Are We Enough Cautious Regarding Blood Pressure Management in Older Adults as a Stroke Preventive Measure?
Year: 2024
Type: article
Abstract: Sir, Blood pressure is the most common modifiable risk factor for stroke and the Asian population compared to the West have higher nocturnal and early morning blood pressure levels. The Asian population has a higher incidence of intracerebral hemorrhage (ICH), and hypertension is the most important cause. Other common causes of ICH (other than hypertension) are head trauma, arteriovenous malformations, coagulation disorders (including oral anticoagulant-induced), amyloid angiopathy, smoking, and low apoB. Now hypertension is also an important association of these ICHs because hypertensive surges (if not controlled) may precipitate or aggravate the bleeds that have already occurred, making the situation worse. Older adults are the worst sufferers as they have additional reasons for blood pressure fluctuations and are often difficult to control. The specific reasons for that are: High incidence of autonomic nervous system dysfunction: 85% of 928 participants with a median of 68 years were noted to have at least one autonomic sign.[1] Increased incidence of diabetic autonomic neuropathies or other small fiber neuropathies, arrhythmias, thyroid disease, heart failure, and neurodegenerative disorders like atypical parkinsonism. Prominent presence of “Labile hypertension” and emotional liability in this group. More stringent lookout for autonomic nervous system dysfunction and 24-hour ambulatory blood pressure monitoring is necessary as blood pressure may fluctuate in the elderly with nobody’s knowledge. We need to use smartwatches more widely to detect autonomic fluctuations, especially heart rate variability, and intervene at the earliest opportunity. Increased stress after recent stressful life events is significantly associated with an increased risk of acute stroke on a multivariable analysis.[1] This needs to be addressed in elderly patients, as some of them unknowingly may also have labile hypertension; adding fuel to the fire. These patients with (labile hypertension) with age over 60 years may have short-term, symptomatic fluctuations in blood pressure and develop both hypertensive and hypotensive episodes. The pathogenesis is linked to disorders of autonomic regulation of heart rate, decreased parasympathetic regulation, anxiety, and depression.[2] Interestingly, clonazepam 1–2 mg/day stabilized blood pressure in 82% of these patients.[2] Thus, the identification of these patients is important and more research is required to identify them to avoid many catastrophic events in the future. The increased stress may lead to skipping of the antihypertensives, and thus, adherence to daily antihypertensive medications, especially in older adults, is another important point of concern. In a study, the proportion of patients with good adherence was not satisfactory and gradually decreased with time poststroke (46.8% at one year, 43.2% at three years, and 41.7% at five years of follow-up).[3] In India, the scenario was found to be grimmer: high adherence was seen in 46% of the patients, while medium and low adherence was seen in 41.3% and 12.7%, respectively.[4] As the families are becoming more and more nuclear, we are losing overseers. The specialized medicine boxes or electronic pillbox may aid adherence by providing visual cues of whether the person has taken the medication or not. Stroke is rising sharply in younger people, and most of them are not routinely checked up for standard modifiable risk factors for stroke, commonly hypertension, which goes undetected until they land up with an emergency. Their increased exposure to “silent risk factors” like stress, substance abuse, and sedentary lifestyle are like slow poisoners, and many of them are found to have minor strokes already in the past (which went undetected) when they ultimately reach doctors with a more obvious one. More stroke programs are required to screen people, keeping in mind all of these to save millions of lives. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Neurology India
Author: Debabrata Chakraborty
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4409106171