COMMENTARY

Can Tight Blood Pressure Control Prevent Dementia?

Richard S. Isaacson, MD

Disclosures

October 29, 2018

I am Dr Richard Isaacson, director of the Alzheimer's Prevention Clinic at Weill Cornell Medicine and NewYork-Presbyterian. I'm here to talk about some very exciting results from the SPRINT MIND study, which may be the strongest evidence to date that it really is possible to delay or possibly prevent the onset of mild cognitive impairment and dementia.[1]

The SPRINT MIND trial was a study that looked at patients who had a variety of levels of blood pressure control. The usual group tried to get a target level of systolic blood pressure at 140; however, the more aggressive or tighter-control group tried to get that systolic blood pressure down to the 120s. When you look at lowering blood pressure just by those 20 mm Hg, unbelievably, in just 3 years of treatment, with just a few years of follow-up, tight control of blood pressure reduced the incidence of mild cognitive impairment by 19%. Considering all-cause dementia, there was a reduction of 17%.

This randomized study used a variety of blood pressure medicines. The good news here is that they used generic medications and a variety of medications, and [the choice of medication] really didn't seem to matter. As long as the person was able to get tighter control of their blood pressure, they had a decreased incidence of mild cognitive impairment in a large randomized study.

The writing's been on the wall for a while about trying to modify cardiovascular risk factors, but this is the strongest evidence to date that doing so in practice can actually lead to improved outcomes. In my clinical practice, we talk about what is normal and what is optimal. When we talk about risk reduction for Alzheimer's disease or the general concept of Alzheimer's prevention, maybe we need to focus on optimal instead of normal.

For years, we thought 140/70 or 140/80 was normal blood pressure. However, new guidelines, even in the cardiovascular literature, are showing that lower may be better.[2] Tighter control of optimal blood pressure in the 120s may not only improve cognitive decline and progression towards dementia, but also reduce white matter hyperintensities, which was also studied in the MRI substudy of the SPRINT MIND trial.

What does this mean? From a practical clinical perspective, I think we all need to pay better attention to blood pressure. There are a variety of modifiable risk factors for Alzheimer's disease, including exercise, nutrition, sleep modification, and especially cardiovascular risk factor modification. When we look at the evidence, the SPRINT MIND study really provides the strongest evidence to date that more aggressive or comprehensive control and targeting from normal to a more optimal blood pressure may reduce risk.

In addition, if we can add blood pressure reduction to the variety of other evidence-based, multimodal lifestyle interventions, then maybe we can truly stave off Alzheimer's. Until that blockbuster drug comes, we're doing the best we can today to have better outcomes tomorrow.

For Medscape, I'm Dr Richard Isaacson.

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