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Outcomes of Intensive Blood Pressure Lowering in Older Hypertensive Patients

Chirag Bavishi1, Sripal Bangalore2, Franz H Messerli3

  • 1Department of Cardiovascular Diseases, Mount Sinai St. Luke's & Mount Sinai West Hospitals, New York, New York.

Journal of the American College of Cardiology
|February 4, 2017
PubMed

Insights

Intensive blood pressure (BP) control in older adults significantly reduced major adverse cardiovascular events (MACE), cardiovascular mortality, and heart failure. However, it may increase the risk of renal failure, requiring careful consideration of benefits versus risks.

Area of Science:

  • Cardiology
  • Geriatrics
  • Nephrology

Background:

  • The 2014 Eighth Joint National Committee (JNC 8) guidelines suggested a systolic blood pressure (BP) target of <150 mm Hg for individuals aged 60 years and older.
  • This recommendation differed from previous guidelines, which recommended a target of <140 mm Hg.

Purpose of the Study:

  • To evaluate the efficacy and safety of intensive BP-lowering strategies in hypertensive patients aged 65 years and older.
  • To assess the impact of intensive BP control on major adverse cardiovascular events (MACE), cardiovascular mortality, stroke, myocardial infarction, and heart failure.
  • To examine the safety profile, including serious adverse events and renal failure, associated with intensive BP management.

Main Methods:

  • A systematic review and meta-analysis of randomized controlled trials (RCTs) published from 1965 to July 1, 2016.
  • Searched databases included MEDLINE, Scopus, EMBASE, and Cochrane.
  • Pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random and fixed effects models.

Main Results:

  • Four high-quality RCTs involving 10,857 older hypertensive patients were analyzed, with a mean follow-up of 3.1 years.
  • Intensive BP lowering significantly reduced MACE by 29% (RR: 0.71; 95% CI: 0.60 to 0.84), cardiovascular mortality by 33% (RR: 0.67; 95% CI: 0.45 to 0.98), and heart failure by 37% (RR: 0.63; 95% CI: 0.43 to 0.99).
  • No significant differences were observed in myocardial infarction or stroke rates. Serious adverse events were similar, but a fixed-effects model suggested an increased risk of renal failure with intensive BP lowering (RR: 2.03; 95% CI: 1.30 to 3.18).

Conclusions:

  • Intensive BP control (systolic BP <140 mm Hg) in older hypertensive patients effectively reduces MACE, including cardiovascular mortality and heart failure.
  • While data on adverse events were limited, an increased risk of renal failure was suggested, particularly under fixed-effects modeling.
  • Clinicians must carefully balance the benefits of intensive BP control against potential risks, such as renal failure, in older hypertensive individuals.
Abstract

Keywords:
blood pressurehypertensionolder adultsprognosis

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