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Below are the 2 articles selected as suggested reading for this week by McMaster editors.
Please be advised that until the end of August Publications of the Week will be temporarily published in a less frequent, biweekly cycle.
Blood pressure targets in the elderly: how low can we go?
Blood pressure (BP) treatment targets have been the subject of recent numerous and – to a degree – difficult to interpret reports. The lowering of BP in the elderly is traditionally controversial. This paper provides reassurance and possibly encouragement for those clinicians who would like to aim at systolic blood pressure (SBP) of 120 mm Hg or less and for those patients who could tolerate such a strategy without major adverse reactions.
Over 2,500 elderly patients (mean age close to 80 years) without a history of diabetes mellitus, heart failure, or stroke participated in the SPRINT study. Those with a target BP of 120 mm Hg or less, versus 140 mm Hg or less, had a decreased risk of total mortality (1.8% vs 2.6% per year; hazard ratio [HR] 0.67, 95% confidence interval [CI] 0.49-0.91) and major cardiovascular events (2.6% vs 3.9% per year; HR 0.66, 95% CI 0.51-0.85). The rate of certain serious adverse events was higher in the lower BP target group, including hypotension (2.4% vs 1.4%), syncope (3.0% vs 2.4%), electrolyte abnormalities (4.0% vs 2.7%), and kidney injury (5.5% vs 4.0%).
Timing of RRT in critically ill patients: the dilemma persists
A few weeks ago, a paper published in the New England Journal of Medicine by Gaudry et al (see Publications of the Week for May 23) provided major support for those who were willing to wait with the initiation of renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI). The current paper, albeit smaller and involving different entry criteria (less severe AKI) as well as a different protocol, provides support for those who believe in an earlier rather than later start of RRT. Disappointingly, more data will be needed (however we may dislike such a statement) and new studies are planned.
In this study, 231 patients in relatively early stages of AKI (doubling of creatinine or urine output <0.5 mL/kg/hour for at least 12 hours despite resuscitation) were dialyzed either immediately or only after progression to more advanced stages of AKI (about 10% of patients in the group were never dialyzed). Early RRT was associated with markedly lower 90-day mortality rates (39% vs 55%; HR 0.66, 95% CI 0.45-0.97).
