Review suggests use of standard rather than intensive blood pressure treatment in the elderly

1. In adults ≥60 years of age with a chronic systolic blood pressure (SBP) ≥150 mm Hg who are otherwise healthy, treatment to current BP guidelines (<150/90 mm Hg) greatly reduces mortality, stroke, and cardiac events.

2. Lower BP targets were linked to syncope, hypotension, and greater medication burden, but varying evidence suggests that SBP targets <120 mm Hg may be of benefit to high-risk patients.

Evidence Rating Level: 1 (Excellent)

Study Rundown: New guidelines in 2014 recommended a SBP lower than 150 mm Hg for adults ≥60 years of age, but there was controversy regarding the benefits and harms of more versus less intensive BP lowering. This systematic review and meta-analysis studied the effects of standard versus intensive blood pressure control in the elderly by evaluating 21 randomized, controlled trials (RCTs) comparing treatment intensity and 3 observational studies analyzing harms. The authors found that treatment to current BP guidelines (<150/90 mm Hg) greatly improved health outcomes (reduction in mortality, stroke, and cardiac events) in the elderly. There was varying evidence that SBP targets <120 mm Hg are of benefit to high-risk patients. Lower BP targets were linked to syncope, hypotension, and greater medication burden. Therefore, data suggests that less intensive SBP targets may offer a suitable balance between benefits and risks for adults ≥60 years of age with a chronic SBP ≥150 mm Hg who are otherwise healthy.

Strengths of this review include focus on older adults, comprehensive examinations of both short- and long-term harms, and evaluation of studies that specifically compared BP treatment targets. Limitations include heterogeneity in treatment, patient population, and co-interventions that may affect analysis of treatment effects. Also, little data is available regarding antihypertensive treatment in patients with multiple comorbidities. In addition, the authors were unable to ascertain how medication class selection may have impacted results.

Click to read the study, published today in Annals of Internal Medicine

Relevant Reading: A randomized trial of intensive versus standard blood pressure control

In-Depth [systematic review and meta-analysis]: This study used multiple databases through January 2015 and MEDLINE through September 2016 to review the effects of standard versus intensive blood pressure control in the elderly. The authors selected 46 publications encompassing 21 RCTs and 3 cohort studies for analysis. Nine trials showed that patients with moderate to severe hypertension (SBP ≥160 mm Hg) had greatly improved health outcomes with intensive BP treatment. Four trials of patients with mild hypertension (SBP <160 mm Hg) also demonstrated some benefit, but results were inconsistent. The outcomes studied were mortality, stroke, and cardiac events (myocardial infarction and sudden cardiac death) after a minimum of 6 months of treatment. The authors evaluated the harms of quality of life, cognitive impairment, functional status, syncope, hypotension, acute kidney injury, fractures, and falls. Generally, patients attaining SBP of 140 mm Hg or lower had results similar to patients attaining SBP below 140 mm Hg. Nine trials had high-strength evidence demonstrating that BP control to below 150/90 mm Hg decreases mortality (relative risk [RR] 0.90; 95%CI 0.83 to 0.98), stroke (RR 0.74; CI 0.65 to 0.84), and cardiac events (RR 0.77; CI 0.68 to 0.89). Six trials had evidence of low to moderate strength that BP targets ≤140/85 mm Hg are linked to a nonsignificant decrease in mortality (RR 0.86; CI 0.69 to 1.06]) and marginally significant reductions in stroke (RR 0.79; CI 0.59 to 0.99]) and cardiac events (RR 0.82; CI 0.64 to 1.00).

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