1. Combination anti-hypertensive therapy (i.e., two or more agents) and low systolic blood pressure (i.e., <130 mmHg) were associated with increased all-cause mortality in elderly patients in nursing homes. The risk of mortality was higher for patients with both risk factors than for those with only one or the other.
2. The increased mortality risk persisted after adjustment for possible confounding cofactors, as well as after sensitivity analyses.
Evidence Rating Level: 2 (Good)
Study Rundown: Blood pressure management in the elderly remains a controversial topic. While hypertension control can provide cardiovascular benefits, aggressive management and polypharmacy may result in drug interactions and a higher incidence of side effects. Current guidelines suggest lowering systolic blood pressure to between 140 to 145 mmHg, if tolerable. However, these recommendations are based on studies that excluded patients with many comorbidities, which may limit generalizability. This study examined mortality in frail elderly patients in nursing homes with a systolic blood pressure (SBP) below 130 mmHg and receiving more than two antihypertensive medications.
After two years of follow-up, the authors found that lower SBP and combination antihypertensive therapy were associated with a higher rate of all-cause mortality. Strengths of this study include the broad inclusion criteria. However, since only nursing home residents were studied, this limits the generalizability of the results to elderly patients not in nursing homes. Moreover, the observational design limits the study’s ability to make statements about causation regarding mortality.
Relevant Reading: Hypertension in the elderly: an evidence-based review.
In-Depth [prospective cohort]: The PARTAGE (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population) trial was a multicenter longitudinal study conducted in France. A total of 1,130 patients at nursing homes across France over the age of 80 were included for study. Morning and evening blood pressure measurements were taken, three times each, for three consecutive days. This resulted in 18 measurements, which were subsequently averaged and included the analysis. The primary endpoint was all-cause mortality.
There was a significantly higher rate of the primary endpoint in patients with SBP less than 130 mmHg (HR 1.36, 95%CI 1.06-1.75, P=0.02), though the difference was not significant for those on combination antihypertensive medications (HR 1.28, 95%CI 0.99-1.65, P=0.06). This was even higher for patients with both low SBP and on combination antihypertensive medications (HR 1.81, 95%CI 1.36-2.41, P<0.001). After adjusting for other variables independently associated with mortality (i.e., age, male sex, low body mass index, and indices of comorbidity and disability), the increased risk of all-cause mortality persisted (HR 1.78, 95%CI 1.34-2.37, P<0.001). This was also true after sensitivity analysis with propensity score-matched subsets (adjusted HR 2.05), cardiovascular comorbidity adjustment (HR 1.73), and excluding patients without a history of hypertension receiving antihypertensive medications (aHR 1.76).
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