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Anti-hypertensive medications and cardiovascular events in older adults with multiple chronic conditions
Mary E Tinetti1, Ling Han2, Gail J McAvay2
1Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America; Yale School of Public Health, New Haven, Connecticut, United States of America.
Insights
In older adults, anti-hypertensive medication lowered mortality risk but did not reduce cardiovascular events. This study questions the generalizability of randomized trial findings to diverse patient populations with multiple chronic conditions.
Area of Science:
- Gerontology
- Cardiovascular Medicine
- Pharmacology
Background:
- Randomized trials on anti-hypertensive treatment in older adults often exclude individuals with multiple comorbidities.
- The generalizability of these findings to the broader elderly population with complex health conditions is uncertain.
Purpose of the Study:
- To investigate the association between anti-hypertensive medication use and cardiovascular events and mortality in a national sample of older adults.
- To assess if treatment intensity influences these outcomes.
Main Methods:
- A competing risk analysis was conducted using the Medicare Current Beneficiary Survey cohort.
- Propensity score adjustment and matching were employed for analysis over a three-year follow-up.
- The study included 4,961 community-living older adults with hypertension.
Main Results:
- Neither moderate nor high anti-hypertensive intensity was associated with a reduced risk of cardiovascular events.
- Anti-hypertensive treatment was linked to a significant reduction in mortality risk across all participants.
- In participants who experienced cardiovascular events, higher intensity anti-hypertensive treatment was associated with lower mortality.
Conclusions:
- Anti-hypertensive treatment in a nationally representative cohort of older adults demonstrated a significant association with reduced mortality.
- The study suggests that current evidence from randomized trials may not fully apply to older adults with multiple chronic conditions.
- Further research is needed to clarify the benefits of anti-hypertensive therapy in complex geriatric populations.
Importance:
Randomized trials of anti-hypertensive treatment demonstrating reduced risk of cardiovascular events in older adults included participants with less comorbidity than clinical populations. Whether these results generalize to all older adults, most of whom have multiple chronic conditions, is uncertain.
Objective:
To determine the association between anti-hypertensive medications and CV events and mortality in a nationally representative population of older adults.
Design:
Competing risk analysis with propensity score adjustment and matching in the Medicare Current Beneficiary Survey cohort over three-year follow-up through 2010.
Participants And Setting:
4,961 community-living participants with hypertension.
Exposure:
Anti-hypertensive medication intensity, based on standardized daily dose for each anti-hypertensive medication class participants used.
Main Outcomes And Measures:
Cardiovascular events (myocardial infarction, unstable angina, cardiac revascularization, stroke, and hospitalizations for heart failure) and mortality.
Results:
Of 4,961 participants, 14.1% received no anti-hypertensives; 54.6% received moderate, and 31.3% received high, anti-hypertensive intensity. During follow-up, 1,247 participants (25.1%) experienced cardiovascular events; 837 participants (16.9%) died. Of deaths, 430 (51.4%) occurred in participants who experienced cardiovascular events during follow-up. In the propensity score adjusted cohort, after adjusting for propensity score and other covariates, neither moderate (adjusted hazard ratio, 1.08 [95% CI, 0.89-1.32]) nor high (1.16 [0.94-1.43]) anti-hypertensive intensity was associated with experiencing cardiovascular events. The hazard ratio for death among all participants was 0.79 [0.65-0.97] in the moderate, and 0.72 [0.58-0.91] in the high intensity groups compared with those receiving no anti-hypertensives. Among participants who experienced cardiovascular events, the hazard ratio for death was 0.65 [0.48-0.87] and 0.58 [0.42-0.80] in the moderate and high intensity groups, respectively. Results were similar in the propensity score-matched subcohort.
Conclusions And Relevance:
In this nationally representative cohort of older adults, anti-hypertensive treatment was associated with reduced mortality but not cardiovascular events. Whether RCT results generalize to older adults with multiple chronic conditions remains uncertain.
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