Publications of the Week: BP targets in older adults

Background: There is uncertainty as to the optimal blood pressure (BP) targets in older adults aged ≥65 years with hypertension. The aim of this review was to assess the effects of a less aggressive BP target, defined as <150 to 160/95 to 105 mm Hg, as compared with a conventional (lower) BP target, defined as <140/90 mm Hg.

Methods: The studies included comprised randomized trials of adults aged ≥65 years with hypertension, each trial spanning ≥1 year and reporting the effect of a higher or lower systolic or diastolic BP treatment target on mortality and morbidity. Higher BP targets ranged from systolic BP <150 to 160 mm Hg or diastolic BP <95 to 105 mm Hg; while lower BP targets were ≤140/90 mm Hg, measured in an ambulatory, home, or office setting. Primary outcomes were all-cause mortality, stroke, institutionalization, and serious cardiorenal vascular adverse events. Secondary outcomes included withdrawal due to adverse events and both serious and minor adverse events.

Results: There were four trials included, totaling 16,732 patients with a mean age of 70.3 years. Of these, one trial used a combined systolic and diastolic BP target and compared a higher target of <150/90 mm Hg to a lower target of <140/90 mm Hg, and two trials used only a systolic BP target and compared systolic BP <150 mm Hg (1 trial) and systolic BP <160 mm Hg (1 trial) to systolic BP <140 mm Hg. The fourth trial used a systolic BP target only, but it introduced a lower limit for systolic BP, comparing systolic BP in the target range of 130 to 150 mm Hg with a lower target range of 110 to 130 mm Hg.

In comparison with conventional or lower BP targets (<140/90 mm Hg) over 2 to 4 years, higher BP targets (systolic BP <150-160 mm Hg or diastolic BP <95-105 mm Hg) appeared to result in little to no difference in all-cause mortality (risk ratio [RR], 1.14; 95% CI, 0.95-1.37) but were associated with an increased risk of stroke (RR, 1.33; 95% CI, 1.06-1.67) and serious cardiovascular adverse events (RR, 1.25; 95% CI, 1.09-1.45). There was no difference between groups in the risk of drug withdrawal due to adverse effects (RR, 0.99; 95% CI, 0.74-1.33).

Conclusions: The authors concluded that older adult patients with a lower BP target had fewer strokes and serious cardiovascular events. Additional research is warranted in patients aged ≥80 years and those with frailty (in whom the risks and benefits may differ), whereas conventional (lower) BP targets may be appropriate for the majority of older adults.

McMaster editors’ commentary: The treatment of patients with hypertension remains a challenge and antihypertensive drug therapy should be combined with nonpharmacologic measures that include regular exercise and a balanced diet, even when applied to an older adult population. This review is consistent with other data in patients with hypertension and comorbidities or end-organ damage, whereby one should aim for a lower BP target. Such treatment should be adjusted according to individualized responses to drug therapy so as to minimize adverse effects, especially in patients with frailty and/or at a very advanced age (≥80 years). As long as a patient can tolerate treatment, one should aim for a lower BP target.