Guidance on Approaching Hypertension in Patients Over 80 Years of Age

In 2017, the American Heart Association (AHA)/American College of Cardiology (ACC) hypertension guideline lowered the definition of hypertension to a blood pressure (BP) of ≥130/80 mmHg.1 BP generally increases with age due to sub-optimal lifestyle habits. There is a high prevalence of hypertension among United States (US) adults and the 40-year risk of developing hypertension (defined as ≥140/≥90 mm Hg) in adults 45 years of age in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort was nearly 100% for all ethnicities.2

The average person over 70 years of age is expected to live an additional 15.5 years and for those over 85 years of age an additional 7 years.3 By 2060, nearly a quarter of the US population will be over 65 years and 5% over 85 years.4

The 2017 guidelines were in part based on results from the Systolic Blood Pressure (SBP) Intervention Trial (SPRINT), which showed that a more intensive treatment goal of <120/80 compared to the prior BP goal of SBP <140/90 had benefits with a similar adverse event rate.  The mean age in the entirety of SPRINT was 68 years with 56% aged 75-80 years. A SBP goal of <120 mmHg was associated with a reduction in the composite of myocardial infarction (MI), acute coronary syndrome (ACS), stroke, heart failure, or cardiovascular death.

The trial ended early due to a significantly lower event rate in the intensive treatment group; after a median of 3.33 years, there was a 27% lower hazard for the primary outcome with intensive treatment (1.77% per year vs. 2.40% per year; hazard ratio [HR] 0.73; 95% confidence interval [CI] = 0.63 - 0.86).5 Additionally, there was a 25% lower hazard for mortality with the intensive treatment target (HR = 0.75; 95% CI = 0.61 - 0.92). There was a similar rate of serious adverse events, although the intensive target group had significantly more events of hypotension, syncope, electrolyte abnormalities, and acute kidney injury or acute renal failure.

Aging does not necessarily lead to increases in BP. Rural, hunter-gatherer societies do not experience an age-associated increase in BP. This was observed from the Yi population, a culture traditionally living in a remote area of mountainous southwestern China. Recordings of BP in 14,505 people aged 15-89 years showed there are only minimal increase BPs in rural Yi farmers.6,7 However, Yi that migrated to urban areas had similar age-associated BP increases when controlling for traditional risk factors.

Subsequent cross-sectional surveys showed persistently higher hypertension prevalence in Yi migrants than Yi farmers.8 This cohort of the Yi farmer population demonstrated that BP does not necessarily have to increase with aging in healthy adults. Indeed, exposure to suboptimal lifestyle habits leads to hypertension through increases in obesity, metabolic syndrome, inflammation, and neurohormonal dysfunction, which increase arterial stiffening.9 These insults are influenced by environmental changes present in Westernized urban settings.

The HYVET trial was the first study focused on elderly patients >80 years.10 Patients with SBP >160 mmHg were randomized to placebo or indapamide with perindopril if needed to reach a target BP of 150/80. The mean starting BP was 173/91 mmHg and the mean decrease in SBP and diastolic blood pressure (DBP) was 29.5±15 and 13±9.5 mmHg, respectively, after 2 years. The primary outcome of stroke showed a non-significant reduction of 30% among the intensive treatment group (p=0.06). However, there was a 39% significant reduction in death from stroke (p=0.05), mortality (p=0.02), and heart failure (p<0.001). These results brought attention to the importance of appropriate hypertension management in the elderly.

Recently, a secondary analysis of the SPRINT trial by Pajewski et al. among the 1,167 adults ≥80 years has been critical in clarifying SBP treatment guidelines in the elderly.11 There were two primary outcomes for this secondary analysis of strict (<120 mmHg) versus standard (<140 mmHg) SBP over 80 years of age: 1) cardiovascular disease (CVD) morbidity and mortality and 2) mild cognitive impairment (MCI) and probable dementia.

The CVD outcome was a composite of nonfatal MI, ACS not resulting in a MI, nonfatal stroke, nonfatal decompensated heart failure, and cardiovascular death. Cognitive outcomes were defined as the occurrence of probable dementia, MCI and probable dementia, and a composite outcome of probable dementia or MCI.

Participants in the intensive treatment group were 24% less likely to experience the primary outcome (HR .66; 95% CI = 0.49 – 0.90), 23% less likely to experience death (HR = 0.67; 95% CI = 0.48 - 0.93), and 28% less likely to experience MCI (HR = 0.72; 95% CI = 0.53 - 0.99). Notable interactions for the benefit of intensive SBP lowering were observed when patients were stratified by Montreal Cognitive Assessment (MoCA) score. The primary outcome and mortality were significantly reduced with intensive treatment in those with MoCA scores >25th percentile, but not in the intensive treatment group with scores <25th percentile.

