Intensive Blood Pressure Control in Elderly Has Benefits—but also Possible Risks

In elderly patients with hypertension, a systolic blood pressure (BP) target of less than 140 mm Hg can improve cardiovascular outcomes. However, this intensive BP-lowering approach also carries potential risks including an increase in renal failure, according to a review and meta-analysis by Chirag Bavishi, MD, MPH, in the Journal of the American College of Cardiology.

Bavishi is affiliated with the Department of Cardiovascular Diseases, Mount Sinai St. Luke’s & Mount Sinai West Hospitals, New York, New York.

The researchers performed a comprehensive literature review to identify randomized controlled trials evaluating the safety and efficacy of intensive versus standard or less intensive BP control for patients aged 65 years or older. Meta-analysis included data on 10,587 patients from four high-quality trials, with a mean follow-up of 3.1 years.

Efficacy outcomes included major adverse cardiovascular events, cardiovascular mortality, stroke, myocardial infarction, and heart failure. Safety evaluation included severe adverse events and the occurrence of renal failure.

In all 4 trials, the intensive therapy group achieved systolic BP of less than 140 mm Hg. Intensive BP control was associated with a 29% reduction in major adverse cardiac events (MACE), a 33% reduction in cardiovascular mortality, and a 37% reduction in heart failure. There was no significant difference in the outcomes of myocardial infarction or stroke.

A random-effects model found no difference in serious adverse events or renal failure between treatments, the researchers said. However, in a fixed-effects model, intensive BP lowering was associated with a significant, twofold increase in the risk of renal failure.

On meta-regression analysis, MACE risk decreased by 3 percentage points for each 1 mm Hg difference in mean achieved systolic BP. The reserachers noticed a similar association for cardiovascular mortality, but not for serious adverse events or renal failure.

The optimal target BP for patients with hypertension is a topic of ongoing controversy. In 2014, the Eighth Joint National Committee recommended a systolic BP target of less than 150 mm Hg in patients aged 60 years or older, compared to the previous target of 140 mm Hg.

The new analysis of high-quality randomized trial data shows that intensive BP reduction in patients aged 65 or older is associated with reductions in MACE, heart failure, and cardiovascular mortality. Although data on adverse events remain limited, Bavishi and his colleagues said, these data suggest a possible increased risk of renal failure at the lower BP target.

Other concerns regarding intensive therapy in this age group include an increased number of antihypertensive drugs and possible increases in other adverse events, including hypotension and syncope. The investigators conclude, “When considering intensive BP control, clinicians should carefully weigh benefits against potential risks”

References

Bavishi C, et al. Outcomes of intensive blood pressure lowering in older hypertensive patients. J Am Coll Cardiol 2017; 69:486–493.

March 2017 (Vol 9, Number 3)