Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents (The PARTAGE Study)

Justin Kyei-Frimpong, PharmD candidate 2015, Mercer University College of Pharmacy

According to the Eight Joint National Commission (JNC8), hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately.1 The American College of Cardiology Foundation/American Heart Association (ACC/AHA) 2011 expert consensus document on hypertension in the elderly mentioned that, for individuals older than 80 years, a systolic blood pressure (SBP) goal between 140 to 145 mmHg, if tolerated, can be acceptable.   However, the ACC/AHA further recommend that SBP less than 130 and diastolic blood pressure (DBP) less than 65 mmHg should be avoided in the elderly.2 The effects of low blood pressure in institutionalized, frail, and elderly patients has not has not been adequately studied and the researchers of the Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population (PARTAGE) study aim to fill this void.

Title: Treatment with multiple blood pressure medications, achieved blood pressure, and mortality in older nursing home residents (The PARTAGE Study)3
Design Multicenter, longitudinal study; 1127 participants
Objective To assess all-cause mortality in institutionalized individuals older than 80 years according to SBP levels and number of antihypertensive drugs
Study groups SBP<130 + (one antihypertensive drug) n=149

SBP>130 + (one antihypertensive drug) n=328

SBP<130 + (≥2 antihypertensive drugs) n=227

SBP>130 + (≥2 antihypertensive drugs) n=423

Methods A total of 18 measurements (three in the morning and evening during three consecutive days) were taken. Morning BP measurements were carried out from 8AM to noon and evening BP measurements from 3PM to 6PM. The mean of these 18 measurements was used for the present analyses with focus being placed on SBP.
Duration Two years
Baseline Characteristics All patients met the following criteria:

  • SBP<140mmHg
  • Taking ≥ 1 Blood pressure drug
  • Age >80 years
Results SBP<130 + ≥2 drugs had 32.2 deaths (P<0.001)

SBP<130 + one drug had 17.5 deaths (P=0.72)

SBP>130 + ≥2 drugs had 20.1 deaths (P=0.72)

SBP>130 + one drug had 20.1 deaths (P=0.72)

Patients with SBP<130 who were receiving multiple BP medicines had an 81% excess of risk and lower survival rate (unadjusted HR, 1.81; 95% CI, 1.36-2.41; P < .001). Survival rates in the 3 other therapy subgroups did not differ significantly (P = 0.72)

Adverse Events None Reported
Study Author Conclusions The findings of this study raise a cautionary note regarding the safety of using combination antihypertensive therapy in frail elderly patients with low SBP

This study aimed to assess the effects of low blood pressure and antihypertensive drugs on mortality in institutionalized octogenarians. The authors suggest that  low blood pressure with the use of multiple antihypertensive medications contributes to mortality in the elderly. A recommendation which can be inferred from this study is in the treatment of hypertension in the elderly,drastic reduction in blood pressure should be done slowly and carefully with appropriate assessment of the benefits and risks to the patient.

References
1. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-20.
2. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol. 2011;57(20):2037-2114.
3. Benetos A, Labat C, Rossignol P et al. Treatment With Multiple Blood Pressure Medications, Achieved Blood Pressure, and Mortality in Older Nursing Home Residents. JAMA Internal Medicine. 2015. doi:10.1001/jamainternmed.2014.8012.

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