Systematic Review Finds Treating Blood Pressure to Current Guidelines in Older Adults Improves Health Outcomes

BACKGROUND:
Hypertension is a common modifiable risk factor for cardiovascular morbidity and mortality, affecting up to two-thirds of adults over age 60. Older adults also might be more susceptible to adverse effects from blood pressure lowering including falls, fracture, and cognitive impairment. In 2014, new guidelines raised the treatment goal for adults 60 years of age and older to a systolic blood pressure (SBP) of <150 mmHg, but the change has been controversial and a newer trial has further fueled debate. This systematic review sought to compare the effects of more versus less intensive blood pressure control in older adults. Investigators searched several databases (i.e., Embase®, Cochrane) through January 2015, and MEDLINE® to September 2016. Following this search, they analyzed findings from 21 randomized controlled trials that compared blood pressure targets or treatment intensity and 3 observational studies that assessed harms for this review.

FINDINGS:

• Treating blood pressure in adults over 60 to at least current guideline standards (<150/90 mmHg) substantially improves health outcomes in older adults, including reducing mortality, stroke, and cardiac events. The most consistent and largest effects were seen in studies of patients with higher baseline blood pressure (SBP >160mmHg) who achieved moderate blood pressure control (<150/90 mmHg).
• There is less consistent evidence, largely from one trial targeting SBP <120 mmHg, that lower blood pressure targets are beneficial for high cardiovascular risk patients.
• In patients with prior stroke or transient ischemic attack, treating to SBP < 140 mmHg reduces the risk of recurrent stroke.
• Lower blood pressure targets did not increase falls or cognitive decline, but were associated with hypotension, syncope, and greater medication burden.

LIMITATIONS:

• Authors were unable to determine how choice of medication class influenced study results.
• There is little evidence to guide treatment decisions in elderly patients who are institutionalized, have dementia, or have multiple co-existent chronic conditions.

AUTHOR/FUNDING INFORMATION:
This review was funded by VA HSR&D's Quality Enhancement Research Initiative (QUERI) Evidence-based Synthesis Program (ESP). Dr. Kansagara is part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR.

Weiss J, Freeman M, Low A, et al., and Kansagara D. Benefits and Harms of Intensive Blood Pressure Treatment in Adults Over Age 60: A Systematic Review and Meta-Analysis. Annals of Internal Medicine. March 21, 2017;166(6):419-29.