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Intensive BP control decreases major adverse CV events
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Intensive BP control in older patients decreased major adverse CV events but was linked to an increased risk for renal failure, according to results of a systematic review and meta-analysis.
“The 2014 Eighth Joint National Committee panel recommended a therapeutic target of systolic BP < 150 mm Hg in patients 60 years of age, a departure from prior recommendations of < 140 mm Hg,” Chirag Bavishi, MD, MPH, of the department of cardiology at Mount Sinai St. Luke's and West Hospitals, and colleagues wrote. “However, many experts and subsequent analyses have argued against lowering the BP cutoff and continue to recommend a systolic BP treatment goal of < 140 mm Hg.”
Four randomized controlled trials of intensive BP lowering vs. standard BP lowering in older adults were pooled (n = 10,857). The outcomes of interest were major adverse CV events, CV mortality, stroke, MI, HF, serious adverse events and renal failure.
Of the study participants, 5,437 were randomly assigned to intensive BP control and 5,420 to standard BP control. Mean follow-up was 3.1 years.
Intensive strategy favorable
An intensive BP control strategy decreased major adverse CV events by 29% (RR = 0.71; 95% CI, 0.6-0.84) compared with a standard BP control strategy, according to the researchers.
Intensive BP control also resulted in a 33% reduction in CV mortality vs. standard BP control (RR = 0.67; 95% CI, 0.45-0.98). Additionally, HF was significantly decreased with intensive BP therapy (RR = 0.63; 95% CI, 0.4-0.99), Bavishi and colleagues wrote.
Although not statistically significant, rates for MI (RR = 0.79; 95% CI, 0.56-1.12) and stroke (RR = 0.8; 95% CI, 0.61-1.05) were lower with intensive BP control. There were no significant differences between intensive BP control and standard control for serious adverse events (RR = 1.02; 95% CI, 0.94-1.09) and renal failure (RR = 1.81; 95% CI, 0.86-3.8).
Analysis by a fixed-effects model yielded similar results, but that analysis showed an increased risk for renal failure with intensive BP therapy (RR = 2.03; 95% CI, 1.3-3.18).
“Although one can argue that [CV] events and renal failure cannot be considered equivalent, clinicians and patients should be aware of the trade-off involved with intensive therapy,” the researchers wrote. “Nevertheless, in older patients, the [CV] benefit of intensive therapy may come at the expense of increase in adverse events.”
Trial populations
George Bakris, MD, director of the Comprehensive Hypertension Center at The University of Chicago Medicine and a member of the Cardiology Today Editorial Board, and Alexandros Briasoulis, MD, a cardiologist at Mayo Clinic, wrote in an accompanying editorial: “Older people constitute a heterogeneous population. Frail patients are underrepresented in trials and the participation of ‘healthier’ less representative elderly individuals may lead to a discrepancy between ‘recommended evidence-based’ and ‘optimal individualized’ approaches.” – by Cassie Homer
Disclosure: Bakris, Bavishi and Briasoulis report no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures.
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