By Harold L. Karpman, MD, FACC, FACP

Clinical Professor of Medicine, David Geffen School of Medicine, UCLA, Cardiovascular Medical Group

Dr. Karpman reports no financial relationships relevant to this field of study.

SYNOPSIS: Among ambulatory adults ≥ 75 years of age, treating to a systolic blood pressure (SBP) target of < 120 mmHg compared with an SBP target of < 140 mmHg resulted in a significantly lower rate of fatal and nonfatal major cardiovascular events and death from any cause.

SOURCE: Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs. standard blood pressure control and cardiovascular disease outcomes in adults aged ≥ 75 years: A randomized clinical trial. JAMA 2016;315:2673-2682.

Seventy-five percent of Americans ≥ 75 years of age suffer from hypertension, which is the leading cause of cardiovascular disease and its complications, including physical disability, morbidity, and mortality.1-3 Current guidelines recommend clinicians help patients ≥ 60 years of age maintain a systolic blood pressure (SBP) of < 140 mmHg.4 The Systolic Blood Pressure Intervention Trial (SPRINT) recently reported that participants assigned to an intensive SBP treatment target of < 120 mmHg vs. a group targeted to the standard SBP treatment goal of < 140 mmHg demonstrated a 25% lower relative risk of major cardiovascular events and death, and a 27% lower relative risk of death from any cause.5

Williamson et al analyzed the results of SPRINT, the multicenter, randomized, clinical trial of patients ≥ 75 years of age that began in 2010 and ended in 2015.6 Participants were randomized to the SBP target of < 120 mmHg group or to a < 140 mmHg SBP group. The primary cardiovascular disease outcome was a composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death from cardiovascular causes. The results revealed that patients treated to a SBP target of < 120 mmHg experienced a 33% reduced incidence of cardiovascular disease and a 32% decrease in total mortality when compared to the group treated to a treatment goal of < 140 mmHg.

COMMENTARY

The results of the Williamson et al analysis emphasize the importance of more aggressive therapy for hypertension in the elderly. Physicians have been inclined to underestimate the burden of hypertension in the elderly and have not recognized the benefits of lowering SBP, resulting in widespread undertreatment. The benefits that resulted from intensive therapy often required treatment with more than one antihypertensive drug and a significant increase in follow-up visits for dose titration and monitoring. The results from SPRINT reinforce the conclusions of the Hypertension in the Very Elderly Trial (HYVET), which randomized 3,845 patients ≥ 80 years of age and found that blood pressure control resulted in a significant reduction in the incidence rate of total mortality, even in the most frail patients.7,8

The analysis of SPRINT participants ≥ 75 years of age clearly has demonstrated that treating SBP to ≤ 120 mmHg resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause when compared to the group in whom SBP was treated to ≤ 140 mmHg.

REFERENCES

  1. Mozaffarian D, Benjamin EJ, Go AS, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics — 2015 update: A report from the American Heart Association. Circulation 2015;1314:e29-e322.
  2. Ferrucci L, Guralnik JM, Pahor M, et al. Hospital diagnoses, Medicare changes, and nursing home admissions in the year when older people become severely disabled. JAMA 1997;277:728-734.
  3. den Ouden MEM, Schuurmans MJ, Mueller-Schotte S, et al. Do subclinical vascular abnormalities precede impaired physical ability and ADL disability? Exp Gerontol 2014;58:1-7.
  4. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC8). JAMA 2014;311:507-520.
  5. SPRINT Research Group. A randomized trial of intensive versus standard blood pressure control. N Engl J Med 2015;373:2103-2116.
  6. Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs. standard blood pressure control and cardiovascular disease outcomes in adults aged ≥ 75 years: A randomized clinical trial. JAMA 2016;315:2673-2682.
  7. Beckett NS, Peters R, Fletcher AE, et al. HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008;358:1887-1898.
  8. Warwick J, Falaschetti E, Rockwood K, et al. No evidence that frailty modifies the positive impact of antihypertensive treatment in very elderly people: An investigation of the impact of frailty upon treatment effect in the HYpertension in the Very Elderly Trial (HYVET) study: A double-blind placebo-controlled study of antihypertensives in people with hypertension aged 80 and over. BMC Med 2015;13:78.