Kathleen Louden

May 26, 2015

NATIONAL HARBOR, Maryland — Elderly patients do not seem to benefit from aggressive systolic blood pressure control to below 120 mm Hg, according to a new study. In fact, it is associated with an increase in cardiovascular events and risk for falls.

"We should help our patients have moderate but not overly aggressive blood pressure control," said principal investigator Lillian Min, MD, from the University of Michigan in Ann Arbor.

"As our patients get older, they may not need to be on so many blood pressure medications, especially if their blood pressure declines," she told Medscape Medical News here at the American Geriatrics Society 2015 Annual Scientific Meeting.

Dr Min's team wanted to determine whether the risk for falls associated with overly aggressive hypertension treatment would be outweighed by the therapy's potential cardiovascular benefit as people age.

They evaluated a longitudinal sample of 5157 participants from the biennial University of Michigan Health and Retirement Study who were 65 years and older, had self-reported hypertension, and were taking medications to lower blood pressure. Mean age of the participants was 75 years, and 58% were female.

 
As our patients get older, they may not need to be on so many blood pressure medications, especially if their blood pressure declines.
 

All study participants underwent a single blood pressure measurement in either 2008 or 2010. Two years later, they completed a health survey that asked about fall injuries requiring medical treatment and the occurrence of cardiovascular events, such as stroke, myocardial infarction, and acute heart failure.

Multinomial logistic regression was used to calculate net changes in medically controlled blood pressure, after age and sex were controlled for.

The risk for injurious falls increased with age, and falls were more prevalent than cardiovascular events in the sample (14% vs 6%).

For 64% of the patients, treatment led to systolic blood pressure of 121 to 159 mm Hg, which was considered adequate.

For 18% of patients, treatment led to systolic blood pressure below 120 mm Hg, which was considered overaggressive. In this group of patients, mean systolic pressure was 110 mm Hg.

When cardiovascular events and fall injuries were counted together for patients older than 73 years, the harm associated with overaggressive treatment became evident. The difference in events between adequate and overaggressive treatment was significant (< .05).

Study limitations included the lack of multiple blood pressure measurements over time and the lack of data on dose and class of antihypertensive agents, Dr Min acknowledged.

Guidelines Unclear on How Low to Go

The guidelines for hypertension management from the Eighth Joint National Committee recommend treating systolic blood pressure to below 150 mm Hg for patients 60 years and older without diabetes or chronic kidney disease (JAMA. 2014;311:507-520). But the guidelines are silent on what to do about blood pressure below 120 mm Hg that results from multiple blood pressure medications, Dr Min pointed out.

"The potential practice change should be to moderate the blood pressure medications we prescribe as patients age to keep the blood pressure at or near what the guidelines recommend," she said.

In contrast to the joint national guidelines, the American Heart Association recommends that hypertension treatment aim for a blood pressure of 140/90 mm Hg until age 80, after which the goal should be 150/90 mm Hg.

"More research needs to be done in real-world clinics caring for older patients with multiple chronic conditions," said Dr Min.

Falls Not the Only Risk

"This is not the first study to suggest negative consequences of treating older persons undergoing antihypertensive treatment to an SBP below 120 mm Hg," said Michael Rich, MD, from Washington University in St. Louis, Missouri.

In one study, progression of cognitive decline was greater in older patients with cognitive impairment whose SBP was below 128 mm Hg (JAMA Intern Med. 2015;175:578-585).

The "take-home message" from that study and the one by Dr Min's team "is that an SBP of less than 120 mm Hg in an older population, particularly those with multimorbidities, is probably too low," said Dr Rich.

Given that no published study has found an advantage to treating systolic pressure to below 120 mm Hg, Dr Rich suggested that a safer target for elderly patients with hypertension would be 120 to 140 mm Hg for those younger than 80 years and 130 to 150 mm Hg for those 80 years and older.

Still, Dr Rich said he does not believe that the 18% prevalence of the overtreated patients in this study was the result of intentional lowering of systolic pressure below 120 mm Hg.

"I think it was probably a combination of medications and illnesses that contributed," he explained.

This study was supported by the University of Michigan Claude D. Pepper Older Americans Independence Center, the John A. Hartford Foundation, and the Department of Veteran Affairs Geriatric Research, Education, and Clinical Centers. The Health and Retirement Survey receives funding from the National Institute on Aging and the Social Security Administration. Dr Lin and Dr Rich have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2015 Annual Scientific Meeting: Abstract P22. Presented May 16, 2015.

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