Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years

Linh Nguyen, Mercer University College of Pharmacy

 

The Eighth Joint National Committee (JNC 8) guideline states that the goal blood pressure for patients 60 years of age and older without diabetes and chronic kidney disease (CKD) is less than 150/90. [1]

The clinical practice guideline for the management of hypertension in the community by American Society of Hypertension (ASH) recommends the treatment goal for blood pressure in patients 80 years of age and older is less than 150/90 and 140/90 for patients that are younger than 80 years of age. [2]

 

 

Title: Intensive versus (vs) Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years [3]
Design Randomized, controlled, open-label clinical trial; N= 2,636
Objective To evaluate the effects of intensive (<120mmHg) compared with standard (<140mmHg) Systolic Blood Pressure (SBP) targets in persons aged 75 years or older with hypertension but without diabetes
Study Groups Intensive treatment with SBP goal < 120 mmHg (n= 1,317); standard treatment with SBP goal < 140 mmHg (n= 1,319)
Methods Patients were randomized to either intensive treatment or standard treatment group. The drug therapy and dosage were depended on physician choice and mean of blood pressure at office visit to maintain blood pressure at goal at assigned. Inclusion criteria: patient age of 75 years or older, having risk for cardiovascular disease. Exclusion criteria: type two diabetes, history of stroke, heart failure with left ventricular ejection fraction less than 35%, dementia, less than three years expected survival, weight loss more than 10% in six months unintentionally, resident of a nursing home
Duration October 20, 2010 to August 20, 2015
Primary Outcome Measure Any cardiovascular outcome including nonfatal myocardial infarction, acute coronary syndrome not leading to myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death from cardiovascular causes
Baseline Characteristics Intensive treatment (n= 1,317) Standard treatment (n= 1,319)
Age (mean years) 79.8 79.9
Female (%) 37.9 38.0
Race/ethnicity (%) White 74.2 74.8
Black 17.1 17.1
Hispanic 6.8 6.4
Other 2.0 1.6
Mean blood pressure (mean mm Hg) Systolic 141.6 141.6
Diastolic 71.5 70.9
Orthostatic hypotension 9.6 9.4
Results Intensive treatment, % (95% CI) with outcome events per year Standard treatment, % (95% CI) with outcome events per year Hazard ratio (HR) (95% CI) p value
Cardiovascular outcome 2.59 (2.13-3.14) 3.58 (3.28-4.53) 0.66 (0.51-0.85) 0.001
Adverse Events Common Adverse Events: N/A
Severe Adverse Events: overall severe adverse events 48.4% vs 48.3%, hypotension 2.4% vs 1.4%, syncope 2.4% vs 1.4%, electrolyte abnormalities 4.0% vs 2.7, acute kidney failure 5.5% vs. 4.0%, injurious falls 4.9% vs. 5.5%, and orthostatic hypotension plus dizziness 1.9% vs 1.3% in comparing intensive treatment group vs standard treatment group
Percentage that Discontinued due to Adverse Events: 6.2% in intensive treatment vs. 6.4% in standard treatment
Study Author Conclusions Among ambulatory adults aged 75 years or older, treating to an SBP target of less than 120mmHg compared with an SBP target of less than 140mmHg resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause.

 

Currently, JNC 8 and ASH recommend to control blood pressure in elderly less intensively (less than 150/90 mmHg) with 60 years of age or older per JNC 8 and 80 years of age or older per ASH. This study, derived from the Systolic Blood Pressure Intervention Trial (SPRINT), shows that intensively controlled systolic blood pressure of less than 120 mmHg in patient aged 75 years or older has more protection in cardiovascular events compare to standard treatment group of less than 140 mmHg. Therefore, the study supports the intensive blood pressure treatment goal in elderly patients. However, the study did not include patients with diabetes or living in a nursing home. More studies are needed to support intensive blood pressure treatment goal for the update of guidelines in treating patients with hypertension.

 

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 2013 Dec 18. doi: 10.1001/jama.2013.284427.
  2. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens (Greenwich) 2013 Dec 17. doi: 10.1111/jch.12237.
  3. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years: A Randomized Clinical Trial. Published online May 19, 2016. doi:10.1001/jama.2016.7050.

 

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