Age- and BP-Stratified Effects of BP-Lowering Pharmacotherapy

Quick Takes

  • Pharmacological BP lowering is effective for older adults and should be considered for management of elevated BP irrespective of age.
  • Absolute CV risk reduction is significant among older age groups.
  • No evidence of adverse mortality associated with pharmacological BP lowering was observed for any age group.

Study Questions:

Is pharmacological blood pressure (BP) lowering associated with cardiovascular (CV) outcomes among older adults?


This meta-analysis included participants from randomized clinical trials which compared pharmacological BP lowering versus placebo or other classes of BP-lowering medications or between more versus less intensive treatment strategies. Included trials had to have at least 1,000 person-years of follow-up in each treatment group. Participants with a previous history of heart failure were excluded. Data were obtained from the Blood Pressure Lowering Treatment Trialists’ Collaboration. Patient-level data were grouped by age using five groups (<55 years, 55-64, 65-74, 75-84, and ≥85 years). Baseline systolic BP was grouped into seven categories (from <120 mm Hg to ≥170 mg Hg). Baseline diastolic BP was grouped into six categories (from <70 mm Hg to ≥110 mm Hg). The primary outcome was a composite of fatal or nonfatal stroke, fatal or nonfatal myocardial infarction or ischemic heart disease, or heart failure causing death or requiring hospital admission. The secondary outcomes were all-cause death and each component of the primary outcome.


A total of 358,707 participants from 51 randomized clinical trials were included in this meta-analysis. The age of participants at randomization ranged from 21 years to 105 years (median 65 years [interquartile range, 59–75 years]), 128,506 (35.8%) 65–74 years, 54,016 (15.1%) 75–84 years, and 4,788 (1.3%) ≥85 years. The hazard ratios for the risk of major CV events per 5 mm Hg reduction in systolic BP for each age group were 0.82 (95% confidence interval, 0.76–0.88) in individuals <55 years, 0.91 (0.88–0.95) in those aged 55–64 years, 0.91 (0.88–0.95) in those aged 65–74 years, 0.91 (0.87–0.96) in those aged 75–84 years, and 0.99 (0.87–1.12) in those aged ≥85 years. Similar patterns of proportional risk reductions were observed for a 3 mm Hg reduction in diastolic BP. Absolute risk reductions for major CV events varied by age and were larger in older groups.


The investigators concluded that pharmacological BP reduction is effective into old age, with no evidence that relative risk reductions for prevention of major CV events vary by systolic or diastolic BP levels at randomization, down to <120/70 mm Hg. Pharmacological BP reduction should, therefore, be considered an important treatment option regardless of age, with the removal of age-related BP thresholds from international guidelines.


These data support the use of antihypertensive medications to treat BP, even among older adults. Furthermore, this meta-analysis demonstrated significant absolute risk reduction in CV events associated with pharmacologic BP treatment.

Clinical Topics: Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure, Hypertension

Keywords: ESC Congress, ESC21, Aged, 80 and over, Antihypertensive Agents, Blood Pressure, Diastole, Geriatrics, Heart Failure, Hypertension, Hypotension, Metabolic Syndrome, Myocardial Infarction, Myocardial Ischemia, Primary Prevention, Risk, Risk Reduction Behavior, Stroke, Systole, Treatment Outcome

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