Intensive blood pressure lowering benefits older adults

Lowering systolic blood pressure (SBP) to <120 mmHg (intensive treatment) or <130 mmHg (standard treatment) has reduced the incidence of cardiovascular (CV) outcomes, mortality, and mild cognitive impairment, especially in older people. This was the main conclusion Prof. William Cushman (University of Tennessee Health Science, USA) drew at a seminar discussing the outcomes of the SPRINT trial published over the past 4 years [1].

The ACC/AHA guidelines state that “Treatment of hypertension with a SBP treatment goal of less than 130 mmHg is recommended for non-institutionalised ambulatory community-dwelling adults (≥65 years of age) with an average SBP of 130 mmHg or higher.” According to Prof. Cushman, “We should be treating a lot more individuals in the older population to these goals according to guidelines and the evidence.” Guideline-changing evidence has especially been offered by the randomised controlled SPRINT trial (NCT01206062). The main results were published in 2014 [2], but many additional aspects and subanalyses have been published since.

The SPRINT trial aimed to investigate whether the cardiovascular disease (CVD) composite event rate would be lower in patients assigned intensive compared with standard SBP treatment. A total of 9,361 patients aged ≥50 years with a treated or untreated SBP of 130–180 mmHg were randomised to intensive or standard treatment, with a target SBP of <120 mmHg and <140 mmHg, respectively. Drug classes with the most favourable CVD outcomes in trials were given priority, specifically chlorthalidone and amlodipine. Importantly, blood pressure measurements were obtained after 5 minutes of rest and measurements were automated without clinician presence.

The trial was terminated early after a median 3.26 years owing to a significantly lower rate of the primary composite CV outcome in the intensive-treatment group: HR 0.75 (95% CI 0.64–0.89; P<0.001). HR for all-cause mortality was also significantly lower: 0.73 (95% CI 0.60–0.90; P=0.003) [2]. In 2,510 participants aged ≥75 years, the HR of the primary composite outcome was 0.67 (95% CI 0.51–0.86); the HR of all-cause mortality was 0.68 (95% CI 0.50–0.92). In this subgroup, this translated into a number-needed-to-treat of 28 and 41 for both endpoints, respectively [3].

The subgroup of patients considered frail (n=815) had a higher event rate but had at least the same benefit from intensive treatment: HR 0.68 (95% CI 0.45–1.02; P_interaction=0.84). In patients with dementia, the benefit failed to reach significance (HR 0.83; 95% CI 0.67–1.04; P=0.10) [4]. A substudy with brain MRIs showed a slower progression of blood pressure related white matter brain lesions in mild cognitive impairment and in dementia: HR 0.81 (95% CI 0.70–0.95; P=0.01) and 0.85 (95% CI 0.74–0.97; P=0.02), respectively [4]. There was no difference in the risk of serious adverse events in the overall trial (HR 1.00; P=0.93) [3]. In intensively treated patients the risk of orthostatic hypotension was significantly reduced: OR 0.89 (95% CI 0.80–0.98; P=0.02) [5].

Prof. Cushman concluded with the following recommendations to clinicians caring for older patients:

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    • Be mindful of blood pressure goals in this population.
    • Be attentive to proper blood pressure measurement technique to apply the goals correctly.
    • Encourage prudent non-pharmacological interventions.
    • Monitor patients appropriately for concomitant conditions, adverse drug events, and complications of hypertension.
    • Adjustment to therapy and therapy goals may be necessary for certain conditions, such as autonomic dysfunction, or as older adults become increasingly frail, cognitively impaired, institutionalised, or have a limited life expectancy.

1. 
   
   1. Cushman WC. Hypertension in Older Adults: SPRINT or Marathon? GR.CVS.446, AHA Scientific Sessions 2020, 13–17 Nov.
   2. SPRINT Research Group. N Engl J Med 2015;373:2103–16.
   3. Williamson JD, et al. JAMA 2016;315(24):2673–82.
   4. The SPRINT MIND Investigators for the SPRINT Research Group. JAMA 2019;321(6):553-61.
   5. Juraschek SP, et al. Ann Intern Med. 2021;174(1)58-68.

 



Posted on 18 February, 202125 March, 2024