Composite significant adverse events (SAE) were similar between the two; there were no differences in hypotension, syncope, electrolyte abnormalities, and falls. However, with intensive treatment there was an increased risk of a 30% reduction in glomerular filtration rate (GFR) (HR 3.41; 95% CI = 1.92 – 6.06) and rates of renal failure or acute kidney injury (HR = 2.12; 95% CI = 1.37-3.26). This suggests a stricter BP goal in the elderly can be safely pursued but should possibly be avoided in those with pre-existing significant chronic kidney disease.

There is a potential risk of a J-curve response to BP treatment with an increase in major adverse cardiovascular events (MACE) in DBP <70 mmHg and those with larger pulse pressures are at greater risk.12 The ACCORD trial showed no difference in MACE at DBP <70, but there was an increase in adverse renal outcomes.13 While SPRINT showed similar benefits in the lowest DBP quintile, caution should be exercised with patients ≥80 years of age and personalized.

In summary, hypertension is extremely common in the elderly and the consequences of uncontrolled hypertension can be devastating to high-functioning and independent elderly. Recent results from SPRINT indicate that the balance in benefits versus harms favors more aggressive BP management. The totality of data suggests BP goals in patients ≥80 years of age can be the same as younger patients, <130/80 mmHg in those with preserved renal function and cognitive status. Shared decision-making approach with more frequent monitoring is key.

References

  1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:2199-69.
  2. Carson AP, Howard G, Burke GL, Shea S, Levitan EB, Muntner P. Ethnic differences in hypertension incidence among middle-aged and older adults: the multi-ethnic study of atherosclerosis. Hypertension 2011;57:1101–07.
  3. Arias E, Tejada-Vera B, Ahmad F. Provisional Life Expectancy Estimates for January through June, 2020 (CDC website). 2021. Available at: https://stacks.cdc.gov/view/cdc/100392. Accessed 10/30/2021.
  4. Vespa J, Medina L, Armstrong DM. Demographic Turning Points for the United States: Population Projections for 2020 to 2060: Population Estimates and Projections (Census.gov). 2020. Available at: https://www.census.gov/content/dam/Census/library/publications/2020/demo/p25-1144.pdf. Accessed 10/30/2021.
  5. Lewis CE, Fine LJ, Beddhu S. Final report of a trial of intensive versus standard blood-pressure control. N Engl J Med 2021;384:1921–30.
  6. He J, Tell GS, Tang YC, Mo PS, He GQ. Effect of migration on blood pressure: the Yi People Study. Epidemiology 1991;2:88–97.
  7. He J, Klag MJ, Whelton PK, et al. Migration, blood pressure pattern, and hypertension: the Yi Migrant Study. Am J Epidemiol 1991;134:1085–1101.
  8. Zhang J, Wan S, Zhang B, et al. Twenty-year time trends in hypertension prevalence in Yi people of China: three successive cross-sectional studies, 1996–2015. BMJ Open 2018;8:e022714.
  9. Sun Z. Aging, arterial stiffness, and hypertension. Hypertension 2015;65:252–56.
  10. Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 Years of age or older. N Engl J Med 2008;358:1887–98.
  11. Pajewski NM, Berlowitz DR, Bress AP, et al. Intensive vs standard blood pressure control in adults 80 years or older: a secondary analysis of the systolic blood pressure intervention trial. J Am Geriatr Soc 2020;68:496–504.
  12. Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Coll Cardiol 2015;65:1372–1407.
  13. Cushman WC, Evans GW, Byington RP. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575–85.

Clinical Topics: Dyslipidemia

Keywords: Aged, 80 and over, Blood Pressure, Indapamide, Perindopril, Cross-Sectional Studies, Goals, Glomerular Filtration Rate, American Heart Association, Metabolic Syndrome, Prevalence, Acute Coronary Syndrome, Cardiovascular Diseases, Transients and Migrants, Confidence Intervals, Decision Making, Shared, Hypertension, Aging, Heart Failure, Risk Factors, Renal Insufficiency, Chronic, Renal Insufficiency, Chronic, Acute Kidney Injury, Myocardial Infarction, Atherosclerosis, Stroke, Mental Status and Dementia Tests, Syncope, Cardiology, Life Style, Obesity, Inflammation, Attention, Hypotension, Electrolytes, Cognition, Dementia, Reference Standards


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