By Harold L. Karpman, MD, FACC, FACP
Clinical Professor of Medicine, David Geffen School of Medicine at UCLA
Dr. Karpman reports no financial relationships relevant to this field of study.
SYNOPSIS: In elderly, hypertensive patients, intensive blood pressure (BP) control (systolic BP < 140 mmHg) decreased major adverse cardiovascular events, including cardiovascular mortality and heart failure.
SOURCE: Bavishi C, Bangalore S, Messerli FH. Outcomes of intensive blood pressure lowering in older hypertensive patients. J Am Coll Cardiol 2017;69:486-493.
The prevalence of hypertension is expected to increase in the United States in parallel with the rapidly aging population for whom cardiovascular disease remains the major cause of mortality and morbidity.1 The 2014 Eighth Joint National Committee (JNC 8) panel recommended a therapeutic target systolic blood pressure (BP) of < 150 mmHg in patients > 60 years of age, which was a departure from the prior recommendation of < 140 mmHg.2 Bavishi et al decided to assess the efficacy and safety of intensive BP lowering strategies in older (age > 65 years) hypertensive patients based on the available evidence from all randomized, controlled trials (RCTs). They conducted a systematic search, without language restriction, from 1965 through July 1, 2016, for RCTs comparing intensive BP lowering vs. standard/liberal BP lowering in older hypertensive patients. In addition, they performed manual searches through the reference lists of studies, reviews, and pertinent meta-analyses. They systematically evaluated cardiovascular outcomes, including major adverse cardiovascular events (MACE), cardiovascular mortality, stroke occurrence, myocardial infarction (MI), and heart failure (HF) occurrence.
The authors performed statistical analyses carefully, recognizing that the heterogeneity of the included trials might influence the treatment effect. The search identified 22 potential RCTs, but most of the trials did not provide separate results for adults ≥ 65 years of age. Only four trials met the established eligibility criteria. A total of 10,857 older hypertensive patients from the four RCTs were included in the final analyses. From these studies, 5,437 patients were randomized to the intensive BP control group, whereas 5,420 patients were randomized to the standard BP control group. The mean follow-up duration across the trial was 3.1 years. One trial excluded patients with diabetes, and the proportion of patients with diabetes in the other three trials was relatively low. All four trials were considered to be of high quality without evidence of significant bias. The authors found that the intensive BP control strategy significantly decreased MACE by 29% and cardiovascular mortality by 33% when compared to the standard BP control group. Rates for MI were lower but not by statistically significant numbers, and the risk for HF was significantly lower in the intensive BP lowering group. There was no significant difference in overall incidence of serious adverse events between the intensive and standard BP lowering groups.
COMMENTARY
In their data analysis, Bavishi et al demonstrated that intensive BP control was associated with a significant reduction in MACE and cardiovascular mortality and that the incidence of MI and stroke were diminished in the intensive control group, although not to a statistically significant degree. Notably, the intensive antihypertensive therapy in older age groups was associated with a two-fold increase in risk for renal failure, although there were no significant differences in the reduction in estimated glomerular filtration rate, dialysis treatment, or renal transplant occurrence between the two groups. However, in participants who suffered from chronic kidney disease at baseline, there was a higher incidence of renal failure. Therefore, cardiovascular benefits of intensive therapy may come at the expense of an increase in renal events, occurring even in participants without chronic kidney disease at baseline in the intensive treatment group compared with the standard treatment groups. Importantly, patients in the intensive treatment group were found to use a higher number of antihypertensive medications in all trials. High medication dosages to achieve desired BP levels could increase adverse effects substantially.
Intensive BP control achieving systolic BPs < 140 mmHg decreased MACE, including cardiovascular mortality and HF. Although the data on adverse events were limited, the observed results suggested an increased risk of renal failure with intensive therapy. Therefore, clinicians should balance the achieved benefits against the potential risks of intensive therapy carefully.
REFERENCES
- Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics — 2015 update: A report from the American Heart Association. Circulation 2015;131:e29-322.
- 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;311:507-520.
In elderly, hypertensive patients, intensive blood pressure (BP) control (systolic BP < 140 mmHg) decreased major adverse cardiovascular events, including cardiovascular mortality and heart failure.
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