Lowering Target Level of Systolic Blood Pressure for Older Adults Reduces Rate of Cardiovascular Events, Death

Among adults 75 years of age or older, treating to a systolic blood pressure target of less than 120 mm Hg compared with less than 140 mm Hg resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause, according to a study published online by JAMA. The study is being released to coincide with its presentation at the American Geriatrics Society Annual Scientific Meeting.1

In the United States, 75 percent of persons older than 75 years have hypertension, for whom cardiovascular disease complications are a leading cause of disability, illness and death. The optimal systolic blood pressure (SBP) treatment target in geriatric populations with hypertension remains uncertain. Jeffrey D. Williamson, M.D., M.H.S., of the Wake Forest School of Medicine, Winston-Salem, N.C., and colleagues analyzed a subgroup (persons age 75 years or older with hypertension but without diabetes) in the Systolic Blood Pressure Intervention Trial (SPRINT) who were randomly assigned to an SBP target of less than 120 mm Hg (intensive treatment group, n = 1,317) or an SBP target of less than 140 mm Hg (standard treatment group, n = 1,319).

Among the participants (average age, 80 years; 38 percent women), 95 percent provided complete follow-up data. At a median follow-up of 3.1 years, there was a significantly lower rate of the primary composite outcome (nonfatal heart attack, acute coronary syndrome not resulting in a heart attack, nonfatal stroke, nonfatal acute decompensated heart failure, and death from cardiovascular causes; 102 events in the intensive treatment group vs 148 events in the standard treatment group). There was also a significantly lower rate of all-cause death (73 deaths vs 107 deaths, respectively).

Additional analysis suggested that the benefit of intensive BP control was consistent among persons in this age range who were frail or had reduced gait speed.

The overall rate of serious adverse events was not different between treatment groups.

“Considering the high prevalence of hypertension among older persons, patients and their physicians may be inclined to underestimate the burden of hypertension or the benefits of lowering BP, resulting in undertreatment. On average, the benefits that resulted from intensive therapy required treatment with 1 additional antihypertensive drug and additional early visits for dose titration and monitoring,” the authors write.

“Future analyses of SPRINT data may be helpful to better define the burden, costs, and benefits of intensive BP control. However, the present results have substantial implications for the future of intensive BP therapy in older adults because of this condition’s high prevalence, the high absolute risk for cardiovascular disease complications from elevated BP, and the devastating consequences of such events on the independent function of older people.”

“Currently, more than 40 percent of persons with hypertension in the United States do not have their blood pressure controlled to levels less than 140/90 mm Hg, and if the goal SBP were reduced to less than 130 mm Hg, more than one-half of persons with hypertension would be considered to have uncontrolled blood pressure,” writes Aram V. Chobanian, M.D., of the Boston University School of Medicine, in an accompanying editorial.2

“Achieving the SBP goal of less than 130 mm Hg may be challenging for clinicians, because doing so could require use of additional medications, more careful monitoring, and more frequent clinic visits. Nevertheless, the important results reported by Williamson et al in this issue of JAMA cannot be discounted, and unless unexpected adverse effects are observed on further examination of the trial data, then major changes in treatment goals for patients 75 years or older with hypertension will be warranted.”

References

1. doi:10.1001/jama.2016.7050;

2. doi:10.1001/jama.2016.7070;