypertension are particularly manifest in the heart, brain, kidney, peripheral arteries, and the eye. Indeed, hypertensive patients with evidence of target organ damage are well recognized to be at high risk of cardiovascular and cerebrovascular events, therefore they should be targeted for aggressive blood pressure and risk factor management.

Limitations of inferences from the present study must also be considered. Target organ damage is expected to be more in the elderly due to age-related factors and other comorbid conditions which are more common in this population. Ageing is associated with alterations in left ventricular geometry, concentric remodelling, and increased left ventricular mass^21,22. This occurs in both hypertensive and normotensive subjects with age²³. Left ventricular mass has been found to increase with age independently of blood pressure. Ideally these factors should be considered when comparative analysis for target organ damage is done between elderly and young hypertensives. Also the inclusion of newly detected hypertensives may not be very appropriate as one would definitely expect more prevalence of newly detected hypertension in younger age group. This factor also would have contributed for difference in target organ damage in two groups as target organ damage increases with duration of hypertension.

Key Messages: Hypertension is not limited to elderly population alone, but also involves younger population. This increase may be due to a change in life style leading on to obesity and other risk factors. Prevention and treatment of hypertension and target organ damage remains important public health challenges.

References:

1. Kjellgren K, Ahlener J . Perceived symptoms amongst hypertensive patients in routine clinical practice. J Intern Med 1998;244:325-332.
2. Deguire S, Gevirty R. Hyperventilation syndrome and the assessment of treatment for functional cardiac symptoms. Am J Cardiol 1992;70:673-77.
3. Kaplan NM. Anxiety induced hyperventilation. Arch Intern Med 1997;157:945-48.
4. Stewart IM. Headache and hypertension. Lancet 1953;1:1261-66.
5. The seventh report of joint national committee on prevention, detection, evaluation and treatment of high blood pressure. The JNC 7th report, J Am Med Assoc, 2003;289: 2560-72.
6. Page IH. The nature of arterial hypertension. Arch Intern Med 1963;111:103-15.
7. Kulkarni V, Bhagwat N, Hakim A, Kamath S. Hypertension in the elderly. J Assoc Phys Ind, 2001;49:873-75.
8. O’Rourke M. Systolic blood pressure: arterial compliance and early wave reflection and their modification by antihypertensive therapy. J Human Hyperten, 1989, 3 (suppl.) 1:47-52.
9. Ferrier C, Esler M. Elevated total body noradrenaline spill over in normotensive members of hypertensive families. Clinical Sciences, 1993;84: 225-30.
10. Amery A, Bresiko P, Borkenagar W. Mortality and morbidity results from the European working party on high blood pressure in the elderly trial. The Lancet 1985;1:1349-54.
11. Coope J, Warrender TS. Randomized trial of treatment of hypertension in elderly patients in primary care. Br Med J 1986;293:1145-51.
12. Smith WM. Treatment of mild hypertension. Cric Res 1977;40:98-115.
13. Helgeland A. Treatment of mild hypertension. Am J Med. 1980;69:725-32.
14. De simone G, Devereux RB. Midwall left ventricular mechanics. Circulation 196;93:259-65.
15. Perticone F, Maio R. Relationship between left ventricular mass and endothelium dependent vasodilatation in hypertensive patients. Circulation, 1999; 99:1991-96.
16. Palambo C, Magagna A. Early impairment of coronary flow reserve and increase in coronary resistance in border hypertensive patients. J Hyperten, 2000;18:1355-64.
17. Kohara K, Hiwada K. End organ damage in essential hypertension in the elderly. J Human Hyperten, 1995;9:717-21.
18. Roman O, Badilla M, Roeiquez N. Profile of treated elderly hypertensive patient. Am J Hyperten, 1996;9:1062-7.
19. Canonica V, Forgione L. Difference in blood pressure profile between young and elderly hypertensive patients. J Hum Hyperten, 1990;4:405-9.
20. Puras A, Alcazar JM, Miranda B. Clinical characteristics of arterial hypertension in the elderly. Blood Pressure, 2005;14:25-31.
21. Ganau A, Saba PS, Roman MJ, de Simone G, Realdi G, Devereux RB. Ageing induces left ventricular concentric remodelling in normotensive subjects. J Hypertens. 1995; 13: 1818–1822.
22. Shigematsu Y, Hamada M, Mukai M, Matsuoka H, Sumimoto T, Hiwada K. Clinical evidence for an association between left ventricular geometric adaptation and extracardiac target organ damage in essential hypertension. J Hypertens. 1995; 13: 155– 160.
23. Levy D, Garrison RJ, Savage DD, Kannel WB, Castelli WP. Left ventricular mass and incidence of coronary heart disease in an elderly cohort: the Framingham Heart Study. Ann Intern Med. 1989; 110: 101–107.