Intensive vs Standard Blood Pressure Control in Adults 80 Years or Older

A Secondary Analysis of the Systolic Blood Pressure Intervention Trial

Nicholas M. Pajewski, PhD; Dan R. Berlowitz, MD, MPH; Adam P. Bress, PharmD; Kathryn E. Callahan, MD; Alfred K. Cheung, MD; Larry J. Fine, MD; Sarah A. Gaussoin, MS; Karen C. Johnson, MD, MPH; Jordan King, PharmD; Dalane W. Kitzman, MD; John B. Kostis, MD; Alan J. Lerner, MD; Cora E. Lewis, MD, MSPH; Suzanne Oparil, MD; Mahboob Rahman, MD; David M. Reboussin, PhD; Michael V. Rocco, MD; Joni K. Snyder, RN; Carolyn Still, PhD; Mark A. Supiano, MD; Virginia G. Wadley, PhD; Paul K. Whelton, MD; Jackson T. Wright Jr, MD, PhD; Jeff D. Williamson, MD, MHS

Disclosures

J Am Geriatr Soc. 2020;68(3):496-504. 

In This Article

Abstract and Introduction

Abstract

Objectives: To evaluate the effect of intensive systolic blood pressure (SBP) control in older adults with hypertension, considering cognitive and physical function.

Design: Secondary analysis.

Setting: Systolic Blood Pressure Intervention Trial (SPRINT)

Participants: Adults 80 years or older.

Intervention: Participants with hypertension but without diabetes (N = 1167) were randomized to an SBP target below 120 mm Hg (intensive treatment) vs a target below 140 mm Hg (standard treatment).

Measurements: We measured the incidence of cardiovascular disease (CVD), mortality, changes in renal function, mild cognitive impairment (MCI), probable dementia, and serious adverse events. Gait speed was assessed via a 4-m walk test, and the Montreal Cognitive Assessment (MoCA) was used to quantify baseline cognitive function.

Results: Intensive treatment led to significant reductions in cardiovascular events (hazard ratio [HR] = .66; 95% confidence interval [CI] = .49-.90), mortality (HR = .67; 95% CI = .48-.93), and MCI (HR = .70; 95% CI = .51-.96). There was a significant interaction (P < .001) whereby participants with higher baseline scores on the MoCA derived strong benefit from intensive treatment for a composite of CVD and mortality (HR = .40; 95% CI = .28-.57), with no appreciable benefit in participants with lower scores on the MoCA (HR = 1.33 = 95% CI = .87–2.03). There was no evidence of heterogeneity of treatment effects with respect to gait speed. Rates of acute kidney injury and declines of at least 30% in estimated glomerular filtration rate were increased in the intensive treatment group with no between-group differences in the rate of injurious falls.

Conclusion: In adults aged 80 years or older, intensive SBP control lowers the risk of major cardiovascular events, MCI, and death, with increased risk of changes to kidney function. The cardiovascular and mortality benefits of intensive SBP control may not extend to older adults with lower baseline cognitive function.

Introduction

The number of adults aged 80 years and older is steadily increasing and expected to reach 7.7% of the population in the United States by 2050.[1] Given that the lifetime risk of developing hypertension is at least 70% by age 80 for whites and blacks in the United States,[2] this demographic shift will induce a growing impact of hypertension and its adverse consequences in older adults. The 2017 American College of Cardiology/American Heart Association blood pressure guidelines recommended treatment to a systolic blood pressure (SBP) below 130 mm Hg in noninstitutionalized ambulatory community-dwelling adults 65 years of age or older.[3] However, hypertension treatment for adults 80 years or older is frequently complicated by multiple chronic conditions such as frailty, polypharmacy, and cognitive impairment.[4,5] Observational analyses indicate an attenuation of the association between elevated blood pressure (BP) and the incidence of vascular and nonvascular disease with increasing age,[6,7] suggesting that the balance of risk to benefit for hypertension treatment may be different for adults 80 years of age or older as compared with adults in their 60s and 70s. Several studies also suggest that older adults with robust functional status may be more likely to benefit from hypertensive therapy, with weaker or null associations between elevated SBP and adverse outcomes in adults with impaired function.[8–10]

Much of the evidence for the benefit of antihypertensive drug therapy in adults 80 years of age or older comes from the Hypertension in the Very Elderly Trial (HYVET) which identified a significant and clinically important reduction in stroke and mortality with the long-acting diuretic indapamide (alone or combined with perindopril) compared with placebo.[11] However, the baseline SBP in HYVET was 160 mm Hg or higher, with participants assigned to indapamide achieving a mean (seated) SBP of 143.5 mm Hg after 2 years of treatment. Thus HYVET provides limited information concerning more intensive treatment of SBP to levels below 140 mm Hg. The Systolic Blood Pressure Intervention Trial (SPRINT) compared treatment to an SBP goal below 120 mm Hg (intensive treatment) with treatment to a goal of below 140 mm Hg (standard treatment) in older adults with hypertension.[12] SPRINT included a large number of participants 75 years or older, with results in this subgroup largely indicating beneficial effects on cardiovascular morbidity and mortality.[13] However, most participants in this age group (55.7%) were between 75 and 80 years of age, and very little was reported specifically for the oldest participants in SPRINT.[14] Here we comprehensively examine a range of outcomes including cardiovascular morbidity and mortality, renal function, adjudicated mild cognitive impairment (MCI) and probable dementia, health-related quality of life (HRQOL), and serious adverse events. We also explore whether baseline impairments in cognitive or physical function modify the effect of intensive BP control on outcomes.

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