Intensive vs. Standard Blood Pressure Lowering in Older Hypertensive Patients

Study Questions:

What is the efficacy and safety of intensive blood pressure (BP)-lowering strategies in older (≥65 years) hypertensive patients?

Methods:

The investigators searched MEDLINE, Scopus, EMBASE, and Cochrane databases for all relevant randomized controlled trials from 1965 through July 1, 2016. Cardiovascular (major adverse cardiovascular events [MACE], cardiovascular mortality, stroke, myocardial infarction [MI], and heart failure) and safety outcomes (serious adverse events and renal failure) were evaluated. Random- and fixed-effects modeling was used to calculate pooled relative risk (RR) and 95% confidence intervals (CIs).

Results:

The authors identified four high-quality trials involving 10,857 older hypertensive patients with a mean follow-up of 3.1 years. Intensive BP lowering was associated with a 29% reduction in MACE (RR, 0.71; 95% CI, 0.60-0.84), 33% in cardiovascular mortality (RR, 0.67; 95% CI, 0.45-0.98), and 37% in heart failure (RR, 0.63; 95% CI, 0.43-0.99) compared with standard BP lowering. Rates of MI and stroke did not differ between the two groups. There was no significant difference in the incidence of serious adverse events (RR, 1.02; 95% CI, 0.94-1.09) or renal failure (RR, 1.81; 95% CI, 0.86-3.80) between the two groups. Fixed-effects model yielded largely similar results, except for an increase in risk of renal failure (RR, 2.03; 95% CI, 1.30-3.18) with intensive BP-lowering therapy.

Conclusions:

The authors concluded that in older hypertensive patients, intensive BP control (systolic BP <140 mm Hg) decreased MACE including cardiovascular mortality and heart failure.

Perspective:

This systematic review and meta-analysis suggests that intensive BP-lowering treatment is associated with lower cardiovascular outcomes in older hypertensive patients. However, there was an increased risk of renal failure with intensive BP lowering. It appears that in older patients, the cardiovascular benefit of intensive therapy may come at the expense of increase in adverse events, and clinicians should carefully consider risk versus benefit for the individual patient. Given limitations of this trial-level meta-analysis, the results of the ongoing ESH-CHL-SHOT (Optimal Blood Pressure and Cholesterol Targets for Preventing Recurrent Stroke in Hypertensives) trial are awaited to provide more definitive data on optimal BP targets.

Clinical Topics: Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Lipid Metabolism, Nonstatins, Acute Heart Failure, Hypertension

Keywords: Blood Pressure, Cholesterol, Geriatrics, Heart Failure, Hypertension, Incidence, Myocardial Infarction, Primary Prevention, Renal Insufficiency, Risk, Stroke


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