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Low systolic BP, multiple BP medications increase mortality risk in frail elderly adults
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In a study of adults older than 80 years living in nursing homes, those who had systolic BP less than 130 mm Hg and were taking at least two BP-lowering agents had an increased risk for mortality.
Although previous research has demonstrated the benefits of lowering BP in community-living, robust individuals with hypertension, it has not demonstrated that lower BP benefits frail elderly individuals, according to the study background.
Athanase Benetos, MD, PhD, and colleagues conducted the PARTAGE longitudinal study of 1,127 men and women older than 80 years living in nursing homes in France and Italy (mean age, 87.6 years; 78.1% women).
They evaluated the interaction between low systolic BP, defined as less than 130 mm Hg, and the presence of at least two antihypertensive treatments, and their effect on all-cause mortality at 2 years.
Benetos, from the department of geriatrics at University Hospital of Nancy in France, and colleagues found a significant interaction between low systolic BP and treatment with at least two antihypertensive medications. Compared with other participants, those who had systolic BP less than 130 mm Hg and were taking at least two BP-lowering medications had a higher risk for mortality at 2 years (unadjusted HR = 1.81; 95% CI, 1.36-2.41; adjusted HR = 1.78; 95% CI, 1.34-2.37).
The results were confirmed when propensity score-matched subsets of participants were compared (unadjusted HR = 1.97; 95% CI, 1.32-2.93; adjusted HR = 2.05; 95% CI, 1.37-3.06), when adjustment was made for CV comorbidities (HR = 1.73; 95% CI, 1.29-2.32) and when patients who had no history of hypertension but were receiving BP-lowering agents were excluded (unadjusted HR = 1.82; 95% CI, 1.33-2.48; adjusted HR = 1.76; 95% CI, 1.28-2.41).
“During the past few years, studies have shown that frailty status, compared with chronological age, can better identify the relationships between BP levels and the risk of morbidity and mortality,” Benetos and colleagues wrote. “The results of the present study highlight our limited understanding of the benefits and harms of BP treatment in frail, older nursing home patients. Since the evidence in these patients is scarce, physicians should be more cautious when implementing international guidelines, which propose to reduce the [systolic] BP to a level between 140 mm Hg and 150 mm Hg ... Rather, in nursing home residents and frail elderly patients, it is advisable to conduct a more comprehensive assessment (eg, comorbidities, polymedication and frailty) to optimize therapeutic decisions.” – by Erik Swain
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Carl J. Pepine, MD, MACC
I am concerned about these data because hypertension and related adverse outcomes like stroke and HF are highly prevalent in elderly people, particularly women who comprised more than 75% of this study cohort and most of our U.S. hypertension population in this age group.
First, it is reassuring that this analysis found no increased risk for death among those with systolic BP < 130 mm Hg or those taking two or more antihypertensive drugs. Risk was only increased among those using two or more antihypertensive drugs with a systolic BP < 130 mm Hg. Second, this excess risk was highly dependent upon age (approximate 25% increase for every 5 years above age 80), male sex (approximate 63% excess), leanness (BMI ≤25, approximate 57% excess), and to a lesser extent comorbidities and reduced activity.
Thus, in an otherwise active, elderly woman with hypertension, who is neither symptomatic nor lean, it would not be advisable to consider changing her treatment unless her systolic BP is < 130 mm Hg and she is also taking two or more antihypertensive drugs. To do so would result in an unnecessary increase in risk. For example in the CALIBER project of 1.2 million people (Rapsomaniki E, et al. Lancet. 2014;383:1899-1911), a 20-mm Hg lower systolic BP was associated with significant reduction in ischemic stroke (HR = 0.86; 95% CI, 0.77–0.96) in those older than 80. This 20-mm Hg systolic BP difference is a conservative estimate of what could result from setting her systolic BP goal to about 150 mm Hg, as suggested for the general population aged 60 years and older by some members of the 2014 JNC8 panel.
What about systolic BP slightly above 120/80 mm Hg (eg, prehypertension) in older women? The Women’s Health Initiative found a 93% increase in stroke risk among women (mean age, 63 years) with systolic BP 130 mm Hg to 139 mm Hg (Hsia J, et al. Circulation. 2007;115:855-860). Furthermore, the increased overall CV risk with prehypertension was twofold greater than that associated with smoking.
Said another way, let’s be very cautious about letting systolic BP drift upward, particularly among older women.
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George L. Bakris, MD, FAHA, FASN
The findings further solidify the notion that lower is not better, especially in octogenarians in whom we have no randomized trial data except for HYVET, in which the achieved BP was between 140 mm Hg and 150 mm Hg systolic and not less than 130 mm Hg. It also supports the 2014 Evidence-Based Guideline for the Management of High BP in Adults written by the panel members appointed to the Eighth Joint National Committee stating that BP goal in older people is less than 150 mm Hg/90 mm Hg. Clearly, the data from this study extend our knowledge in this older cohort.
With so few data, the findings reinforce the notion that less is more in older people and aggressiveness should be avoided when it comes to BP lowering beyond a certain level.
I very much agree that frailty is a more important consideration than chronological age in this population, having seen referrals in my own practice that were overtreated when I saw them initially, and actually reduced therapy to achieve a BP level of both systolic and diastolic BP that is within the current guidelines and where the patient could function.
Each patient needs to be evaluated based on their own physiology. Many octo- and nonagenarians have systolic BP values that are 140 mm Hg to 160 mm Hg, but diastolic values of 65 mm Hg to 75 mm Hg. These people would do well to maintain BP values around 140 mm Hg/65 mm Hg to 70 mm Hg. This is reinforced by SHEP, SYST-Eur and HYVET. I do not think that systolic BP values between 140 mm Hg and 149 mm Hg need to be managed in this group, as there is no evidence of benefit. Epidemiologists will perhaps disagree with this statement, but again, there is a reason many of these people lived this long, and trying to normalize BP is incongruous with the vascular physiology at this advanced age range. The guidelines can’t reflect this because they are evidence-based and we have no evidence in this advanced age.
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